Distal Left Main Bifurcation Lesions Research Articles

Comparison of simple versus complex stenting in patients with true distal left main bifurcation lesions.

Distal left main (LM) bifurcation disease is one of the most challenging lesion subsets for percutaneous coronary intervention (PCI) and optimal stenting strategy for such complex lesions is still debated. This study aimed to compare clinical outcomes following single versus dual stenting for true distal LM bifurcation lesions. Patients with true distal LM bifurcation lesions (type 1,1,1 or 0,1,1: both left anterior descending and circumflex artery >2.5 mm diameter) receiving PCI with drug-eluting stents (DES) from two large clinical registries were evaluated. The primary outcome was target-lesion failure (TLF), defined as a composite of cardiac death, target-vessel myocardial infarction (MI), or target-lesion revascularization (TLR). Outcomes were compared with the use of propensity scores and inverse probability-weighting adjustment to reduce treatment selection bias. Among 1,002 patients undergoing true distal LM PCI, 440 (43.9%) and 562 (56.1%) were treated with single and dual stents, respectively. The TLF rates at 3 year was 20.3% in the single-stent group and 24.1% in the dual-stenting group (log-rank p = 0.18). The adjusted risk for TLF did not differ significantly between two groups (hazard ratio [HR] with dual-stent vs. single-stent: 1.27, 95% confidence interval [CI]: 0.95-1.71). The adjusted risks for death, MI, repeat revascularization, or stent thrombosis were also similar between the single- and dual-stenting groups. In patients undergoing PCI for true distal LM disease, single- and dual-stent strategies showed a similar adjusted risk of TLF at 3 years. Our findings should be confirmed or refuted through large, randomized clinical trials.

Clinical outcomes of double stent strategy for unprotected left main distal bifurcation lesions using current generation drug eluting stent comparing to early generation drug eluting stent; The Milan and New Tokyo (MITO) registry.

There are only little data available on the comparison of clinical outcomes between a early generation drug eluting stent (eDES) and a current generation drug eluting stent (cDES) for percutaneous coronary intervention (PCI) with double stent strategy (DSS) for unprotected distal left main disease (ULMD). Between April 2005 and December 2015, we recruited 452 consecutive ULMD patients treated with DSS (eDES, 236 patients; cDES, 216 patients). In this study, eDES included Cipher, Taxus, and Endeavor and cDES included Ultimaster, Resolute family, Xience family, Promus family, Synergy, and Nobori. The primary endpoint was target lesion failure (TLF) defined as a composite of cardiac death, target lesion revascularization (TLR) and myocardial infarction (MI) during the median follow-up period of 1,809(IQR: 1,190-2,510) days. In entire population, the rate of overall TLR was significantly lower in cDES group than that in eDES group (adjusted HR 0.62, 95% CI 0.40-0.96, p = .032). The rate of TLR for the ostium of LCX was significantly lower in cDES group than that in eDES group (adjusted HR 0.63, 95% CI 0.39-0.99, p = .047). Cardiac mortality, the rate of TLR for LM-LAD, MI and definite/probable ST did not significantly differ between both groups. The results were preserved in the propensity adjusted population. cDES significantly improved the clinical outcomes in population treated with DSS mainly driven by the reduction of TLR for the ostium of LCX.

Influence of final kissing balloon inflation on long-term outcomes after PCI of distal left main bifurcation lesions in the EXCEL trial.

The impact of final kissing balloon inflation (FKBI) after percutaneous coronary intervention (PCI) of bifurcation lesions on long-term clinical outcomes remains controversial. We sought to determine the impact of FKBI on four-year outcomes after PCI of distal left main (LM) bifurcation lesions. The EXCEL trial compared PCI with everolimus-eluting stents and coronary artery bypass graft surgery (CABG) in patients with left main (LM) disease. We examined four-year clinical outcomes after PCI of distal LM bifurcation lesions according to use of FKBI. The primary endpoint was the composite rate of death, myocardial infarction (MI), or stroke. The major secondary endpoint was the composite rate of death, MI, stroke, or ischaemia-driven revascularisation (IDR). Among 948 patients randomised to PCI, 759 had distal LM lesions treated, 430 of which were treated with one stent and 329 of which were treated with two or more stents. The four-year rates of the primary and major secondary endpoints were similar with versus without FKBI in both the one-stent and ≥2-stent groups in both unadjusted and adjusted analyses. In the EXCEL trial, the performance of FKBI after PCI of distal LM bifurcation lesions was not associated with improved four-year clinical outcomes regardless of whether one stent or ≥2 stents were implanted.

