Left Main Coronary Artery Stenting Research Articles

Long-Term Results of Stenting in Patients with Hemodynamically Significant Lesions of the Left Main Coronary Artery

The aim. To study the long-term results of stenting in patients with coronary artery disease with hemodynamically significant left main coronary artery (LMCA) stenoses.
 Materials and methods. The study included 67 patients (56 men, 11 women) with a mean age of 63 ± 2.1 years.
 Results. Among the 67 patients included in the study, 29 patients (43.3%) underwent percutaneous coronary inter-vention using a single-stent technique. These were patients with ostial LMCA lesions, lesions of the middle third of the LMCA and some patients with Medina 1.1.0; 1.0.1; 1.0.0; 0.1.0; 0.0.1 lesions of the distal part of the LMCA. The median follow-up was 2 years. Using a questionnaire, we managed to establish contact with 25 patients (86.2%). Among these, 1 patient (3.4%) died of non-cardiac causes and 7 patients (24.1%) had a recurrence of angina within 2 years. The causes of angina recurrence in 2 cases (6.9%) were restenosis in the stent with transition to the mouth of the side branch, which required repeated stenting of the LMCA with transition to the left circumflex artery. In 5 patients (17.2%), angina recur-rence was associated with progression of coronary atherosclerosis of another localization.
 Among 67 patients with LMCA stenting, the two-stent technique was used in 38 patients (56.7%). These were pa-tients with Medina 1.1.0; 1.0.1; 1.0.0; 0.1.0; 0.0.1 lesions of the distal part of the LMCA. The median follow-up was 2 years. Using a questionnaire, we managed to contact 35 patients (92.1%). Among these, 4 patients (10.5%) died, but only one of them due to cardiac causes (2.6%), and 3 patients (7.9%) had recurrent angina within 2 years, two of whom underwent stenting by the T and protrusion (TAP) technique and one by culotte. The first two patients underwent angioplasty of restenosis in stents using balloons with a therapeutic coating. In the last patient, stent recoil in the left circumflex artery mouth was observed due to severe calcification, so this patient underwent re-implantation of the stent system in the recoil zone.
 Conclusions. The problem of choosing a method of revascularization for patients with hemodynamically significant LMCA lesions remains controversial to this day, despite the wide range of evidence. Doctors should jointly decide on the choice of treatment methodology solely in the interests of the patient, taking into account all the factors that may affect the patient’s quality of life in the long term.

The Evaluation of Stent Patency Using Computed Angiography Following Left Main Coronary Artery Stenting

The increased chances of in-stent restenosis have led to repeated coronary angiography and left main percutaneous coronary intervention. However, for the evaluation of coronary arteries, computed tomography angiography (CTA) is regarded as a non-invasive intervention. Objectives: To evaluate the proportion of in-stent restenosis in the left main PCI and to determine the diagnostic efficacy of CTA in detecting in-stent restenosis. Methods: We conducted this study from June 2021 to July 2022. 130 patients were chosen for the study among the 300 LM PCI patients. The CTA was conducted 3 months after the LM PCI. The data were collected and entered into the SPSS software and the descriptive analysis was conducted. Results: In our study, the majority of the patients (n=92, 70.8%) of the patients undergoing PCI from the LM to LAD, and the number of patients who went from LM to LCX was 19 patients (14.6%). Only 14.6% of the patients in our study had bifurcation PCI and all 130 (100%) patients had DES. The average period for the development of ISD was 11 months. Conclusions: CTA is quite efficient in accurately assessing the selected patients who have undergone LM PCI and CTA can be utilized as the 1" line treatment modality.

Transcatheter aortic valve replacement using the two-step inflation technique and the kissing-balloon technique for a patient with a protruding stent in the left main coronary artery: a case report

Abstract Background When performing transcatheter aortic valve replacement (TAVR) for a patient with a protruding stent in the coronary arteries, there is a risk of stent deformation and coronary occlusion. However, safe and optimal methods have not been established. Case summary An 87-year-old woman with a protruding stent in the left main coronary artery (LMCA) underwent TAVR. The two-step inflation and kissing-balloon techniques were performed to optimize the transcatheter heart valve (THV) and to avoid LMCA stent deformation. The THV was implemented with minimal aortic regurgitation and no deformation of the stent in the LMCA. Discussion This was the first case report of TAVR, performed in a patient with a protruding stent in the coronary arteries, using the kissing-balloon technique and the two-step inflation technique. The combination of these two techniques was the optimal method for THV implantation without stent deformation in coronary arteries.

