Unprotected Left Main Coronary Artery Research Articles

Strategies of Handling a Stenotic Unprotected Left Main Coronary Artery by Multi-Artery Fractional Flow Reserve Method

Background and aims: By present guidelines, unprotected stenotic LMCA that requires revascularization is revascularized in most cases by a coronary artery bypass graft (CABG) operation whereas only select groups of patients that are contraindicated for CABG operation are treated by percutaneous transluminal coronary angioplasty (PTCA). A possibility of a CABG operation is never taken lightly, therefore ways of avoiding it within the LMCA-LCx-LAD stenotic configuration are explored in this article.

Strategies of Handling a Stenotic Unprotected Left Main Coronary Artery by Multi-Artery Fractional Flow Reserve Method

Strategies of Handling a Stenotic Unprotected Left Main Coronary Artery by Multi-Artery Fractional Flow Reserve Method

Sirolimus-eluting BiOSS LIM dedicated bifurcation stent in the treatment of unprotected distal left main stenosis.

Proximal optimization technique (POT) has been proposed to adapt the conventional drug-eluting stent (DES) with the fractal anatomy of the bifurcation. However, only few DES are labeled for post-expansion beyond 5.0 mm. Furthermore, recrossing in the side branch (SB) through the main vessel (MV) stent cells may be challenging. To compare the sirolimus-eluting, balloon-expandable dedicated bifurcation stent BiOSS LIM DES versus the second generation DES in the treatment of distal unprotected left main coronary arteries (ULMCAs) lesions. Forty-two consecutive patients with distal ULMCA lesions were treated with the BiOSS LIM (BiOSS LIM group) in our center. A matched-group of patients treated with second-generation DES was selected from our database (Control group). The primary endpoint was the procedural complication rate, including (a) SB occlusion, defined as intraprocedural TIMI flow grade <3 immediately after MV stenting; and/or (b) trouble in SB access, defined as the need of ≥2 guidewires or a failure to recross in the SB trough the MV stent cells. The need of POT in the two groups was also analyzed. The primary endpoint occurred in four (9.5%) patients in the BiOSS LIM group and in 13 (31%) in the Control group (p = 0.028; OR = 4.25; 95% confidence interval: 1.25-14.43). POT was performed more often in the Control group (71% vs. 35%; p = 0.004). Compared to conventional DES, the BiOSS LIM stent (1) facilitates SB recrossing and (2) fits well with the fractal anatomy of the left main bifurcation.

Contemporary Use and Trends in Unprotected Left Main Coronary Artery Percutaneous Coronary Intervention in the United States

Recent data support percutaneous revascularization as an alternative to coronary artery bypass grafting in unprotected left main (ULM) coronary lesions. However, the relevance of these trials to current practice is unclear, as patterns and outcomes of ULM percutaneous coronary intervention (PCI) in contemporary US clinical practice are not well studied. To define the current practice of ULM PCI and its outcomes and compare these with findings reported in clinical trials. This cross-sectional multicenter analysis included data collected from 1662 institutions participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry between April 2009 and July 2016. Data were collected from 33 128 patients undergoing ULM PCI and 3 309 034 patients undergoing all other PCI. Data were analyzed from June 2017 to May 2018. Patient and procedural characteristics and their temporal trends were compared between ULM PCI and all other PCI. In-hospital major adverse clinical events (ie, death, myocardial infarction, stroke, and emergent coronary artery bypass grafting) were compared using hierarchical logistic regression. Characteristics and outcomes were also compared against clinical trial cohorts. Of the 3 342 162 included patients, 2 223 570 (66.5%) were male, and the mean (SD) age was 64.2 (12.1) years. Unprotected left main PCI represented 1.0% (33 128 of 3 342 162) of all procedures, modestly increasing from 0.7% to 1.3% over time. The mean (SD) annualized ULM PCI volume was 0.5 (1.5) procedures for operators and 3.2 (6.1) procedures for facilities, with only 1808 of 10 971 operators (16.5%) and 892 of 1662 facilities (53.7%) performing an average of 1 or more ULM PCI annually. After adjustment, major adverse clinical events occurred more frequently with ULM PCI compared with all other PCI (odds ratio, 1.46; 95% CI, 1.39-1.53). Compared with clinical trial populations, patients in the CathPCI Registry were older with more comorbid conditions, and adverse events were more frequent. Use of ULM PCI has increased over time, but overall use remains low. These findings suggest that ULM PCI occurs infrequently in the United States and in an older and more comorbid population than that seen in clinical trials.