The Impact of Diabetes Mellitus on Clinical Outcomes after Percutaneous Coronary Intervention with Drug-Eluting Stents for Left Main Distal Bifurcation Lesions in Patients with Chronic Kidney Disease

Background: The impact of diabetes mellitus (DM) on clinical outcomes after percutaneous coronary intervention (PCI) for unprotected left main (ULM) distal bifurcation lesions in patients with chronic kidney disease (CKD) is poorly understood in the era of drug-eluting stents (DESs). Objective: We assessed the impact of DM on clinical outcomes after PCI for ULM distal bifurcation lesions in CKD patients compared to patients without DM. Methods: We identified 1,832 consecutive patients who underwent PCI for ULM lesions at New Tokyo Hospital, Matsudo, Japan, San Raffaele Scientific Institute, Milan, Italy, and EMO-GVM, Centro Cuore Columbus, Milan, Italy between January 2005 and August 2015. Of the 1,832 patients, 1,391 were treated with DESs. We excluded 750 patients without CKD and 89 hemodialysis patients. Finally, 552 patients with CKD were included: 219 with DM (DM group) and 333 without DM (no DM group). The primary endpoint was target lesion failure (TLF) at 5 years. TLF was defined as a composite of cardiac death, target lesion revascularization (TLR), and myocardial infarction. Results: Patients in the DM group were more likely to have hypertension, dyslipidemia, peripheral artery disease, and lower ejection fraction and were more frequently using insulin for DM. The TLF rate during the follow-up period was significantly higher in the DM than in the no DM group (adjusted hazard ratio [HR] 1.50; 95% confidence interval [CI] 1.06–2.13; p = 0.023). Cardiac mortality was comparable between both groups (adjusted HR 1.11; 95% CI 0.63–1.95; p = 0.71). The TLR rate was significantly higher in the DM group than in the no DM group (adjusted HR 1.69; 95% CI 1.12–2.54; p = 0.012). Conclusion: DM is strongly associated with adverse event after PCI for ULM distal bifurcation lesions in CKD patients compared to those without DM.

TCT-68 Influence of Final Kissing Balloon Inflation on Long-Term Outcomes After PCI of Distal Left Main Bifurcation Lesions: Analysis From the EXCEL Trial

Final kissing balloon inflation (FKBI) after percutaneous coronary intervention (PCI) of bifurcation lesions has been advocated based on bench tests and computer simulations; however, the impact of FKBI on long-term clinical outcomes remains controversial. The study aims to determine the impact of

TCT-382 Technical Issues in 2-Stent Distal Left Main Bifurcation Treatment: An EXCEL Trial Intravascular Ultrasound Substudy

Optimal technique is critical when treating complex distal left main (LM) bifurcation lesions, especially when using 2 stents. In 127 patients with a distal LM bifurcation lesion treated with 2 everolimus-eluting stents in the EXCEL trial, post–percutaneous coronary intervention intravascular

3-Year Outcomes of the DKCRUSH-V Trial Comparing DK Crush With Provisional Stenting for Left Main Bifurcation Lesions