Multi-Slice Computed Angiography for The Evaluation of Stent Patency After Left Main Coronary Artery Stenting

Due to the high frequency of in-stent restenosis, repeat coronary angiography and left main percutaneous coronary intervention is recommended. But Computed Tomography Angiography is a noninvasive procedure for evaluating coronary arteries. Objectives: To assess the proportion of InStent restenosis in left main per-Cutaneous coronary intervention and to evaluate diagnostic efficacy of Computed Tomography Angiography in detecting In stent Restenosis. Methods: We assessed 263 consecutive LM PCI patients; 130 patients were chosen for this study procedure as they meet our criteria. CTA was conducted three months following the LM PCI. Results: The vast majority of patients (73.8 %) had PCI from LM to LAD and 16.2 % from LM to LCX. Only 10% of patients had bifurcation PCI, and all patients had DES (100%). The average period for ISR development was 125 months, with ISR rates of 32.2 % in the LM to LAD cohort and 38 % in the LM to LCX cohort. The median time between PCI and CTA was 194 days, with a mean basal heart rate of 69 ± 12 beats per minute. CTA exhibited a positive predictive value of 84.7%. Conclusion: CTA enables an accurate noninvasive assessment of selected patients following LM PCI. And CTA can be used as a first-line treatment instead of coronary angiography.

Value of Intravascular Ultrasound Guidance in Patients Undergoing Unprotected Left Main Coronary Artery Stenting

Value of Intravascular Ultrasound Guidance in Patients Undergoing Unprotected Left Main Coronary Artery Stenting

Short and Intermediate Term Clinical Outcomes of Patients with Unprotected Left Main Coronary Artery Stenting

Short and Intermediate Term Clinical Outcomes of Patients with Unprotected Left Main Coronary Artery Stenting

Provisional Versus Dual Stenting of Left Main Coronary Artery Bifurcation Lesions (from a Comprehensive Meta-Analysis)

The optimal technique for bifurcation of left main coronary artery (LMCA) stenting has been a subject of controversy since the inception of drug-eluting stents. We searched PubMed, Clinical Trials Registry, and the Cochrane Central Register of Controlled Trials from January 2002 through October 2021. A total of 13 studies comparing the use of provisional versus dual stenting in patients with LMCA bifurcation lesions were included. Any major adverse cardiac event (MACE) was considered the primary composite end point. The secondary end points included individual components of MACE, including death, myocardial infarction, and target lesion revascularization. The treatment effect was defined as the log odds ratio (OR) of provisional over dual stenting for cumulative event rate at 3 years. In 12 studies with 8,377 patients included for MACE, the use of a provisional-stenting strategy was associated with a significant reduction of 3-year MACE (OR 0.64, 95% confidence interval [CI] 0.46 to 0.88) compared with a dual-stenting strategy, primarily driven by target lesion revascularization (OR 0.51, 95% CI 0.36 to 0.73). No significant difference was found regarding death (OR 0.88; 95% CI 0.65 to 1.21) or myocardial infarction (OR 0.97, 95% Cl 0.61 to 1.54). In conclusion, our meta-analysis suggests that provisional stenting should be the preferred technique over dual stenting when treating LMCA bifurcation lesions with drug-eluting stents. Further randomized controlled studies compounded with intracoronary imaging comparing the 2 strategies are warranted.

