Percutaneous Left Main Coronary Intervention: A Review of Plaque Modification in Left Main Percutaneous Coronary Intervention.

Chirag Shah,Steven Pfau

doi:10.3390/jcm7070180

Abstract

Left main coronary artery (LMCA) stenosis has long been recognized as a marker of increased morbidity and mortality. Current treatment algorithms for LMCA stenosis consider both percutaneous coronary intervention (PCI) with drug eluting stents (DES) and coronary bypass surgery, each with advantages based on individual patient characteristics. Since the LMCA is the largest artery in the coronary tree, plaque volume and calcification is greater than other coronary segments and often extends to the distal bifurcation segment. In LMCA bifurcation lesions, larger minimal stent area is strongly associated with better outcome in the DES era. Plaque modification strategies such as rotational, orbital, or laser atherectomy are effective mechanisms to reduce plaque volume and alter compliance, facilitating stent delivery and stent expansion. We present a case of a calcified, medina class 1,1,1 LMCA lesion where intravascular ultrasound (IVUS) and orbital atherectomy were employed for optimal results. In this context, we review the evidence of plaque modification devices and the rationale for their use in unprotected left main PCI.

Highlights

Stenosis of the left main coronary artery (LMCA) is associated with increased morbidity and mortality in patients with coronary artery disease, when compared to elsewhere in the coronary tree [1]
With experience, improved stent technology, and important randomized trials, outcomes of percutaneous coronary intervention (PCI) with second generation drug-eluting stents (DES) may be similar to surgery in many patients, and PCI is the preferred strategy in patients with increased surgical risk [3,4,5,6,7,8,9,10]
Durable clinical success in unprotected left main (UPLM) PCI is dependent on a number of procedural factors

Summary

Introduction

Stenosis of the left main coronary artery (LMCA) is associated with increased morbidity and mortality in patients with coronary artery disease, when compared to elsewhere in the coronary tree [1]. A recent meta-analysis, which examined 4499 subjects from 5 randomized studies (EXCEL, NOBLE, LE MANS, SYNTAX, and PRECOMBAT) suggested no difference between PCI and CABG for the treatment of UPLM disease for the composite endpoints of death, stroke, and MI (OR of 1.03, 95% CI 0.81–1.32, p-value of 0.81) [24]. While these trials enrolled patients with acceptable surgical risk, in patients with excess surgical risk, such as the case presented here, clearly UPLM PCI would be the preferred revascularization strategy

Technical Considerations

Achieving

Atherectomy in UPLM PCI

Post-PCI

Findings

Conclusions