Stent versus Coronary Artery Bypass Surgery in Multi-Vessel and Left Main Coronary Artery Disease: A Meta-Analysis of Randomized Trials with Subgroups Evaluation.

BackgroundComparison between percutaneous coronary intervention (PCI) using stents and Coronary Artery Bypass Grafting (CABG) remains controversial.ObjectiveTo conduct a systematic review with meta-analysis of PCI using Stents versus CABG in randomized controlled trials.MethodsElectronic databases were searched to identify randomized trials comparing PCI using Stents versus CABG for multi-vessel and unprotected left main coronary artery disease (LMCAD). 15 trials were found and their results were pooled. Differences between trials were considered significant if p < 0.05.ResultsIn the pooled data (n = 12,781), 30 days mortality and stroke were lower with PCI (1% versus 1.7%, p = 0.01 and 0.6% versus 1.7% p < 0.0001); There was no difference in one and two year mortality (3.3% versus 3.7%, p = 0.25; 6.3% versus 6.0%, p = 0.5). Long term mortality favored CABG (10.6% versus 9.4%, p = 0.04), particularly in trials of DES era (10.1% versus 8.5%, p = 0.01). In diabetics (n = 3,274) long term mortality favored CABG (13.7% versus 10.3%; p < 0.0001). In six trials of LMCAD (n = 4,700) there was no difference in 30 day mortality (0.6%versus 1.1%, p = 0.15), one year mortality (3% versus 3.7%, p = 0.18), and long term mortality (8.1% versus 8.1%) between PCI and CABG; the incidence of stroke was lower with PCI (0.3% versus 1.5%; p < 0.001). Diabetes and a high SYNTAX score were the subgroups that influenced more adversely the results of PCI.ConclusionCompared with CABG, PCI using Stents showed lower 30 days mortality, higher late mortality and lower incidence of stroke. Diabetes and a high SYNTAX were the subgroups that influenced more adversely the results of PCI.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Unprotected Left Main Coronary Artery Stenosis

BackgroundThe present study performed a meta-analysis of randomized and prospective trials to compare the outcomes of percutaneous coronary intervention (PCI) with stents versus coronary artery bypass graft surgery (CABG) for unprotected left main coronary artery (UPLM) stenosis. MethodsThe Cochrane Library, PubMed and EMBASE databases were systematically searched until July 2017. The Newcastle-Ottawa scale was used for quality assessment. ResultsA total of 19 studies with 16,900 participants were included. Pooled analysis showed no significant differences in all-cause mortality (odds ratio [OR] 0.94; 95% CI 0.74-1.20) and cardiac death (OR 1.04; 95% CI 0.74-1.47). However, subgroup analysis showed that PCI was associated with a low all-cause mortality rate at 30-day follow up (OR 0.48; 95% CI 0.26-0.89). The stroke rate in PCI was lower in short-term follow up (OR 0.45; 95% CI 0.23-0.88) and long-term follow up (OR 0.36; 95% CI 0.27-0.47). On the other hand, PCI was associated with higher risk of myocardial infarction (OR 1.59; 95% CI 1.34-1.88), repeat revascularization (OR 2.47; 95% CI 1.80-3.37) and target vessel revascularization (OR 2.10; 95% CI 1.72-2.57) compared to CABG in the pooled analysis. ConclusionsThe current evidence suggests that the risk of stroke was significantly reduced in PCI compared to that in CABG. Therefore, PCI is the preferred treatment for patients with a high risk of stroke. Additionally, in short-term follow up, PCI was reported to be safe and effective for UPLM patients compared to CABG. However, CABG caused fewer complications long term.