Behavior of restenosis after distal unprotected bifurcation left main coronary artery stenting

Behavior of restenosis after distal unprotected bifurcation left main coronary artery stenting

Compression of the left main coronary artery by a pulmonary artery aneurysm – treated with endovascular approach

Pulmonary artery aneurysms (PAAs) are rare with non-specific clinical presentation but may lead to serious complications such as pulmonary artery dissection, rupture and compression of the left main coronary artery (LMCA). Their complications and PAA association with pulmonary hypertension lead to significant morbidity and mortality. The standard treatment strategy is surgical correction of the aneurysm, however percutaneous coronary intervention in patients with clinically significant compression of the LMCA, due to PAA should be considered as a possible treatment approach. In this article, we present a case report of a 73-year-old with polymorbidity, presenting with an acute coronary syndrome, caused by extrinsic compression of the LMCA by PAA. Due to the high surgical risk, we adopted an endovascular approach with stenting of the compressed LMCA with successful restoration of the blood flow and clinical stabilization. In this case, a percutaneous coronary intervention proved to be a safe and effective treatment option for selected patients, who are at high operative risk. 

P201 PURSUING COMPLETENESS OF CORONARY REVASCULARIZATION IN ACUTE SETTING: TIMING AND STRATEGIES

Abstract Patient Presentation A 59 y/o male with history of arterial hypertension and allergic asthma was admitted to our Coronary Care Unit because he went to a spoke emergency department after complaining oppressive and not continuous chest pain for a couple of hours travelling up to the left arm. Increase in cardiac troponin and mild ST–elevation in D3 lead were found. At the spoke cardiology department was treated with intravenous nitrates with relief and Ticagrelor loading dose was administered. He underwent two coronary angiographies, the first one aimed to treat the culprit lesion and the second one to complete revascularization before discharge Management: A heart ultrasound (US) described normal left ventricle ejection fraction (LVEF) with some of the right coronary segments akinesis. The first coronary angiography showed eccentric stenosis (80%) of distal right coronary artery (RCA) with endoluminal thrombosis; intraluminal filling defect of the left main coronary artery (LMCA) which request Optical Coherence Tomography evaluation that showed plaque rupture and red thrombus of LMCA; chronic total occlusion of left anterior descending artery (LAD) with several stenosis up to the apical segments. Glycoprotein IIb/IIIa receptor antagonist infusion was started, and we’ve been forced to treat first the LMCA with drug–eluting stent and then the culprit lesion with angioplasty and two drug–eluting stents complicated by intrastent thrombosis treated with mechanic and rheolytic thrombectomy. Seven days later rotational atherectomy was performed due to LAD artery’s severe calcifications complicated by LMCA intrastent thrombosis caused by stenting crush; cardiopulmonary arrest occurred. Impella ventricular assist device was placed. After LMCA stent optimization, one more drug–eluting stent was placed. Eight days later, heart US described LVEF 37% with apex and right coronary segments hypo–akinesis. Discussion According to latest NSTEMI guidelines, a single stage pursuing of completeness revascularization on multiple vessel disease would have been the best option. In this case, completeness of revascularization hasn’t been achievable due to LMCA plaque rupture. From a technical point of view, considering the complexity of the few days earlier treated LMCA lesion, proximal to LAD lesions we were going to treat, it would have been suitable waiting about four weeks to complete stent endothelization. By the way, it would have been out–guidelines approach.

Eisenmenger syndrome with left main compression syndrome: a case report

BackgroundLeft main coronary artery disease secondary to pulmonary artery compression related to Eisenmenger syndrome is an under-suspected condition that can cause fatal outcomes if left untreated. It presents with typical angina but is frequently mistaken for pulmonary hypertension (PH) symptoms. It is now recognized as one of the few important causes of angina in PH.Case presentationA 37-year-old man with a history of unoperated atrial septal defect and Eisenmenger syndrome came to the outpatient department with a chief complaint of angina on exertion. Electrocardiogram showed regular sinus rhythm with right axis deviation, right ventricular hypertrophy, deep T-wave inversion in inferior and anterior leads suggestive of ischemia or strain, and incomplete right bundle branch block. Cardiac CT showed compression of the left main coronary artery due to a dilated main pulmonary artery. Therefore, this patient was diagnosed with Eisenmenger syndrome with left main compression due to dilated pulmonary artery. He was treated successfully with IVUS-guided stent implantation. The patient experienced marked improvement in regular activities, with no recurrence of angina symptoms. Angiography 3 months after the procedure revealed good patency of the stent, without significant stenosis.ConclusionsLeft main coronary artery compression is a complication that should be suspected in patients with Eisenmenger syndrome presenting with angina symptoms. Non-invasive modalities are recommended for diagnostic evaluation, but the gold-standard technique remains coronary angiography. The best treatment is not well-established, with either myocardial revascularization or PH treatment, but a left main coronary artery stenting procedure is considered an ideal emergent treatment to provide a better quality of life for patients in this condition.