ObjectivesThe present study aimed to investigate the difference in target lesion failure (TLF) at 3 years after double kissing (DK) crush stenting versus provisional stenting (PS) for unprotected left main distal bifurcation (UPLMb) lesions. BackgroundThe multicenter and randomized DKCRUSH-V (Double Kissing Crush versus Provisional Stenting for Left Main Distal Bifurcation Lesions: The DKCRUSH-V Randomized Trial) study showed fewer 1-year TLF after DK crush for UPLMb lesions compared with PS. The study reports the 3-year clinical outcome of the DKCRUSH-V study. MethodsA total of 482 patients with UPLMb lesions who were randomly assigned to either the DK crush group (DK group) or PS group in the DKCRUSH-V study were followed for 3 years. The primary endpoint was the occurrence of a TLF at 3 years. Stent thrombosis (ST) was the safety endpoint. Patients were classified by lesion’s complexity and NERS (New Risk Stratification) II or SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) score. ResultsAt 3 years, TLF occurred in 41 (16.9%) patients in the PS group and in 20 (8.3%) patients in the DK group (p = 0.005), mainly driven by increased target vessel myocardial infarction (5.8% vs. 1.7%; p = 0.017) and target lesion revascularization (10.3% vs. 5.0%; p = 0.029). Definite or probable ST rate at 3 years was 4.1% in the PS group and 0.4% in the DK group (p = 0.006). Notably, DK crush was associated with a significant reduction in both primary and secondary endpoints for patients with complex lesions or at high risk. ConclusionsProvisional stenting for UPLMb lesions was associated with significantly increased rates of TLF and ST over 3 years of follow-up. Further randomized study is warranted to confirm the benefits of DK crush stenting for complex UPLMb lesions. (Double Kissing and Double Crush versus Provisional T Stenting Technique for the Treatment of Unprotected Distal Left Main True Bifurcation Lesions: A Randomized, International, Multi-center Clinical Trial; ChiCTR-TRC-11001213).

Double Kissing Crush Versus Provisional Stenting for Left Main Distal Bifurcation Lesions: DKCRUSH-V Randomized Trial

BackgroundProvisional stenting (PS) is the most common technique used to treat distal left main (LM) bifurcation lesions in patients with unprotected LM coronary artery disease undergoing percutaneous coronary intervention. The double kissing (DK) crush planned 2-stent technique has been shown to improve clinical outcomes in non-LM bifurcations compared with PS, and in LM bifurcations compared with culotte stenting, but has never been compared with PS in LM bifurcation lesions. ObjectivesThe authors sought to determine whether a planned DK crush 2-stent technique is superior to PS for patients with true distal LM bifurcation lesions. MethodsThe authors randomized 482 patients from 26 centers in 5 countries with true distal LM bifurcation lesions (Medina 1,1,1 or 0,1,1) to PS (n = 242) or DK crush stenting (n = 240). The primary endpoint was the 1-year composite rate of target lesion failure (TLF): cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. Routine 13-month angiographic follow-up was scheduled after ascertainment of the primary endpoint. ResultsTLF within 1 year occurred in 26 patients (10.7%) assigned to PS, and in 12 patients (5.0%) assigned to DK crush (hazard ratio: 0.42; 95% confidence interval: 0.21 to 0.85; p = 0.02). Compared with PS, DK crush also resulted in lower rates of target vessel myocardial infarction I (2.9% vs. 0.4%; p = 0.03) and definite or probable stent thrombosis (3.3% vs. 0.4%; p = 0.02). Clinically driven target lesion revascularization (7.9% vs. 3.8%; p = 0.06) and angiographic restenosis within the LM complex (14.6% vs. 7.1%; p = 0.10) also tended to be less frequent with DK crush compared with PS. There was no significant difference in cardiac death between the groups. ConclusionsIn the present multicenter randomized trial, percutaneous coronary intervention of true distal LM bifurcation lesions using a planned DK crush 2-stent strategy resulted in a lower rate of TLF at 1 year than a PS strategy. (Double Kissing and Double Crush Versus Provisional T Stenting Technique for the Treatment of Unprotected Distal Left Main True Bifurcation Lesions: A Randomized, International, Multi-Center Clinical Trial [DKCRUSH-V]; ChiCTR-TRC-11001213)

Design and rationale for the treatment effects of provisional side branch stenting and DK crush stenting techniques in patients with unprotected distal left main coronary artery bifurcation lesions (DKCRUSH V) Trial

