Coronary artery disease
Long-Term Clinical and Angiographic Outcomes of Treatment of Unprotected Left Main Coronary Artery Stenosis With Sirolimus-Eluting Stents

https://doi.org/10.1016/j.amjcard.2007.03.041Get rights and content

Favorable early results of percutaneous drug-eluting stents in unprotected left main (LM) disease are available, but outcome data beyond 6 to 10 months are lacking. We evaluated the long-term results of sirolimus-eluting stents (SESs) in patients with LM disease. From November 2002 to December 2004, consecutive patients with LM disease, without contraindications to double antiplatelet therapy and undergoing SES implantation, were enrolled prospectively. The primary end point of the study was occurrence of major adverse cardiovascular events. In total 85 patients were treated with 118 SES and followed for 595 ± 230 days. Event-free survival rates at 1 year and 2 years were 85.5% and 78.6%, respectively. Only 2 deaths occurred overall (2.4%), the first in-hospital in a very high-risk patient according to the European System for Cardiac Operative Risk Evaluation and the second in a patient with severe systolic dysfunction already at the index procedure). Myocardial infarction was adjudicated in 3 patients (3.6%), 2 occurring periprocedurally and 1 during follow-up for a de novo nontarget lesion. There were 7 (10.8%) target lesion revascularizations at 24 months, with all but 1 percutaneous and in a subject with bifurcation LM disease at baseline. At 9-month angiography, late loss was 0.15 ± 0.81 mm and restenosis rate was 8.2%. An increased incidence of adverse events was noted in patients undergoing SES after dilation with extremely oversized balloons. No case of stent thrombosis was reported. In conclusion, this single-center experience suggests that percutaneous use of SESs to treat LM disease in unselected high-risk patients is safe and effective even 1 year after implantation.

Section snippets

Methods

From a total population of 2,126 consecutive patients referred for coronary angiography to our institution (a tertiary academic care center with an annual caseload of >1,000 percutaneous coronary interventions) between November 2002 and December 2004 because of established or suspected coronary artery disease, we prospectively enrolled 85 consecutive patients (4.0%) with significant LM stenosis (≥50% diameter stenosis by visual estimate), coronary anatomy suitable for percutaneous

Results

Baseline clinical and angiographic characteristics are listed in Table 1, Table 2. Patients’ mean age was 68 ± 10 years; 24 patients (28%) patients had previous percutaneous coronary intervention on other coronary vessels, 20 (24%) had peripheral artery disease, and 4 (5%) chronic renal failure; and ejection fraction was 52 ± 10%. The principal clinical indication for referral was unstable angina in 40 (47%) followed by acute myocardial infarction in 17 (20%), with ST-elevation myocardial

Discussion

The present study suggests that use of drug-eluting stents to treat LM disease in unselected patients without major contraindications to cardiac surgery may be feasible, safe, and associated with a high procedural success rate. These findings are based on the lack, in our population, of episodes of stent thrombosis and on the very low incidence of procedure-related complications and in-hospital adverse events rate although many procedures were primary angioplasties for ST-elevation myocardial

References (26)

Cited by (43)

  • Left main coronary stenting in a non surgical octogenarian population: A possible approach

    2012, Cardiovascular Revascularization Medicine
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    Percutaneous coronary intervention (PCI) of unprotected LMCA has increased with improvements in equipment, interventional techniques, and drug therapy [5]. Indeed, the wide diffusion of drug eluting-stent (DES) that significantly reduces the restenosis and the repeat target vessel revascularization (TVR) has improved the outcome of PCI for these lesions [6–27]. Despite the compelling evidence supporting the PCI with a DES [28] and the reduction in cardiac events during the peri-interventional period [8,14,17], LMCA lesions continue to be treated surgically because recent randomized trials failed to prove superiority or at least non-inferiority of DES for unprotected LMCA stenosis compared with CABG [2,22].

  • Routine versus selective coronary artery bypass for left main coronary artery revascularization: The appraise a customized strategy for left main revascularization (CUSTOMIZE) study

    2011, International Journal of Cardiology
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    The introduction of drug-eluting stents (DES) in clinical practice has significantly reduced the risk of restenosis and reintervention over time, leading to their rapid widespread and extensive use, even for more complex, off-label lesions such as ULMCA stenosis [13]. The excellent results obtained with DES suggest that these devices can be an effective and safe alternative to CABG when treating left main disease in cases with anatomy suitable for percutaneous intervention [14–18]. The SYNTAX study, the first randomized, controlled clinical trial to compare DES to CABG in patients with ULMCA, has recently concluded that CABG remains the standard of care for three-vessel or left main coronary artery disease, as due to lower rates of the combined endpoint of major adverse cardiac or cerebrovascular events at 1 year [19].

  • 5-year outcomes following percutaneous coronary intervention with drug-eluting stent implantation versus coronary artery bypass graft for unprotected left main coronary artery lesions: The Milan experience

    2010, JACC: Cardiovascular Interventions
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    Some retrospective studies evaluating surgical treatment for this disease reported an in-hospital mortality rate varying from 1.7% to 7.0% and a 1-year mortality rate of 6% to 14% (18–21). Encouraging 1-year and more recently 3-year results have been reported for PCI with DES implantation in this particular subset of patients (2–11). Observational, nonrandomized registries (5,13,16) reported thus far have shown no difference in the occurrence of MACCE between patients treated with DES compared with the ones treated with CABG in this subset of patients.

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