Short- and Long-Term Outcomes of Left Main Coronary Artery Stenting in Patients Disqualified from Coronary Artery Bypass Graft Surgery.

The study aims to evaluate the short- and long-term outcomes of left main percutaneous coronary interventions (LM PCI) in patients disqualified from coronary artery bypass graft surgery (CABG). We included 459 patients (mean age: 68.4 ± 9.4 years, 24.4% females), with at least 1-year follow-up; 396 patients in whom PCI was offered as an alternative to CABG (Group 1); and 63 patients who were disqualified from CABG by the Heart Team (Group 2). The SYNTAX score (29.1 ± 9.5 vs. 23.2 ± 9.7; p < 0.001) and Euroscore II value (2.72 ± 2.01 vs. 2.15 ± 2.16; p = 0.007) were significantly higher and ejection fraction was significantly lower (46% vs. 51.4%; p < 0.001) in Group 2. Patients in Group 2 more often required complex stenting techniques (33.3% vs. 16.2%; p = 0.001). The procedure success rates were very high and did not differ between groups (100% vs. 99.2%; p = 0.882). We observed no difference in periprocedural complication rates (12.7% vs. 7.8%; p = 0.198), but the long-term all-cause mortality rate was higher in Group 2 (26% vs. 21%; p = 0.031). LM PCI in patients disqualified from CABG is an effective and safe procedure with a low in-hospital complication rate. Long-term results are satisfactory.

Fractional flow reserve [FFR] guided stenting of left main coronary artery in acute coronary syndrome: A single centre experience

The present study assesses the clinical outcomes after left main coronary stenting, using clinical evaluation, angiography, and Fractional Flow Reserve (FFR). A prospective observational study was conducted on 72 patients undergoing left main coronary artery (LMCA) stenting, transthoracic echocardiography, coronary angiography, and percutaneous coronary intervention were done and FFR was recorded. At the end of 6 months, follow up check angiography, FFR study were performed. The stent was placed from LMCA to left anterior descending artery (LAD) artery among 45.83% of patients and 9.72% had from LMCA to Left circumflex artery. The mortality rate was 8.33%. The fractional flow reserve was 0.81 on an average ranging from 0.58 to 0.90. Relatively low incidence of major cardiac event was noted among patients with single vessel disease and ostial LMCA disease.

In-stent restenosis and stent thrombosis rates after left main coronary artery stenting

Purpose: The aim of this study was to evaluate the in-stent restenosis (ISR) and stent thrombosis rates along with one-month and one-year survival rates in patients with left main coronary artery disease (LMCAD) with different methods of stenting, lesion characteristics, and clinical disease presentation. Methods: A total of 297 consecutive patients with unprotected LMCAD were treated by percutaneous coronary intervention (PCI) at University Clinical Center Maribor between January 2008 and October 2016. One hundred and thirty-two (50.8%) eligible patients underwent angiographic follow-up. The majority of patients (86.5%) were treated with a single drug-eluting stent (DES). Results: The overall prevalence of angiographic ISR in unprotected LMCA lesions was 33.3% (44 out of 132 patients with angiographic follow-up). The in-stent restenosis rate was 31.7% (39) in the group initially treated with DES (123). Most patients (63.6%) with ISR underwent repeated PCI, 22.7% had coronary artery bypass graft surgery, and 13.6% were treated conservatively. Only hypertension was shown to be statistically significant as a predictor of ISR in the present study. Stent thrombosis rate was 2.0% (six out of 297 patients). The mortality rate was 12.5% one month after the procedure on the left main coronary artery lesion, and 17.2 % after one year. Conclusion: Patients presenting with acute coronary syndrome had worse outcomes. While the numbers in the present study are higher compared to some other studies, they represent a real-world example of patients with different clinical presentations.