Intervenção coronária percutânea em tronco de coronária esquerda não protegido: acesso radial vs. femoral

ABSTRACT Background Percutaneous intervention for obstructive lesions of the unprotected left main coronary artery is complex. Choosing the vascular access can be decisive to a successful procedure. The objective of the present study was to describe the characteristics and hospital outcomes of patients with unprotected left main coronary artery disease and compare the radial and femoral access approaches. Methods Clinical and angiographic data, access routes and hospital outcomes of patients that have undergone percutaneous coronary intervention of the unprotected left [...]

Transradial Versus Transfemoral Access for Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery Stenosis: A Systematic Review and Meta-Analysis.

PCI of ULMS is frequently performed through TFA because of technical complexity and safety concern. Studies have shown comparable efficacy and safety of TRA versus TFA, however, these studies are few in number. We intended to compare the clinical outcomes between transradial access (TRA) and transfemoral access (TFA) in patients undergoing percutaneous coronary intervention (PCI) for unprotected left main coronary artery stenosis (ULMS) by performing a meta-analysis. A systematic search of database, including, PubMed, Web of Science, Google scholar and Cochrane Database were performed by two independent reviewers. Studies were included comparing "TRA" versus "TFA" in patients undergoing PCI in ULMS. The primary outcome was a procedural success rate. Secondary outcomes were major bleeding, access site complications, in-hospital and long term: major adverse cardiac events (MACE), myocardial infarction (MI) and cardiovascular mortality. Eight studies were included in the analysis. The procedural success rate was 97.3% and there was no statistically significant difference between TRA and TFA groups (OR, 1.41 [CI 0.64, 3.12], I2 = 26%). The rates of access site complications (OR, 0.17 [CI 0.07, 0.41], I2 = 16%), major bleeding (OR, 0.39 [CI 0.17, 0.86], I2 = 0%) and all-cause mortality (OR, 0.28 [CI 0.12, 0.64], I2 = 0%) were lower in the TRA group. There were no significant differences in in-hospital and long term cardiovascular mortality, MI and MACE between the two groups. In contrast to TFA, TRA is associated with reduced bleeding and access site complications, with similar procedural success rate in patients undergoing PCI of ULMS.

Incidence, predictors, clinical profile and outcome of patients with unprotected left main coronary artery angioplasty

Incidence, predictors, clinical profile and outcome of patients with unprotected left main coronary artery angioplasty

Percutaneous coronary intervention or coronary artery bypass graft in left main coronary artery disease: a comprehensive meta-analysis of adjusted observational studies and randomized controlled trials.

Treatment of patients with ULMCA (unprotected left main coronary artery disease) with percutaneous coronary intervention (PCI) has been compared with coronary artery bypass graft (CABG), without conclusive results. All randomized controlled trials (RCTs) and observational studies with multivariate analysis comparing PCI and CABG for ULMCA were included. Major cardiovascular events (MACEs, composite of all-cause death, MI, definite or probable ST, target vessel revascularization and stroke) were the primary end points, whereas its single components were the secondary ones, along with stent thrombosis, graft occlusion and in-hospital death and stroke. Subgroup analyses were performed according to Syntax score. Six RCTs (4717 patients) and 20 observational studies with multivariate adjustment (14 597 patients) were included. After 5 (3-5.5) years, MACE rate was higher for PCI [odds ratio (OR) 1.10, 95% confidence interval (CI) 1.07-1.14], without difference in death, whereas more relevant risk of MI was because of observational studies. Coronary stenting increased risk of revascularization (OR 1.52; 95% CI 1.34-1.72). At meta-regression, performance of PCI was improved by use of intra-coronary imaging and worsened by first generation stents, whereas two arterial grafts increased benefit of CABG. For patients with Syntax score less than 22, MACE rates did not differ, whereas for higher values, CABG reduced MACE because of lower risk of revascularization. Incidence of graft occlusion was 3.24% (2.25-4.23), whereas 2.13% (1.28-2.98: all CI 95%) of patients experienced stent thrombosis. Surgical revascularization reduces risk of revascularization for ULMCA patients, especially for those with Syntax score greater than 22, with a higher risk of in-hospital death. Intra-coronary imaging and use of arterial grafts improved performance of revascularization strategies.

