Advertisement
top banner image  

topleft corner image     top right corner image
 
ACCF/AHA Clinical Guidelines and Statements
ACCF / SCAI / STS / AATS / AHA / ASNC / HFSA / SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update
2012 ACCF/ AHA/ ACR/ SCAI/ SIR/ STS/ SVM/ SVN Key Data Elements and Definitions for Peripheral Atherosclerotic Vascular Disease
2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy

CME logo image
bullet
About CME
bullet
Important Information
bullet
Policy on Privacy and Confidentiality
bullet
Disclosures and Copyrights

JACC Homepage JACC Imaging Homepage
Still not a subscriber to JACC Imaging or JACC Interventions?
Click here
to sign up now!

take action
bullet
Member Sign Up
bullet
Submit Manuscripts
bullet
Subscribe/Renew
bullet
Order Reprints
bullet
Email Alerts
bullet
Contact Us
bullet
Feedback
bullet
RSS Feed

acc links
bullet
Cardiosmart
bullet
CardioSource
bullet
Current Clinical Collection - Noninvasive Cardiology
bullet
Current Clinical Collection - CT/MRI
bullet
CVN
bullet
Imaging Library
bullet
JACC
bullet
JACC Imaging
bullet
Talk Back - Imaging Community on Cardiosource

jacc interventions image
bullet
Author Information
bullet
Editorial Board & Staff
bullet
About the Journal
bullet
Help

     top nav image

     

J Am Coll Cardiol Intv, 2008; 1:5-13, doi:10.1016/j.jcin.2007.12.001
© 2008 by the American College of Cardiology Foundation
This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Teirstein, P. S.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Teirstein, P. S.

State-of-the-Art Paper

Unprotected Left Main Intervention

Patient Selection, Operator Technique, and Clinical Outcomes

Paul S. Teirstein, MD1,*

Division of Cardiology and Interventional Cardiology, Scripps Clinic, La Jolla, California.


   Abstract
Top
 Abstract
Early Clinical Results of...
 Patient Selection
 Operator Technique
 Conclusions
 REFERENCES
 
In the 1980s, early attempts at balloon angioplasty of the unprotected left main coronary artery (UPLM) were associated with poor early outcomes because of coronary dissection, abrupt closure, and restenosis. Mortality rates as high as 30% at 1 year were reported. In the 1990s, bare-metal stents helped reduce acute complications, but high rates of repeat revascularization (20% to 30%) were observed because of restenosis. In the early 2000s, the introduction of drug-eluting stents (DES), with the promise of vastly reduced rates of restenosis, raised the possibility of improved late outcomes for UPLM patients receiving stents. Although use of DES for UPLM is currently a class III indication in patients who are candidates for coronary artery bypass graft (CABG), many patients are currently undergoing this procedure. Published registries indicate the procedural and in-hospital risks are acceptable and seem to be the same or lower than the procedural risks of CABG. Unprotected left main ostial and midshaft lesions have excellent early and midterm outcomes that will likely (although not yet proven) be similar to those of CABG. Distal left main lesions involving the bifurcation are technically more challenging and associated with a higher rate of late revascularization. Early registry data have not found excess mortality in patients receiving DES for UPLM when compared with historical bypass surgery data, even when the distal bifurcation is stented. However, current follow-up of stented patients is limited to 1 year or less. Over the next few years, the results of randomized trials will expand the evidence base available to clinicians caring for this challenging patient group.

Abbreviations and Acronyms
  CABG = coronary artery bypass graft
  DES = drug-eluting stent(s)
  IVUS = intravascular ultrasound
  LAD = left anterior descending artery
  PES = paclitaxel-eluting stent(s)
  SES = sirolimus-eluting stent(s)
  TLR = target lesion revascularization
  TVR = target vessel revascularization
  UPLM = unprotected left main coronary artery

The left main coronary artery’s critical importance to coronary circulation has focused attention on this specific anatomical subgroup for decades. In the early 1970s, coronary artery bypass graft (CABG) was found to improve late survival in patients with significant left main stenosis in comparison with medical therapy (1–3). Once CABG became the standard of care for left main disease, a distinction between protected—by at least 1 patent bypass graft to the left coronary artery—and unprotected left main coronary arteries (UPLM)—no patent bypass graft to the left coronary artery—was made. This review is confined to the treatment of UPLM disease. In the 1980s, early attempts at balloon angioplasty of the UPLM were associated with poor early outcomes because of coronary dissection, abrupt closure, and restenosis. Mortality rates as high as 30% at 1 year were reported (4–6). In the 1990s, bare-metal stents were introduced and soon were used to treat UPLM disease. Several small registries found a low rate of procedural complications, but rates of repeat revascularization of 20% to 30% because of restenosis were considered unacceptable (7–12). Early bare-metal stent registries for UPLM also found high mortality rates, particularly in high-risk patients, such as patients with acute coronary syndromes and poor left ventricular function. Importantly, high-risk subgroups often presented with late sudden death (11,13). In the early 2000s, the introduction of drug-eluting stents (DES), with the promise of vastly reduced rates of restenosis (14–17), raised the possibility of improved late outcomes in this challenging patient group.


