Stent Area by Intravascular Ultrasound and Outcomes in Left Main Intervention With Drug-Eluting Stents

Abstract

While the standard revascularization for left main lesions traditionally has been surgical coronary artery bypass grafting, increasingly studies suggest that percutaneous coronary intervention (PCI) with drug-eluting stents (DES) may be an acceptable alternative to surgery for selected patients. In total, the current evidence suggests that rates of death, myocardial infarction, and stroke may be similar between patients managed with PCI and coronary artery bypass grafting, but revascularization occurs less frequently in patients undergoing surgery. This was illustrated in the recently published randomized PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease) trial, where the 2-year risk of death, myocardial infarction, or stroke was similar (hazard ratio: 0.92; 95% confidence interval (CI), 0.43 to 1.96; P =0.83) in patients with unprotected left main disease managed with PCI using DES (N=300) and coronary artery bypass grafting (N=300), but revascularizations were more common in patients undergoing PCI (hazard ratio: 2.18; 95% CI, 1.10–4.32; P =0.02).1 A recent meta-analyses of 1611patients from 4 randomized trials comparing PCI with coronary artery bypass grafting for unprotected left main lesions found similar results.2 Article see p 562 Given the significant consequences associated with stent thrombosis and restenosis in the left main, intravascular ultrasound (IVUS) guidance has been advocated to optimize stent deployment in this important lesion subset. Increasing evidence suggests that IVUS-guidance reduces adverse events in PCI with DES in various clinical settings.3,4 This likely relates to the preintervention assessment of appropriate stent size and interventional strategy, as well as the postintervention detection and correction of suboptimal stent deployment, such as dissections, underexpansion, geographic miss, plaque/tissue prolapse, and incomplete stent apposition. Of these, stent underexpansion most consistently has been associated with adverse events in nonleft main PCI with DES.5 …