10-Year Outcomes of Stents Versus Coronary Artery Bypass Grafting for Left Main Coronary Artery Disease

BackgroundComparative outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for left main coronary artery (LMCA) disease were previously reported. However, data on very long-term (>10 years) outcomes are limited. ObjectivesThe authors compare 10-year outcomes after PCI and CABG for LMCA disease. MethodsIn this observational study of the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty versus Surgical Revascularization) registry, the authors evaluated 2,240 patients with unprotected LMCA disease who underwent PCI (n = 1,102) or underwent CABG (n = 1,138) between January 2000 and June 2006. Adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction, or stroke; and target-vessel revascularization) were compared with the use of propensity scores and inverse-probability-weighting adjustment. The follow-up was extended to at least 10 years of all patients (median 12.0 years). ResultsIn the overall cohort, there was no significant difference in adjusted risks of death and the composite outcome between the groups up to 10 years. The risk of target-vessel revascularization was significantly higher in the PCI group. In the cohort comparing drug-eluting stents and concurrent CABG, the 2 study groups did not differ significantly in the risks of death and the composite outcome at 5 years. However, after 5 years, drug-eluting stents were associated with higher risks of death (hazard ratio: 1.35; 95% confidence interval: 1.00 to 1.81) and the composite outcome (hazard ratio: 1.46; 95% confidence interval: 1.10 to 1.94) compared with CABG. ConclusionsIn patients with significant LMCA disease, as compared with CABG, PCI showed similar rates of death and serious composite outcomes, but a higher rate of target-vessel revascularization at 10 years. However, CABG showed lower mortality and serious composite outcome rates compared with PCI with drug-eluting stents after 5 years. (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty versus Surgical Revascularization [MAIN-COMPARE]; NCT02791412)

Patient-Centered Decision-Making of Revascularization Strategy for Left Main or Multivessel Coronary Artery Disease

Patient preference plays an important role in daily practice; however, its implication has not been well investigated regarding treatment strategy for complex coronary artery disease. We prospectively evaluated a trend of patient-centered decision-making of revascularization strategy in patients with multivessel or unprotected left main coronary artery disease. A standardized protocol that favors coronary artery bypass graft surgery (CABG) as the primary treatment of choice, rather than percutaneous coronary intervention, was adopted. According to the protocol, patients decided whether or not they received CABG. Among the 763 consecutively enrolled patients, 293 patients (38%) consented to receive CABG. Fifty-six percent of patients with a high Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score chose CABG. SYNTAX score was independently correlated with consent to receive CABG in each patient SYNTAX score stratum. In-stent restenosis was an independent predictor of choosing CABG in patients with low and intermediate SYNTAX scores. Unprotected left main coronary artery disease was negatively correlated with the decision to choose CABG in patients with intermediate SYNTAX score. Reasons for declining CABG included refusal of open-heart surgery in 318 patients (68%), mild presentation of angina symptoms in 132 patients (28%), low self-confidence to expect long-term survival in 120 patients (26%), and economic factors in 10 patients (2%). Short-term major adverse cardiac and cerebrovascular events occurred in about 1% of patients without significant differences between the 2 groups. In conclusion, despite the preferred use of the CABG protocol, more than half of the patients declined CABG. Patient-centered decision-making as well as heart team approach should be considered in real-world practice situations.

TCT-329 Prospective Evaluation of Drug Eluting Self Apposing Stent for the Treatment of Unprotected Left Main Coronary Artery Disease: 1-Year Results of the TRUNC Study

Percutaneous intervention with stents has emerged as a valid alternative to surgical revascularization to treat unprotected left main (LM) stem disease. Conventional, tubular, balloon expandable stents face technical challenges, particularly in large LM diameter, tapered anatomy requiring extensive

TCT-332 Serial IVUS Substudy Results from J-LESSON: Japan Unprotected Left Main Coronary Artery Disease PCI Strategy On New Generation Stents

There is limited data regarding long-term morphological changes after everolimus-eluting stent (EES) implantation for unprotected left main coronary artery (ULMCA) disease. J-LESSON was a prospective, multi-center registry in pts with ULMCA disease who underwent PCI regardless of SYNTAX score.