   Early Clinical Results of DES for UPLM Stenosis
Top
 Abstract
 Early Clinical Results of...
Patient Selection
 Operator Technique
 Conclusions
 REFERENCES
 
Clinical outcomes after treatment of UPLM disease with either the sirolimus-eluting stent (SES) or the paclitaxel-eluting stent (PES) from nearly 20 small registries have been published. Results reported in these registries vary widely (18–40). As depicted in Table 1, cardiac mortality between 6 and 12 months ranges from 0% to 11%. Target lesion revascularization (TLR) or target vessel revascularization (TVR) rates range from 2% to 38%. This wide variation in clinical outcome seems largely attributable to variation in both patient selection and procedural technique.


View this table:
[in this window]
[in a new window]

  		Table 1 DES for the Unprotected Left Main Coronary Artery
 
Although results after UPLM stenting are usually reported as a single, homogeneous subgroup of coronary artery disease, in reality, UPLM encompasses a wide spectrum of disease states. Outcomes will be particularly dependent on lesion location. Left main disease can be confined solely to the left main ostium or to the midshaft, regions technically not difficult to treat with a single stent, where excellent outcomes can be expected. In contradistinction, UPLM disease can be located distally, involving the ostium of the left anterior descending (LAD) and/or circumflex arteries, resulting in a much more technically complex procedure, often requiring double stenting, with expected less favorable long-term outcomes. Additionally, the UPLM vessel can be large in diameter and free of calcium, which is associated with better outcomes, or small in diameter and contain significant quantities of calcium, creating a technically demanding procedure that results in less favorable short-term and long-term outcomes.

Another important differentiating patient characteristic is the presence of significant distal disease in the LAD and/or circumflex arteries, requiring multilesion intervention. The presence of multiple downstream lesions will obviously increase procedural complexity and also increase the risk for subsequent revascularization. Finally, any study of UPLM must take patient comorbidity into consideration. Often, patients are refused CABG for UPLM disease because of serious comorbidities (i.e., stenting in the setting of acute myocardial infarction, advanced age, poor left ventricular function, coexisting malignancy, renal failure, and porcelain aorta) that will also impact long-term outcome after coronary stenting. Thus, published studies of UPLM stenting must be viewed in the context of the clinical, angiographic, and procedural (especially, number of stents needed) characteristics of patients enrolled in each specific study.

Figure 1 shows a patient with midshaft UPLM stenosis. This is one of the most straightforward UPLM lesions for stenting, and an excellent outcome was obtained after deployment of a single stent in the shaft of the left main artery. A recent multicenter registry of 147 patients (35) undergoing UPLM stenting of ostial or midshaft lesions with SES (n = 107) or PES (n = 40) found excellent results at midterm clinical follow-up (886 ± 308 days). In this registry, cardiac mortality was 0% in-hospital and 2.7% at follow-up. Cardiac mortality was 0% in 87 patients judged at low risk because of a EuroSCORE ≤6 and/or Parsonnet score ≤13 (41,42), but was 6.7% in 60 patients with high-risk scores. With over a 2-year mean follow-up in the entire group, TVR was only 4.7%. Thus, patients with ostial and midshaft UPLM lesions seem to have excellent outcomes after DES. These outcomes are likely to compare favorably with surgical outcomes, but we await the results of randomized trials before drawing conclusions.


Figure 1
View larger version (73K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1 Critically Narrowed Midshaft Stenosis in an 83-Year-Old Man With Unstable Angina

This is one of the most straightforward unprotected left main coronary artery lesions for stenting (A). The arrow shows the stenosis. Excellent angiographic outcomes were achieved after implantation of a single 8-mm-long drug-eluting stent, in addition to stenting of the mid left anterior descending artery (B).

 
In contradistinction to patients with ostial or midshaft lesions, patients with distal bifurcation lesions are more challenging to treat and have less favorable long-term outcomes. The initial Scripps Clinic UPLM experience contained patients with predominantly distal bifurcation disease (32). In this small, 50-patient registry using SES for UPLM, 94% of patients had disease at the distal left main location. Instead of a single stent treating the left main and/or ostium of the LAD or circumflex artery, multiple stents were used in 84% of patients. This registry found a 9-month cardiac mortality rate of only 2%, but a TLR rate of 38%. Interestingly, the high TLR rate was also driven by an extremely high rate of angiographic follow-up. Fully 98% of patients had a follow-up angiogram at 3 and/or 9 months. Using an ischemia-driven TLR definition (patient has signs or symptoms of coronary ischemia), TLR was only observed in 14% of patients. This emphasizes the confounding impact of the occulostenotic reflex when interpreting results of UPLM stenting studies. Patients undergoing stenting of UPLM are often compliant with protocol-mandated surveillance angiography, and interventionalists are likely to have a low threshold to intervene when clinically silent restenosis is found in the left main vessel or the ostium of the circumflex artery or LAD because of the large quantity of myocardial territory perceived at risk.

Interestingly, a universal finding of the many DES UPLM registries is the predominance of restenosis occurring at the ostium of the left circumflex artery, especially in patients initially presenting with distal bifurcation disease and treated with 2 stents. The cause of this restenosis predilection for the ostium of the circumflex is unknown, but may be attributable to the sharp bend often taken by the circumflex artery in this location, which could result in lack of stent and drug apposition to the vessel wall, or perhaps even stent fracture.