Left main coronary artery compression in patients of atrial septal defect with dilated pulmonary artery

BackgroundExternal compression of left main coronary artery (LMCA) by dilated pulmonary artery is a rare and less known phenomenon. ObjectiveTo find incidence and associated angiographic findings of LMCA compression by a dilated pulmonary artery in adult patients with an Atrial septal defect (ASD). MethodsIt was a retrospective observational study done in 55 patients with ASD and age more than 35 years. All patients underwent coronary angiogram along with cardiac catheterization to look for hemodynamic parameters and status of the epicardial coronary artery. Patients with significant LMCA compression underwent computed tomography and intravascular imaging to confirm significant compression and rule out atherosclerotic stenosis. Patients with and without LMCA compression were compared to find any causation, and patients with LMCA compression were followed up after the final consensus of management. ResultsAs compared to patients without LMCA compression, significant LMCA compression was found in 4 (7.27%) of patients and associated with reduced ejection fraction (46.3 ± 10.3% vs 60 ± 2.0%; p-value 0.001), increased pulmonary artery diameter (55 ± 14.5 mm vs 24.9 ± 4.7 mm; p-value <0.01), increased pulmonary artery to aortic diameter ratio (2.6 ± 0.8 vs 1.2 ± 0.2; p-value <0.01) and raised mean pulmonary artery pressure (mPAP) (43.3 ± 5.1 mmHg vs 24.5 ± 6.1; p-value 0.003). Patients underwent surgical correction or LMCA stenting or followed up medically. ConclusionsLMCA compression is rarely seen in patients with an atrial septal defect and is associated with a reduced ejection fraction, increased pulmonary artery diameter, increased pulmonary artery/aortic diameter ratio, and raised mPAP. Treatment modalities like medical management, percutaneous intervention by stenting, and surgical correction play an important role in management.

Rare Complication in The Coronary Angiography Laboratory: Stent Stripping

Although foreign body embolization is a rare complication of percutaneous coronary intervention, the increase in the number of procedures results in this problem being more frequently encountered by interventional cardiologists. Contemporary case studies have reported the rate of stent stripping to be below 1%. Interventional cardiologists attend to a considerable number of cases in everyday practice and witness a diverse spectrum of complications. Stent stripping can result in severe complications such as emergency coronary bypass surgery, coronary thrombosis, myocardial infarction, cerebrovascular event and death. Thus, the proper management of stent stripping is important for reducing the risk of mortality and morbidity. In this article, we present a case of left main coronary artery stent stripping; we discuss the removal procedure and the complications that arose.

The Case of Left Main Coronary Stenting in Acute ST Elevation Myocardial Infarction

In the light of present studies, the left main coronary artery (LMCA) lesions more suitable for surgery on stable and planned patients. But invasive tools like OCT, FFR and IVUS usage in this stenting of LMCA lesions gains popularity for procedural optimization in interventional cardiologist era. Although long term results are debatable but short term studies revealed same mortality and morbidity rates between stenting and surgery in acute coronary syndromes. We herein present an acute anterior ST elevation myocardial infarction (MI) with hemodynamic disturbance because of total obstruction of LMCA with no distal flow in left coronary system. After crush stenting of LMCA, patient’s situation was going well and discharged with medical therapy shortly after intervention.

CORRIGENDUM: Acute Coronary Syndrome With Unprotected Left Main Coronary Artery Culprit - An Observation From the AOI-LMCA Registry.

BACKGROUND Data on the clinical outcomes of percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) in patients with acute coronary syndrome (ACS) are limited. Therefore, this study aimed to assess the clinical outcome of patients with ACS who underwent PCI for LMCA culprit lesion.Methods and Results:Of 1,809 patients enrolled in the Assessing Optimal Percutaneous Coronary Intervention for the LMCA (AOI-LMCA) registry (a retrospective 6-center registry of consecutive patients undergoing LMCA stenting in Japan), the current study population consisited of 1,500 patients with unprotected LMCA stenting for LMCA ACS (ACS with shock: 115 patients, ACS without shock: 281 patients) and stable CAD (1,104 patients). The cumulative 180-day incidence of death was markedly higher in the ACS with shock group than in the other groups (49.5%, 8.6%, and 3.3%, respectively; P<0.0001), but mortality beyond 180-day was not significantly different among the 3 groups (30.2%, 20.4%, and 19.5%, respectively; P=0.65). In the ACS with shock group, the initial TIMI flow grade did not affect 5-year mortality (57.1% and 62.2%, P=0.99), but in the ACS without shock group, 5-year mortality was significantly higher in patients with initial TIMI flow grade ≤1 than in patients with TIMI flow grade ≥2 (44.4% and 23.7%, respectively; P=0.008). CONCLUSIONS In patients with LMCA ACS, survival correlates with baseline hemodynamic and coronary flow status.