BackgroundProvisional stenting (PS) is effective for great majority of patients with coronary bifurcation lesions. Double kissing (DK) crush approach demonstrated significant reduction of target lesion revascularization (TLR) for patients with more complex bifurcation lesion when compared with PS. Furthermore, DK crush technique was associated with lower rate of composite major adverse cardiac event (MACE), revascularization and stent thrombosis (ST) for patients with unprotected distal left main coronary artery bifurcation lesions (ULMb), compared to culotte stenting approach. The DKCRUSH V trial is designed to elucidate the benefits of DK crush over PS in patients with ULMb. Study designDKCRUSH V is a randomized, prospective, multinational clinical trial designed to evaluate the efficacy and safety of DK crush over PS for patients with ULMb. Subjects with Medina 1,1,1 or 0,1,1 ULMb will be randomized in a 1:1 fashion to PS or DK crush. The primary endpoint is target lesion failure (TLF) including target vessel myocardial infarction, cardiac death and TLR. Other endpoints address individual event of primary endpoint, and target vessel revascularization. The safety objective is the ST. Recruitment began in January 2012 and was completed in December 2015; 484 patients were randomized. The trial will continue until at least 56 adjudicated primary endpoints occur. ConclusionsThe DKCRUSH V study is investigating if DK crush approach versus PS will reduce the incidence of TLF in patients with symptomatic ULMb.

Clinical Outcome After DK Crush Versus Culotte Stenting of Distal Left Main Bifurcation Lesions: The 3-Year Follow-Up Results of the DKCRUSH-III Study.

The present study aimed to investigate the difference in major adverse cardiac events (MACE) at 3 years after double-kissing (DK) crush versus culotte stenting for unprotected left main distal bifurcation lesions (LMDBLs). The multicenter and randomized DKCRUSH-III (Comparison of double kissing crush versus culotte stenting for unprotected distal left main bifurcation lesions: results from a multicenter, randomized, prospective study) showed that DK crush stenting was associated with fewer MACE at 1-year follow-up in patients with LMDBLs compared with culotte stenting. Here, we report the 3-year clinical outcome of the DKCRUSH-III study. A total of 419 patients with LMDBLs who were randomly assigned to either the DK crush or culotte group in the DKCRUSH-III study were followed for 3 year. The primary endpoint was the occurrence of a MACE at 3 years. Stent thrombosis (ST) was the safety endpoint. Patients were classified by simple and complex LMDBLs according to the DEFINITION (Definition and Impact of Complex Bifurcation Lesions on Clinical Outcomes After Percutaneous Coronary Intervention Using Drug-Eluting Stents) study criteria. At 3 years, MACE occurred in 49 patients the culotte group and in 17 patients in the DK crush group (cumulative event rates of 23.7% and 8.2%, respectively; p < 0.001), mainly driven by increased myocardial infarction (8.2% vs. 3.4%, respectively; p = 0.037) and target-vessel revascularization (18.8% vs. 5.8%, respectively; p < 0.001) between groups. Definite ST rate was 3.4% in the culotte group and 0% in the DK crush group (p = 0.007). Complex LMDBLs were associated with a higher rate of MACE (35.3%) at 3 years compared with a rate of 8.1% in patients with simple LMDBLs (p < 0.001), with an extremely higher rate in the culotte group (51.5% vs. 15.1%, p < 0.001). Culotte stenting for LMDBLs was associated with significantly increased rates of MACE and ST. (Double Kissing [DK] Crush Versus Culotte Stenting for the Treatment of Unprotected Distal Left Main Bifurcation Lesions: DKCRUSH-III, a Multicenter Randomized Study Comparing Double-Stent Techniques; ChiCTR-TRC-11001877).