Figure 2 shows a relatively favorable UPLM distal bifurcation lesion. This 54-year-old patient with unstable angina has a lesion involving the distal left main vessel but very little involvement of the ostium of the circumflex artery. A single stent can be deployed from the distal left main vessel into the LAD crossing over the circumflex artery (the crossover technique). This lesion can be contrasted with the patient depicted in Figure 3. Here we see a highly stenotic, calcified UPLM lesion involving the distal left main and both left coronary branch ostia in a 92-year-old woman with concomitant critical aortic valve disease. This patient was considered at such high risk that an intra-aortic balloon pump was placed prophylactically and 2 stents spanning the left main vessel and each branch were simultaneously deployed (the double-barrel technique). This patient is at particularly high risk for restenosis, especially at the circumflex ostium.


Figure 2
View larger version (76K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2 A 54-Year-Old Man With Favorable UPLM Distal Bifurcation Lesion

The lesion involves the distal left main vessel (arrow), but there is very little involvement of the ostium of the circumflex (A). A single stent was deployed from the distal left main vessel into the left anterior descending artery (arrow), crossing over the circumflex artery (the crossover technique). Mild plaque shift into the circumflex was treated with a final kissing balloon inflation, providing an excellent angiographic result (B). UPLM = unprotected left main coronary artery.

 

Figure 3
View larger version (58K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 3 Pre-Procedure Angiogram From a 92-Year-Old Woman With Critical Aortic Stenosis in Preparation for Percutaneous Aortic Valve Implantation

This critically narrowed distal left main lesion (A) involves both the left anterior descending artery and circumflex ostia (arrow). To reduce the risk of closing one of the branch vessels, 2 stents were deployed simultaneously (arrow) using the double-barrel technique (B). The final angiographic result was excellent (C), but this lesion is at higher risk for restenosis, particularly at the circumflex ostium (arrow).

 
There have been several small published registries comparing UPLM DES with CABG. Lee et al. (28) compared 173 consecutive patients at a single institution undergoing both procedures. The investigators found a nonsignificantly higher mortality rate at 6 months with CABG compared with DES (11% vs. 4%). Conversely, the rate of TVR was nonsignificantly higher in DES patients (7% vs. 1%). Similarly, Chieffo et al. (22) compared 107 DES to 142 CABG patients in a nonrandomized registry. At 1 year, death also trended higher in CABG patients (6.4% vs. 2.8%), and TVR was similarly higher in DES patients (19.6% vs. 3.6%).

Recently, a meta-analysis of 1,278 patients from 17 published studies undergoing DES for UPLM disease was reported (40). As previously highlighted, there was wide variation among trials with respect to baseline patient and angiographic characteristics. The overall midterm results (median follow-up was 10 months, range 6 to 19 months) found a mortality rate of 5.5% and TVR rate of 6.5%. Although these results are encouraging, it must be emphasized that there was substantial variation in outcome among these 17 trials (Figs. 4 and 5).Go The 5.5% pooled risk of late mortality reported in the meta-analysis may not apply to a specific patient in whom treatment options are being considered.


Figure 4
View larger version (29K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 4 Recent Meta-Analysis of 1,278 Patients Undergoing UPLM DES From 15 Registries

At a median of 10 months of follow-up, the mortality risk was only 5.5% (range 3.4% to 7.7%). However, there was significant variation between registries, and the follow-up time was relatively short. Data from Biondi-Zoccai et al. (40). CI = confidence interval; DES = drug-eluting stents; UPLM = unprotected left main coronary artery.

 

Figure 5
View larger version (28K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 5 Recent Meta-Analysis of 1,278 Patients Undergoing UPLM DES From 15 Registries

At a median of 10 months of follow-up, the target vessel revascularization (TVR) risk was only 6.5% (range 3.7% to 9.2%). Note the extremely wide variation among the different registries. Data from Biondi-Zoccai et al. (40). Abbreviations as in Figure 4.

 

   Patient Selection
Top
 Abstract
 Early Clinical Results of...
 Patient Selection
Operator Technique
 Conclusions
 REFERENCES
 
Although numerous patients throughout the world are currently undergoing DES for UPLM, it should be emphasized that the current American College of Cardiology (ACC)/American Heart Association (AHA)/Society for Cardiovascular Angiography and Interventions (SCAI) Practice Guidelines for percutaneous coronary interventions clearly categorize UPLM stenting as a class III indication (43) (meaning it should not be undertaken) unless the patient is not a candidate for bypass surgery. However, the level of evidence provided is C (i.e., only consensus opinion of experts, case studies, or standard-of-care). Currently, without randomized trials, there is little evidence-based medicine available to guide patient care decisions. Therefore, the discussion that follows is the author’s opinion based on consideration of available registry data and personal experience.

Before selecting a patient for UPLM intervention, one should be certain that left main disease exists. This is particularly important if a patient has an ostial main lesion evident angiographically only in the cranial angulation. This projection is notorious for artifactually enhancing the appearance of left main vessel stenoses. Intravascular ultrasound (IVUS) is the ideal method for confirming the presence of significant left main disease and also for guiding selection of stent size, assessing the presence of calcification, and documenting the involvement of the distal left main vessel and its branches. One commonly used IVUS threshold for significant left main disease is a minimal luminal area of <6.0 mm2 (44); another is <7.5 mm2 (45).

