Stenting in unprotected left main coronary artery

Stenting in unprotected left main coronary artery

Conventionally unprotected left main coronary artery stenosis is treated by coronary artery bypass grafting (CABG). But of late there have been several studies on balloon angioplasty and stenting in unprotected left main coronary artery disease. MAIN-COMPARE [1] by Duk-Woo Park, Ki Bae Seung, Young-Hak Kim, Jong-Young Lee, Won-Jang Kim, Soo-Jin Kang, Seung-Whan Lee, Cheol Whan Lee, Seong-Wook Park, Sung-Cheol Yun, Hyeon-Cheol Gwon, Myung-Ho Jeong, Yang-Soo Jang, Hyo-Soo Kim, Pum Joon Kim, In-Whan Seong, Hun Sik Park, Taehoon Ahn, In-Ho Chae, Seung-Jea Tahk, Wook-Sung Chung and Seung-Jung Park was published the Journal of the American College of Cardiology. This trial evaluated a registry of over two thousand patients in a registry of patients with unprotected left main disease who had undergone stenting or coronary artery bypass grafting between 2000 and 2006. Patients who had an ST elevation myocardial infarction or cardiogenic shock at presentation were excluded. Those with prior CABG and those who underwent concomitant valvular or aortic surgery were also excluded from the study. 97% of those who underwent stenting had angiographic features which made them eligible for either CABG or PCI, but underwent PCI due to the preference of the patient or the physician. 3% of those who underwent PCI had comorbid situations which made them ineligible for surgery.

318 patients were in the bare metal stent (BMS) era while 784 were in the drug eluting stent (DES) era. BMS was used upto 2003 and DES after that. The median follow up was over five years (range: three to nine years) and they found that stenting was better in terms of survival, stroke and Q-wave myocardial infarction. But freedom from target vessel revascularization was better in the CABG group (96% vs 84%, P < 0.001). It is also worth noting that triple vessel disease was much less common in the PCI group (24.8% vs 57%, P < 0.001) compared to the CABG group. Five year cumulative stent thrombosis incidence in those who received DES was 1.5%. The authors caution that though PCI is a safe option in selected cases of unprotected left main disease, the narrow margin for error makes it mandatory that the operators be well experienced and supported by a highly competent team of cardiac surgeons.

Reference

1. Duk-Woo Park, Ki Bae Seung, Young-Hak Kim, Jong-Young Lee, Won-Jang Kim, Soo-Jin Kang, Seung-Whan Lee, Cheol Whan Lee, Seong-Wook Park, Sung-Cheol Yun, Hyeon-Cheol Gwon, Myung-Ho Jeong, Yang-Soo Jang, Hyo-Soo Kim, Pum Joon Kim, In-Whan Seong, Hun Sik Park, Taehoon Ahn, In-Ho Chae, Seung-Jea Tahk, Wook-Sung Chung, Seung-Jung Park. Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry. J Am Coll Cardiol. 2010 Jul 6;56(2):117-24.