Comparison of Double Kissing Crush Versus Culotte Stenting for Unprotected Distal Left Main Bifurcation Lesions

The study aimed to investigate the difference in major adverse cardiac event (MACE) at 1-year after double kissing (DK) crush versus Culotte stenting for unprotected left main coronary artery (UPLMCA) distal bifurcation lesions. DK crush and Culotte stenting were reported to be effective for treatment of coronary bifurcation lesions. However, their comparative performance in UPLMCA bifurcation lesions is not known. A total of 419 patients with UPLMCA bifurcation lesions were randomly assigned to DK (n = 210) or Culotte (n = 209) treatment. The primary endpoint was the occurrence of a MACE at 1 year, including cardiac death, myocardial infarction, and target vessel revascularization (TVR). In-stent restenosis (ISR) at 8 months was secondary endpoint, and stent thrombosis (ST) served as a safety endpoint. Patients were stratified by SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) and NERS (New Risk Stratification) scores. Patients in the Culotte group had significant higher 1-year MACE rate (16.3%), mainly driven by increased TVR (11.0%), compared with the DK group (6.2% and 4.3%, respectively; all p < 0.05). ISR rate in side branch was 12.6% in the Culotte group and 6.8% in the DK group (p = 0.037). Definite ST rate was 1.0% in the Culotte group and 0% in the DK group (p = 0.248). Among patients with bifurcation angle ≥70°, NERS score ≥20, and SYNTAX score ≥23, the 1-year MACE rate in the DK group (3.8%, 9.2%, and 7.1%, respectively) was significantly different to those in the Culotte group(16.5%, 20.4%, and 18.9%, respectively; all p < 0.05). Culotte stenting for UPLMCA bifurcation lesions was associated with significantly increased MACEs, mainly due to the increased TVR. (Double Kissing [DK] Crush Versus Culotte Stenting for the Treatment of Unprotected Distal Left Main Bifurcation Lesions: DKCRUSH-III, a Multicenter Randomized Study Comparing Double-Stent Techniques; ChiCTR-TRC-00000151).

AS-173 Impact of Final Kissing Balloon in Distal Left Main Bifurcation Lesions Treated With Single or Two Stents Techniques

The optimal revascularization strategy for unprotected left main coronary disease (ULMCD) is the subject of ongoing debate. Further, optimal strategy for distal left main (LM) bifurcation is still matter of controversy.

Response to Letter Regarding Article, “Outcomes in Patients With De Novo Left Main Disease Treated With Either Percutaneous Coronary Intervention Using Paclitaxel-Eluting Stents or Coronary Artery Bypass Graft Treatment in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) Trial”