Informed consent is essential when considering patients for UPLM stenting. Patients who are not candidates for surgery because of comorbidities or poor distal targets are the least controversial to treat. These patients should be informed that although stenting may be their best option, the long-term outcome after DES is, at present, poorly characterized. Patients who are acceptable candidates for CABG are extremely challenging to consent. Usually these patients request stenting instead of bypass surgery, with varying degrees of conviction. It is important to spend considerable time with this patient group, going over the DES procedure and its potential risks and benefits in comparison with CABG. Ad-hoc stenting (46), wherein the patient gives consent while remaining on the catheterization table after the diagnostic examination, should be avoided. The importance of the UPLM artery should be graphically described to the patient. It is helpful to use an analogy, such as "the trunk of the tree," to visually emphasize the importance of this lesion’s location. It is critical to make it very clear to the patient that UPLM stenting is not currently considered the standard-of-care by practice society guidelines and that the dataset we have regarding midterm and long-term outcomes is limited. It is often helpful to have a cardiovascular surgeon speak independently with the patient, as well as another cardiologist who is not an interventionalist. However, it is worth noting that having multiple physicians provide multiple opinions to a patient can also confuse some patients, upsetting them and making the decision process more difficult. The requirement for routine follow-up surveillance angiography must be explained and agreed to by the patient. Although some physicians do not believe routine surveillance angiography is warranted after UPLM stenting, this author strongly believes that follow-up angiography at 3 to 9 months is important, particularly in light of the limited data we have concerning late outcomes. Surveillance angiography after UPLM stenting is currently an ACC/AHA/SCAI Practice Guideline Class IIa (meaning it is favored) Recommendation (43).

One UPLM patient subgroup in whom DES might wisely be avoided are patients who have heavily calcified left main, ostial LAD, and/or circumflex coronary arteries and are otherwise good candidates for bypass surgery. These lesions are particularly challenging for percutaneous intervention and should be avoided even if a patient insists on DES. Finally, it should be noted that patients receiving DES for UPLM must be able to take dual antiplatelet therapy for a minimum of 12 months per current ACC/AHA/SCAI Practice Guidelines for DES (43). If possible, a longer duration of antiplatelet therapy may be advantageous.


   Operator Technique
Top
 Abstract
 Early Clinical Results of...
 Patient Selection
 Operator Technique
Conclusions
 REFERENCES
 
Left main ostial and midshaft lesions.   Although ostial and midshaft left main vessel lesions are technically straightforward, there are some procedural caveats. Pre- and post-procedural IVUS is helpful for judging the degree of calcification, stent diameter selection, final stent expansion, and stent apposition, and for confirming the absence of stent edge dissection. In the U.S., the currently available SES can be expanded to 4.75 mm and the PES can be expanded to 4.25 mm. An intra-aortic balloon pump is rarely needed for ostial and midshaft lesions, but should be considered in patients who present with relative hypotension (i.e., systolic blood pressure <110 mm Hg), poor left ventricular function, and/or a totally occluded right coronary artery. Platelet glycoprotein IIb/IIIa inhibition should also be considered. Occasionally, a patient will have an extremely large diameter left main coronary vessel that is >4.75 mm. In these patients, in whom a DES of the necessary size is not available, consideration can be given to implanting a large-diameter bare-metal stent. There are no data describing the outcome after large-diameter bare-metal stents in UPLM lesions. However, in other native vessel lesion locations, large-diameter bare-metal stents are associated with low restenosis rates. As with DES, surveillance angiography of a bare-metal stent is also extremely important.

Distal left main bifurcation involvement.   Patients with distal left main disease involving the ostium of the LAD and/or circumflex artery are the most technically difficult to treat with stents. These patients often have significant coronary disease downstream from the left main vessel, which should be taken into consideration when making a decision between DES and CABG. When approaching these patients with DES, it is helpful to stent all of the downstream lesions first because stenting the left main vessel may make accessing the downstream lesions more difficult. In these patients, one should have a lower threshold for using an intra-aortic balloon pump, particularly if the systolic blood pressure is <110 mm Hg, the right coronary artery is occluded, left ventricular function is impaired, or the left main, LAD, and/or circumflex artery are significantly calcified. Heavily calcified UPLM arteries may require pre-treatment with rotational atherectomy, which increases procedural risk. These factors increase procedural risk and reduce long-term success and must be taken into consideration during the patient selection process.

From the available registry data, it seems that restenosis and repeat revascularization rates are profoundly lower if only 1 stent is used when treating the distal left main bifurcation (18–40). Provided the risk of closing the side branch is low, the currently favored technique is the provisional approach of stenting across the distal bifurcation, usually into the LAD. Often, the circumflex must be pre-dilated to avoid plaque shift and vessel shutdown with stent deployment. After stenting across the branch vessel, the branch will usually need to be rescued by recrossing with a guidewire and performing simultaneous kissing balloon inflation in both the stent and the branch vessel. Most interventionalists will perform a final kissing inflation even if the branch ostium is not compromised after stent implantation to widen the stent struts that cross the large branch vessel. Rarely, the ostium to the circumflex artery is heavily diseased with minimal disease of the LAD ostium, necessitating crossing over the LAD and stenting from the left main into the circumflex artery.

Deploying 2 stents in the distal left main vessel should be undertaken only when the operator strongly believes that the probability of acute closure of one of the branches is very high (i.e., the lesion shown in Figure 3). Faced with this situation, any 1 of the well-described double stent techniques (i.e., a double barrel, crush, T-stent, or modified T-stenting with intentional protrusion of the side-branch stent within the main vessel stent—TAP stenting) can be used (47–59). When double stents are used, a final simultaneous inflation of both stents (kissing balloon inflation) at high pressure (>16 atm) with noncompliant balloons is considered critical to optimize outcomes. Whatever technique is chosen, a final examination using IVUS should be performed to ensure adequate stent expansion, complete stent strut apposition to the vessel wall, and absence of peri-stent dissection.