TCT-294 Long Term Outcome of Unprotected Left Main Coronary Artery Disease: Comparison between Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Intervention (PCI) in Korean Single Center

The benefit of CABG over PCI for the patients with ULMCAD is controversial. Although many studies had less favorable short and mid-term outcomes of PCI in patients compare to CABG, there were limited papers on the long term survival outcomes. We sought to compare the long term (10 years) outcomes of

TCT-293 Incidence, procedural aspects and prognosis of percutaneous coronary intervention of Unprotected Left Main Coronary Artery disease in patients with ST-segment elevation Myocardial Infarction.

Data on procedural and clinical outcomes after primary percutaneous coronary intervention in patients presenting an STEMI with ULMCA affection are scarce. All consecutive patients who suffered an STEMI presenting a lesion in ULMCA (either culprit or non-culprit) treated with primary PCI in both

P2642Long-term outcomes of unprotected left main coronary artery bifurcation lesions treated by second-generation drug-eluting stent implantation: 1-stent vs. 2-stent strategy

P2642Long-term outcomes of unprotected left main coronary artery bifurcation lesions treated by second-generation drug-eluting stent implantation: 1-stent vs. 2-stent strategy

P3584Long term outcome of unprotected left main coronary artery disease: comparison between CABG and pci in korean single center

P3584Long term outcome of unprotected left main coronary artery disease: comparison between CABG and pci in korean single center

Sex difference among patients with unprotected left main coronary artery disease undergoing percutaneous coronary intervention in northern China.

Unprotected left main coronary artery (ULMCA) disease is associated with high mortality and morbidity. The aim of this study is to investigate the efficacy of percutaneous coronary intervention (PCI) on gender-specific patients with ULMCA in the Chinese population and provide a basis for further treatment of PCI in ULMCA disease. 173 patients (female, N = 52; male, N = 121; mean age = 61.02 ± 7.95) with ULMCA disease, who underwent PCI between January 2010 and December 2014, were investigated in our study. The mean follow-up time was 23.8 ± 7.3 months. The baseline clinical characteristics, coronary angiography (CAG) and PCI procedures, and in-hospital and follow-up outcomes of gender-specific patients were evaluated. There were no statistically significant differences in baseline clinical characteristics with the exception of body weight, height, and smoking indexes between women and men. During PCI procedure, femoral artery puncture was more preferred in women than men (P < .05), whereas radial artery puncture was more preferred in men than women (P < .05). The characteristics of CAG and PCI procedures (except puncture path) were showed with no markedly difference between women and men. The incidences of MACCEs in male patients during the in-hospital and follow-up periods were slightly higher than those of the female patients although with no statistical differences. In northern China, the incidence of ULMCA disease in men is likely to be higher than in women, whereas PCI for ULMCA disease shows similarly favorable outcomes in women as well as in men. During the PCI procedure, femoral artery puncture in women and radial artery puncture in men are recommended.

Long-term results after PCI of unprotected distal left main coronary artery stenosis: the Bifurcations Bad Krozingen (BBK)-Left Main Registry.

Percutaneous coronary intervention (PCI) of unprotected distal left main stenosis (UDLM) is increasingly performed as an alternative to surgical treatment. The optimal strategy for stenting in this setting is still a matter of debate. Therefore, this analysis investigated the long-term clinical outcome of a single- versus a double-stenting strategy for treatment of UDLM. From a large registry, 867 consecutive patients with UDLM undergoing either single or double stenting with drug-eluting stents (DES) were identified. Follow-up was up to 10 (median 3.1, interquartile range 1.1-5.3) years. Primary endpoint was MACE consisting of all-cause death, myocardial infarction, or target lesion re-intervention (TLR). Secondary clinical endpoints included these single endpoints and stent thrombosis. MACE occurred in 41.5% after single and in 49.0% after double stenting (P = 0.03). TLR was lower after single (17.4%) as compared to double stenting (27.2%; P < 0.01). Between single and double stenting, there were no significant differences for death (26.4 versus 23.3%; P = 0.31), death or myocardial infarction (29.1 versus 27.2%; P = 0.55), or definite/probable stent thrombosis (1.3 versus 2.1%; P = 0.42). Compared with single stenting, double stenting was associated with a significantly higher long-term risk of MACE. This was driven by a higher incidence of TLR, whereas the risk of death, MI, or stent thrombosis was similar between the two strategies.