HomeCirculationVol. 123, No. 13Response to Letter Regarding Article, “Outcomes in Patients With De Novo Left Main Disease Treated With Either Percutaneous Coronary Intervention Using Paclitaxel-Eluting Stents or Coronary Artery Bypass Graft Treatment in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) Trial” Free AccessReplyPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReplyPDF/EPUBResponse to Letter Regarding Article, “Outcomes in Patients With De Novo Left Main Disease Treated With Either Percutaneous Coronary Intervention Using Paclitaxel-Eluting Stents or Coronary Artery Bypass Graft Treatment in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) Trial” Marie-Claude Morice, MD Marie-Claude MoriceMarie-Claude Morice Institut Hospitalier Jacques Cartier Massy, France (Morice) Search for more papers by this author Originally published5 Apr 2011https://doi.org/10.1161/CIRCULATIONAHA.110.003616Circulation. 2011;123:e399We thank Dr Uretsky for his interest in our study.1 He is correct that 248 of 705 patients who were visually assessed as having distal left main (LM) bifurcation disease by the site's Heart Team (interventional cardiologist, cardiothoracic surgeon, and study coordinator) were later determined by the core laboratory to not strictly meet the study protocol definition of LM disease (eg, the patients were determined to have B- [Medina type 0,1,0]- or E- [Medina type 0,0,1]-type distal LM bifurcation lesions). This discrepancy between the site and core laboratory determinations is typical of clinical trials that use a core laboratory for standardization. We have not separately assessed outcomes excluding those patients whom the core laboratory did not deem to have LM disease because, on an intent-to-treat basis, study investigators treated them as having LM disease.Because it is likely that clinicians will treat this group as having LM disease in the future, subanalysis of outcomes in this group, as Dr Uretsky suggests, is a good idea. We agree with Dr Uretsky that visual assessment of lesions identified by angiography does have limitations. We also agree that increased use of other techniques (such as fractional flow reserve, optical coherence tomography, or intravascular ultrasound) will aid in making appropriate treatment decisions in this patient population, and that increased use of these techniques should be encouraged. However, in clinical practice, most patients are treated by surgery or percutaneous coronary intervention without any additional evaluation. In this regard, we look forward to the results from the Evaluation of Xience Prime versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial, which will require fractional flow reserve or intravascular ultrasound confirmation of visual estimates in those patients who have more intermediate lesions.2Marie-Claude Morice, MD Institut Hospitalier Jacques Cartier Massy, FranceAcknowledgmentsThe authors for the SYNTAX Left Main Subset analysis were as follows: Patrick W. Serruys, MD, PhD and A. Pieter Kappetein, MD, PhD (Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands); Ted E. Feldman, MD (Evanston Hospital, Evanston, IL), Elisabeth Ståhle, MD (University Hospital Uppsala, Uppsala, Sweden); Antonio Colombo, MD and Lucia Torracca, MD (San Raffaele Scientific Institute, Milan, Italy); Michael J. Mack, MD (Heart Hospital Baylor Plano, Dallas, TX); David R. Holmes, MD (Mayo Clinic, Rochester, MN); Gerrit-Anne van Es, PhD (Cardialysis, Rotterdam, The Netherlands); Katrin Leadley, MD and Keith D. Dawkins, MD (Boston Scientific Corporation, Natick, MA); and Friedrich Mohr, MD (University of Leipzig Heart Center, Leipzig, Germany).DisclosuresDrs Serruys and Mohr were the SYNTAX Study Principal Investigators, and Drs Kappetein and Morice were co-Principal Investigators. Drs Leadley and Dawkins report being full-time employees of, and owning equity within, Boston Scientific Corporation. Dr van Es is a full-time employee of Cardialysis. Drs Ståhle and Colombo report receiving research grants from Boston Scientific Corporation. Dr Feldman reports receiving research grants and Speaker's Bureau/honoraria from Boston Scientific Corporation and Abbott Vascular. The other authors report no conflicts of interest.

Role of Bare-Metal Stents for Left Main Coronary Artery Disease in the Era of Drug-Eluting Stents - Which Coronary Stent Should Be Used for Left Main Trunk Disease? BMS or DES? (BMS-Side) -

In the past, coronary artery bypass graft surgery has been applied to revascularization for unprotected left main coronary artery (ULMCA) disease. In recent years, due to the advent of drug-eluting stents (DES), restenosis rates have decreased in comparison to conventional bare-metal stents (BMS), and the range of applications of percutaneous coronary intervention (PCI) for ULMCA disease has been expanded. However, even if DES is used, outcomes of PCI for distal left main coronary artery bifurcation lesions are not sufficient. Moreover, problems specific to DES, such as late stent thrombosis and late catch-up phenomenon, have been identified. There are still unknown points regarding remote-stage outcomes of DES. Thus, further investigation is needed on PCI for ULMCA disease, along with further analysis of remote-stage outcomes of BMS.

Distal Left Main Coronary Bifurcation Lesions Predict Worse Outcome in Patients Undergoing Percutaneous Implantation of Drug-Eluting Stents: Results from the Drug-Eluting Stent for the Treatment of Left Main Disease (DISTAL) Study

Objectives: We investigated the clinical outcome of stenting of unprotected left main coronary artery (LMCA). Methods: We studied 164 patients with nonbifurcated LMCA lesions (group A) and 96 patients with distal bifurcated lesions (group B). Results: Clinical follow-up was available in 100%. Angiographic follow-up was 87.3% in group A and 86% in group B (p = 0.922). There were significant differences in major adverse cardiac events at 1 (p = 0.014) and 2 years (p = 0.002) between group B (19.8%, 25.0%) and group A (9.1%, 10.4%), mainly due to increased target-vessel revascularization (16.7, 21.9% in group B vs. 6.1, 7.3% in group A, p = 0.006 and 0.001, respectively). The double-stent technique was associated with worse outcomes at 1 year in group B compared to group A. Bifurcation lesions (HR 3.42, 95% CI 1.34–5.61, p = 0.001), diabetes (HR 2.68, 95% CI 2.01–12.11, p = 0.015), three-vessel disease (HR 0.83, 95% CI 0.27–0.96, p = 0.001), incomplete revascularization (HR 0.15, 95% CI 0.11–0.35, p = 0.001) and stent diameter (HR 5.05, 95% CI 2.71–10.01, p = 0.03) were the independent factors of major adverse cardiac events in the whole patient cohort. Conclusion: Stenting unprotected distal bifurcated LMCA was associated with unfavorable results when compared to stenting other LMCA lesions.