Surveillance angiography.   Although controversial, this author believes 3- to 9-month surveillance angiography is important to rule out the possibility of restenosis presenting as sudden death. Although presently unproven, noninvasive surveillance with CT angiography may have a future role for the follow-up of UPLM stents. Unfortunately, routine surveillance angiography is likely to result in a higher rate of TVR; however, it seems prudent in light of our limited data regarding late mortality in this patient subgroup. When performing surveillance angiography, 1 caveat is to be aware of the potential for pseudostenosis at the ostium of the left circumflex artery. In patients treated with double stenting of a distal left main bifurcation, we and others have occasionally observed the angiographic appearance of a high-grade ostial circumflex stenosis that is not present when assessed with IVUS. This is likely because of the quantity of metal at the bifurcation, perhaps coupled with eccentric stent expansion (Fig. 6). It is important to use IVUS to rule out a pseudostenosis in this location and to avoid unnecessary repeat intervention, particularly in asymptomatic patients undergoing surveillance angiography.


Figure 6
View larger version (71K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 6 Bifurcation Stenting of a UPLM 5 Months Earlier

Follow-up angiography (left), when viewed in the left anterior oblique and caudal projection, showed the appearance of an important stenosis at the circumflex ostium. However, intravascular ultrasound (right) showed no important stenosis and no neointimal hyperplasia, but instead, an eccentrically expanded stent (arrows). The patient was asymptomatic with a fractional flow reserve after intracoronary adenosine of 0.92. This pseudostenosis in this asymptomatic patient was not treated. Image courtesy of Dr. Antonio Columbo, not previously published. UPLM = unprotected left main coronary artery.

 
When true in-stent restenosis of the unprotected left main vessel is observed at follow-up angiography, the results should be discussed with the patient in detail. If the patient is a candidate for CABG, the potential benefits and risks of CABG therapy versus percutaneous intervention should be once again explained. Usually left main in-stent restenosis is treated with repeat balloon angioplasty; stents are only added if the restenosis occurs at a stent margin. If repeat intervention is undertaken, further surveillance angiography is strongly recommended.

The future.   At present, UPLM DES is controversial because there is so little scientific evidence to support it. Over the next several years, results of randomized trials comparing DES to CABG in this patient subset will become available. The SYNTAX (SYNergy Between Percutaneous Coronary Intervention With TAXus and Cardiac Surgery) trial has completed enrollment, and results should be available over the next 1 to 2 years. This large, randomized trial of surgery versus DES in patients with UPLM and/or 3-vessel disease has a pre-specified UPLM subgroup containing 710 randomized patients (60). This trial, along with other randomized trials, should provide important information, particularly with respect to comparative late mortality and the need for future revascularization. It will be important to analyze the results of these trials in the context of the lesion subtype (i.e., ostial, midshaft, and distal location) and the procedural stenting techniques used.

It should be noted that current DES technology has not been directed at UPLM intervention. If evidence accumulates indicating that this patient subgroup benefits from DES, dedicated UPLM DES technology will likely be developed. We are especially in need of a dedicated bifurcation DES stent with the dimensional requirements suited to the UPLM. For ostial and midshaft lesions, we are in need of a larger-diameter DES as well as a shorter-length DES, consistent with the dimensions of this vessel.


   Conclusions
Top
 Abstract
 Early Clinical Results of...
 Patient Selection
 Operator Technique
 Conclusions
REFERENCES
 
Although DES for UPLM is currently a class III indication in patients who are candidates for CABG, many patients are currently undergoing this procedure. Published registries indicate the procedural and in-hospital risks are acceptable and probably the same or lower than the procedural risks of CABG. Unprotected left main ostial and midshaft lesions have excellent early and midterm outcomes that will likely (although yet unproven) be similar to those of CABG. Distal left main vessel lesions involving the bifurcation are technically more challenging and are associated with a higher rate of late revascularization. Surveillance angiography of patients undergoing UPLM DES, although not universally advocated, seems to be a reasonable method of minimizing the chance of a restenosis presenting as sudden death. There are many technical caveats to UPLM stenting. Improved technology, especially dedicated left main bifurcation stents, are needed. Early registry data have not found excess mortality in patients receiving DES for UPLM when compared with historical bypass surgery data. However, as yet, we have only early, 6-month to 1-year, follow-up of registry patients, and randomized trial results are not available. Over the next 1 to 2 years, the results of randomized trials will likely inform and transform the treatment of this important patient group.


   Footnotes
 
1 Dr. Teirstein is a consultant for Cordis, Boston Scientific, Abbott, Medtronic, and Conor; receives royalties (not on drug-eluting stents) from Boston Scientific; and owns equity in MediVas. Back

* Reprint requests and correspondence: Dr. Paul S. Teirstein, Scripps Clinic, 10666 North Torrey Pines Road, La Jolla, California 92037. (Email: pteirstein{at}scrippsclinic.com).

Manuscript received November 16, 2007; revised manuscript received November 28, 2007, accepted December 3, 2007.


