Late drug-eluting stent thrombosis in unprotected left main coronary artery lesions--sometimes possible, but rarely definite or probable

Abstract

Beyond relieving angina, revascularization strategies for coronary artery disease (CAD) have focused on the subsequent occurrence of death, myocardial infarction, repeat revascularization, and, more recently, stent thrombosis. Numerous trials comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) have shown the long-term rates of death and myocardial infarction to be similar between these strategies, largely independently of the extent and location of CAD.1,2 The main outcome gap between percutaneous and surgical approaches has been the higher rate of repeat revascularization procedures for those initially undergoing PCI. At 5-year follow-up in the Bypass Angioplasty Revascularization Investigation (BARI) trial,1 54% of patients initially undergoing multivessel balloon angioplasty required a repeat procedure vs. 8% among those assigned to bypass surgery. With the introduction of bare-metal stents (BMS), this gap between PCI and CABG was narrowed. The 5-year follow-up from the Arterial Revascularization Therapies Study (ARTS) trial2 demonstrated the need for repeat target vessel revascularization (TVR) for those undergoing multivessel stent placements vs. CABG to be 30 and 9%, respectively. Most recently, drug-eluting stents (DES) have reshaped the landscape of interventional cardiology by substantially reducing rates of restenosis, and this intuitively should narrow the repeat TVR gap between PCI and bypass surgery further. In particular, the 5-year data from randomized trials comparing BMS and DES3,4 have shown TVR rates to be additionally reduced by one-half to two-thirds with DES, such that the ∼10–15% need for repeat revascularization for the DES cohort at long-term follow-up should be nearing that associated with bypass surgery. Several important CAD subsets, such as chronic total occlusions, complex bifurcation lesions, and stenoses of unprotected left main coronary arteries (ULMCAD), have been considered unattractive or ‘verboten’ for PCI, but are being increasingly considered with the availability of DES. Large-scale trials comparing … *Corresponding author. Tel: +1 859 323 5843, Fax: +1 859 257 3537, Email: Moliterno{at}uky.edu