Comparison of Long-Term Efficacy of the Paclitaxel-Eluting Stent Versus the Bare-Metal Stent for Treatment of Unprotected Left Main Coronary Artery Disease

The use of paclitaxel-eluting stents (PES) for the treatment of unprotected left main coronary artery (LMCA) disease is controversial. Between January 2003 and December 2006, a total of 287 patients undergoing percutaneous coronary intervention for LMCA lesions were consecutively registered. Of those patients, 178 received PES and 109 received bare-metal stents (BMS). Estimated perioperative mortality rates were 7.3% and 6.8% for the BMS and PES groups, respectively (p=0.51). PES recipients had distal left main bifurcation lesions more frequently compared with BMS recipients (72 vs 42%, p<0.01). At an average follow-up of 35 months, the rates of major adverse cardiac events (4.5 vs 23.9%, adjusted odds ratio [OR] 0.23, 95% confidence interval [CI] 0.09 to 0.58, p<0.001) and target-lesion revascularization (2.2 vs 13.8%, adjusted OR 0.26, 95% CI 0.08 to 0.83, p<0.001) were significantly lower in the PES group than in the BMS group. Overall thrombotic event rates were 1.1% and 4.6% in the PES and BMS groups, respectively (p=0.08). Angiographic follow-up was performed in 61% and 59% of PES and BMS recipients, respectively. The angiographic restenosis rate was significantly lower in the PES group as compared with the BMS group (3.7 vs 23.4%, p<0.001). In conclusion, PES implantation provides a safe, effective therapy for unprotected LMCA disease and decreases the risk of major adverse cardiac events compared with BMS at a mean follow-up of 35 months.

Final kissing balloon inflation by classic crush stenting did not improve the clinical outcomes for the treatment of unprotected left main bifurcation lesions: The importance of double‐kissing crush technique

The mechanisms contributing to final kissing balloon inflation between classic crush and double-kissing (DK) crush stenting techniques for the treatment of coronary bifurcation lesions contrast. The authors compared the clinical outcomes in patients with unprotected distal left main bifurcation lesions treated by classic crush or DK crush stenting techniques. Thirty-seven patients with unprotected left main bifurcation lesions were selected (20 in classic crush, 17 in DK crush groups) from a prospective, multicenter, randomized DKCRUSH-1 BIFURCATION STUDY. Clinical and angiographic data were analyzed. Follow-up was available for all patients. There were significant differences of the bifurcation angle between the classic and the DK crush group (83.28 +/- 20.69)(0) vs. (67.71 +/- 26.35)(0), P = 0.02). Unsatisfactory kissing rate in the classic group was significantly higher (26.32% vs. 5.88%, P = 0.01). The acute gain in the side branch was greater in the DK crush stent group (1.48 +/- 0.50 mm vs. 1.36 +/- 0.55 mm, P = 0.03). The accumulative restenosis rate in the main vessel segments, side branch, and accumulative MACE were higher in the classic group than the DK crush group (13.39% vs. 5.12%, P = 0.058, 42.10% vs. 5.88%, P = 0.01, 42.10% vs. 5.82%, P = 0.001, respectively). By logistic regression, acute gain in side branch immediately after PCI, bifurcation angle and unsatisfactory kissing were three independent factors of TLR at 8-month follow-up. Classic crush stenting with final kissing balloon inflations did not improve the clinical outcomes for the treatment of left main bifurcation lesion when compared with DK crush stenting technique.