   REFERENCES
Top
 Abstract
 Early Clinical Results of...
 Patient Selection
 Operator Technique
 Conclusions
 REFERENCES
 

  1. Chaitman BR, Fisher LD, Bourassa MG, et al. Effect of coronary bypass surgery on survival patterns in subsets of patients with left main coronary artery disease. Report of the Collaborative Study in Coronary Artery Surgery (CASS). Am J Cardiol 1981;48:765-777.[CrossRef][Web of Science][Medline]
  2. Caracciolo EA, Davis KB, Sopko G, et al. Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease. Long-term CASS experience. Circulation 1995;91:2335-2344.[Abstract/Free Full Text]
  3. Coles JC, Goldbach MM, Ahmed SN, Wells GA, Mehta HV. Left main-stem coronary artery disease: surgical versus medical management Can J Surg 1984;27:571-573.[Web of Science][Medline]
  4. O’Keefe Jr. JH, Hartzler GO, Rutherford BD, et al. Left main coronary angioplasty: early and late results of 127 acute and elective procedures Am J Cardiol 1989;64:144-147.[CrossRef][Web of Science][Medline]
  5. Stertzer SH, Myler RK, Insel H, Wallsh E, Rossi P. Percutaneous transluminal coronary angioplasty in left main stem coronary stenosis: a five-year appraisal Int J Cardiol 1985;9:149-159.[CrossRef][Web of Science][Medline]
  6. Tommaso CL, Vogel JH, Vogel RA. Coronary angioplasty in high-risk patients with left main coronary stenosis: results from the National Registry of Elective Supported Angioplasty Cathet Cardiovasc Diagn 1992;25:169-173.[Web of Science][Medline]
  7. Takagi T, Stankovic G, Finci L, et al. Results and long-term predictors of adverse clinical events after elective percutaneous interventions on unprotected left main coronary artery Circulation 2002;106:698-702.[Abstract/Free Full Text]
  8. Park SJ, Hong MK, Lee CW, et al. Elective stenting of unprotected left main coronary artery stenosis: effect of debulking before stenting and intravascular ultrasound guidance J Am Coll Cardiol 2001;38:1054-1060.[Abstract/Free Full Text]
  9. Silvestri M, Barragan P, Sainsous J, et al. Unprotected left main coronary artery stenting: immediate and medium-term outcomes of 140 elective procedures J Am Coll Cardiol 2000;35:1543-1550.[Abstract/Free Full Text]
  10. Lopez JJ, Ho KK, Stoler RC, et al. Percutaneous treatment of protected and unprotected left main coronary stenoses with new devices: immediate angiographic results and intermediate-term follow-up J Am Coll Cardiol 1997;29:345-352.[Abstract]
  11. Black A, Cortina R, Bossi I, Choussat R, Fajadet J, Marco J. Unprotected left main coronary artery stenting: correlates of midterm survival and impact of patient selection J Am Coll Cardiol 2001;37:832-838.[Abstract/Free Full Text]
  12. Tan WA, Tamai H, Park SJ, et al. Long-term clinical outcomes after unprotected left main trunk percutaneous revascularization in 279 patients Circulation 2001;104:1609-1614.[Abstract/Free Full Text]
  13. Marso SP, Steg G, Plokker T, et al. Catheter-based reperfusion of unprotected left main stenosis during an acute myocardial infarction (the ULTIMA experience). Unprotected Left Main Trunk Intervention Multi-center Assessment. Am J Cardiol 1999;83:1513-1517.[CrossRef][Web of Science][Medline]
  14. Colombo A, Drzewiecki J, Banning A, et al. Randomized study to assess the effectiveness of slow- and moderate-release polymer-based paclitaxel-eluting stents for coronary artery lesions Circulation 2003;108:788-794.[Abstract/Free Full Text]
  15. Moses JW, Leon MB, Popma JJ, et al. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery N Engl J Med 2003;349:1315-1323.[CrossRef][Web of Science][Medline]
  16. Stone GW, Ellis SG, Cox DA, et al. A polymer-based, paclitaxel-eluting stent in patients with coronary artery disease N Engl J Med 2004;350:221-231.[CrossRef][Web of Science][Medline]
  17. Morice MC, Serruys PW, Sousa JE, et al. Randomized study with the sirolimus-coated Bx velocity balloon-expandable stent in the treatment of patients with de novo native coronary artery lesions. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med 2002;346:1773-1780.[CrossRef][Web of Science][Medline]
  18. Agostoni P, Valgimigli M, Van Mieghem CA, et al. Comparison of early outcome of percutaneous coronary intervention for unprotected left main coronary artery disease in the drug-eluting stent era with versus without intravascular ultrasonic guidance Am J Cardiol 2005;95:644-647.[CrossRef][Web of Science][Medline]
  19. Chieffo A, Stankovic G, Bonizzoni E, et al. Early and midterm results of drug-eluting tent implantation in unprotected left main Circulation 2005;111:791-795.[Abstract/Free Full Text]
  20. Park SJ, Kim YH, Lee BK, et al. Sirolimus-eluting stent implantation for unprotected left main coronary artery stenosis: comparison with bare metal stent implantation J Am Coll Cardiol 2005;45:351-356.[Abstract/Free Full Text]
  21. Carrie D, Lhermusier T, Hmem M, et al. Clinical and angiographic outcome of paclitaxel-eluting stent implantation for unprotected left main coronary artery bifurcation narrowing EuroIntervention 2006;1:396-402.