Optimal Duration for Dual Antiplatelet Therapy After Left Main Coronary Artery Stenting

Coronary interventions using drug-eluting stents (DESs) of left main coronary artery (LMCA) lesions have shown favorable clinical outcomes. However, duration of dual antiplatelet therapy (DAPT) after LMCA interventions has not yet been investigated.Methods and Results:From a multicenter Korean Multicenter Angioplasty Team (KOMATE) registry, 1,004 patients who received DES implantations for LMCA lesions and did not experience major adverse cardiovascular events (including major bleeding) for 1 year after coronary intervention were analyzed. Patients were divided into 2 groups; DAPT ≤12 (n=503) and >12 months (n=501). The primary endpoint was number of net clinical adverse events (NACEs), composite of cardiac deaths, myocardial infarctions, stent thrombosis and major bleeding events. During a 4.5-year follow-up period after LMCA interventions, the DAPT >12 months group showed a lower NACE rate than the DAPT ≤12 months group (adjusted-HR 0.53 [0.29-0.99], P=0.045). For patients who maintained DAPT >12 months, rate of cardiac deaths, myocardial infarctions, and stent thrombosis events were lower than in patients who had DAPT ≤12 months (adjusted-HR 0.35 [0.17-0.73], P=0.005) without increased major bleeding (P=0.402).For patients who can continue DAPT without major bleeding events, prolonged DAPT (>12 months) after LMCA stenting demonstrated better long-term efficacy outcomes than DAPT ≤12 months with comparable safety.

Abstract 13722: There Will be Blood: A Cautionary Tale of Triple Therapy

A 54-year-old man with coronary artery disease, chronic kidney disease, atrial flutter, and chronic right internal carotid artery (ICA) occlusion was transferred to our institution for management of cardiogenic shock following an anterior ST-elevation myocardial infarction status post percutaneous coronary intervention of the left main coronary artery (LMCA). He was placed on short-term triple antithrombotic therapy. On the day before discharge, he acutely developed left sided neurological deficits and hypotension. Exam was concerning for a right hemispheric stroke. Labs revealed a creatinine of 2.8 mg/dL, INR of 3.7, and a hemoglobin of 6.6 g/dL (previously 10 g/dL). Prior to sending the patient for brain imaging, we performed a bedside echocardiogram to further evaluate his hypotension. This revealed a large pericardial effusion with tamponade physiology. We suspected hemorrhagic cardiac tamponade secondary to triple antithrombotic therapy. His hypotension initially responded to intravenous fluids and packed red blood cells, resulting in an improved neurologic exam and supporting our hypothesis that his deficits represented right cerebral hemispheric hypoperfusion in the setting of a known right ICA occlusion and tamponade. Pericardiocentesis was initially deferred, as the risk of bleeding appeared prohibitive without reversal of apixaban and his coagulopathy, and these measures would subject the patient to a significant risk of thrombosis (e.g. LMCA stent thrombosis). Unfortunately, the patient developed progressive shock. After careful informed consent, we proceeded with high-risk pericardiocentesis involving pre-procedural reversal of apixaban with andexanet alfa and successful evacuation of 300 ml of hemorrhagic fluid. The pericardial pressure improved from 24 mmHg to 4 mmHg with complete resolution of the patient’s shock and neurological deficits. Our case demonstrates the risks associated with triple antithrombotic therapy as well as the nuanced clinical decision-making and risk-benefit assessment required when considering the use of anticoagulant reversal agents to prevent bleeding complications in the context of recent ischemic events and the need for urgent invasive procedures.