  22. Chieffo A, Morici N, Maisano F, et al. Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience Circulation 2006;113:2542-2547.[Abstract/Free Full Text]
  23. Christiansen EH, Lassen JF, Andersen HR. Outcome of unprotected left main percutaneous coronary intervention in surgical low-risk, surgical high-risk, and acute myocardial infarction patients EuroIntervention 2006;1:403-408.
  24. de Lezo JS, Medina A, Pan M, et al. Rapamycin-eluting stents for the treatment of unprotected left main coronary disease Am Heart J 2004;148:481-485.[CrossRef][Web of Science][Medline]
  25. Dudek D, Heba G, Giszterowicz D, et al. Stenting of unprotected left main coronary artery in patients with low preoperative risk of coronary artery bypass grafting Kardiol Pol 2006;64:929-936.[Medline]
  26. Han YL, Wang SL, Jin QM, et al. Efficacy of stenting for unprotected left main coronary artery disease in 297 patients Chin Med J (Engl) 2006;119:544-550.[Medline]
  27. Lee SH, Ko YG, Jang Y, et al. Sirolimus- versus paclitaxel-eluting stent implantation for unprotected left main coronary artery stenosis Cardiology 2005;104:181-185.[CrossRef][Web of Science][Medline]
  28. Lee MS, Kapoor N, Jamal F, et al. Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease J Am Coll Cardiol 2006;47:864-870.[Abstract/Free Full Text]
  29. Lozano I, Herrera C, Morís C, et al. Drug-eluting stents in patients with left main coronary lesions who are not candidates for surgical revascularization Rev Esp Cardiol 2005;58:145-152.[CrossRef][Web of Science][Medline]
  30. Migliorini A, Moschi G, Giurlani L, et al. Drug-eluting stent supported percutaneous coronary intervention for unprotected left main disease Catheter Cardiovasc Interv 2006;68:225-230.[CrossRef][Web of Science][Medline]
  31. Palmerini T, Marzocchi A, Marrozzini C, et al. Comparison between coronary angioplasty and coronary artery bypass surgery for the treatment of unprotected left main coronary artery stenosis (the Bologna Registry) Am J Cardiol 2006;98:54-59.[CrossRef][Web of Science][Medline]
  32. Price MJ, Cristea E, Sawhney N, et al. Serial angiographic follow-up of sirolimus-eluting stents for unprotected left main coronary artery revascularization J Am Coll Cardiol 2006;47:871-877.[Abstract/Free Full Text]
  33. Sheiban I, Meliga E, Moretti C, et al. Sirolimus-eluting stents vs. bare metal stents for the treatment of unprotected left main coronary artery stenosis EuroIntervention 2006;2:356-362.
  34. Wood F, Bazemore E, Schneider JE, Jobe RL, Mann T. Technique of left main stenting is dependent on lesion location and distal branch protection Catheter Cardiovasc Interv 2005;65:499-503.[CrossRef][Web of Science][Medline]
  35. Chieffo A, Park SJ, Valgimigli M, et al. Favorable long-term outcome after drug-eluting stent implantation in nonbifurcation lesions that involve unprotected left main coronary artery: a multicenter registry Circulation 2007;116:158-162.[Abstract/Free Full Text]
  36. Ruygrok PN, Melkert R, Morel MA, et al. Does angiography six months after coronary intervention influence management and outcome?. Benestent II Investigators. J Am Coll Cardiol 1999;34:1507-1511.[Abstract/Free Full Text]
  37. Valgimigli M, van Mieghem CA, Ong AT, et al. Short- and long-term clinical outcome after drug-eluting stent implantation for the percutaneous treatment of left main coronary artery disease: insights from the Rapamycin-Eluting and Taxus Stent Evaluated At Rotterdam Cardiology Hospital registries (RESEARCH and T-SEARCH) Circulation 2005;111:1383-1389.[Abstract/Free Full Text]
  38. Erglis A, Narbute I, Kumsars I, et al. A randomized comparison of paclitaxel-eluting stents versus bare-metal stents for treatment of unprotected left main coronary artery stenosis J Am Coll Cardiol 2007;50:491-497.[Abstract/Free Full Text]
  39. Baim DS, Mauri L, Cutlip DC. Drug-eluting stenting for unprotected left main coronary artery disease: are we ready to replace bypass surgery? J Am Coll Cardiol 2006;47:878-881.[Free Full Text]
  40. Biondi-Zoccai GGL, Lotrionte M, Moretti C, et al. A collaborative systematic review and meta-analysis on 1278 patients undergoing percutaneous drug-eluting stenting for unprotected left main coronary artery disease Am Heart J 2008;155:274-283.[CrossRef][Medline]
  41. Nashef SA, Roques F, Michel P, et al. European system for cardiac operative risk evaluation (EuroSCORE) Eur J Cardiothorac Surg 1999;16:9-13.[Abstract/Free Full Text]
  42. Parsonnet V, Dean D, Bernstein AD. A method of uniform stratification of risk for evaluating the results of surgery in acquired adult heart disease Circulation 1989;79:I3-I12.[Medline]
  43. Smith Jr. SC, Feldman TE, Hirshfeld Jr. JW, et al. ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention) J Am Coll Cardiol 2006;47:216-235.[Free Full Text]
  44. Sano K, Mintz GS, Carlier SG, et al. Assessing intermediate left main coronary lesions using intravascular ultrasound Am Heart J 2007;154:983-988.[CrossRef][Web of Science][Medline]
  45. Fassa AA, Wagatsuma K, Higano ST, et al. Intravascular ultrasound-guided treatment for angiographically indeterminate left main coronary artery disease: a long-term follow-up study J Am Coll Cardiol 2005;45:204-211.[Abstract/Free Full Text]
  46. O’Keefe Jr. JH, Reeder GS, Miller GA, Bailey KR, Holmes Jr. DR. Safety and efficacy of percutaneous transluminal coronary angioplasty performed at time of diagnostic catheterization compared with that performed at other times Am J Cardiol 1989;63:27-29.[CrossRef][Web of Science][Medline]
  47. Melikian N, Airoldi F, Di Mario C. Coronary bifurcation stenting. Current techniques, outcome and possible future developments. Minerva Cardioangiol 2004;52:365-378.[Medline]
  48. Colombo A, Tsuchida K, Lefevre T, et al. Efficacy of sirolimus-eluting stent in the treatment of patients with bifurcation lesions in multivessel coronary artery disease: a substudy of the ARTS II Trial (abstr) Circulation 2005;112(Suppl II):421.
  49. Iakovou I, Ge L, Colombo A. Contemporary stent treatment of coronary bifurcations J Am Coll Cardiol 2005;46:1446-1455.[Abstract/Free Full Text]
  50. Colombo A, Moses JW, Morice MC, et al. Randomized study to evaluate sirolimus-eluting stents implanted at coronary bifurcation lesions Circulation 2004;109:1244-1249.[Abstract/Free Full Text]
  51. Pan M, de Lezo JS, Medina A, et al. Rapamycin-eluting stents for the treatment of bifurcated coronary lesions: a randomized comparison of a simple versus complex strategy Am Heart J 2004;148:857-864.[CrossRef][Web of Science][Medline]
  52. Colombo A, Stankovic G, Orlic D, et al. Modified T-stenting technique with crushing for bifurcation lesions: immediate results and 30-day outcome Catheter Cardiovasc Interv 2003;60:145-151.[CrossRef][Web of Science][Medline]
  53. Colombo A. Bifurcational lesions and the "crush" technique: understanding why it works and why it doesn’t—a kiss is not just a kiss Catheter Cardiovasc Interv 2004;63:337-338.[CrossRef][Web of Science][Medline]
  54. Ge L, Airoldi F, Iakovou I, et al. Clinical and angiographic outcome after implantation of drug-eluting stents in bifurcation lesions with the crush stent technique: importance of final kissing balloon post-dilation J Am Coll Cardiol 2005;46:613-620.[Abstract/Free Full Text]
  55. Ge L, Iakovou I, Cosgrave J, et al. Treatment of bifurcation lesions with two stents: one year angiographic and clinical follow up of crush versus T stenting Heart 2006;92:371-376.[Abstract/Free Full Text]
  56. Hoye A, Iakovou I, Ge L, et al. Long-term outcomes after stenting of bifurcation lesions with the "crush" technique: predictors of an adverse outcome J Am Coll Cardiol 2006;47:1949-1958.[Abstract/Free Full Text]
  57. Moussa I, Costa RA, Leon MB, et al. A prospective registry to evaluate sirolimus-eluting stents implanted at coronary bifurcation lesions using the "crush technique." Am J Cardiol 2006;97:1317-1321.[CrossRef][Web of Science][Medline]
  58. Steigen TK, Maeng M, Wiseth R, et al. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study Circulation 2006;114:1955-1961.[Abstract/Free Full Text]
  59. Burzotta F, Gwon HC, Hahn JY, et al. Modified T-stenting with intentional protrusion of the side-branch stent within the main vessel stent to ensure ostial coverage and facilitate final kissing balloon: the T-stenting and small protrusion technique (TAP-stenting). Report of bench testing and first clinical Italian-Korean two-centre experience. Catheter Cardiovasc Interv 2007;70:75-82.[CrossRef][Web of Science][Medline]
  60. Ong AT, Serruys PW, Mohr FW, et al. The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) study: design, rationale, and run-in phase Am Heart J 2006;151:1194-1204.[CrossRef][Web of Science][Medline]



This article has been cited by other articles:


Home page
 J Am Coll CardiolHome page
S. R. Dixon, C. L. Grines, and W. W. O'Neill
The Year in Interventional Cardiology
J. Am. Coll. Cardiol., June 2, 2009; 53(22): 2080 - 2097.
[Full Text] [PDF]

Home page
 J Am Coll Cardiol IntvHome page
A. C. Weustink, A. F.L. Schinkel, M. van der Ent, and P. J. de Feyter
Pre-Procedural Dual Source 64-Slice Computed Tomography in Unprotected Left Main Intervention
J. Am. Coll. Cardiol. Intv., May 1, 2009; 2(5): 470 - 471.
[Full Text] [PDF]

Home page
 CirculationHome page
P. S. Teirstein
Percutaneous Revascularization Is the Preferred Strategy for Patients With Significant Left Main Coronary Stenosis
Circulation, February 24, 2009; 119(7): 1021 - 1033.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Teirstein, P. S.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Teirstein, P. S.

Advertisement
 
   
Home
Current Issue
Search
Past Issues
Topic Collections
Cardiology Careers
  © 2008 American College of Cardiology Foundation
home link current link search link archive link topics link cardiology careers link