Percutaneous transluminal coronary angioplasty in left main stem coronary stenosis: a five-year appraisal

doi:10.1016/0167-5273(85)90194-9

International Journal of Cardiology

Volume 9, Issue 2, October 1985, Pages 149-159

https://doi.org/10.1016/0167-5273(85)90194-9 Get rights and content

Abstract

Left main stem coronary stenosis is now uniformly treated with coronary artery bypass grafting. The advent of percutaneous transluminal coronary angioplasty has permitted a non-operative improvement in myocardial blood flow in many cases of single- and multi-vessel coronary atherosclerosis. The use of percutaneous transluminal coronary angioplasty in left main stem coronary stenosis has been sporadic and controversial. Twenty percutaneous transluminal coronary angioplasties were attempted in 19 patients as the treatment of choice for left main stem coronary stenosis in the past 66 months. The primary success rate was 95% ( $1920$ patients). The emergency surgery was performed only once (5%), and no death occurred secondary to percutaneous transluminal coronary angioplasty itself. In the follow-up (mean 41 months) period, 12 patients (63%) remained in satisfactory condition with no further need for surgical intervention. Seven patients (37%) ultimately required coronary artery bypass grafting. Although coronary artery bypass grafting will remain the fundamental treatment for left main stem coronary stenosis, this series delineates those anatomic and clinical exceptions wherein percutaneous transluminal coronary angioplasty may be utilized as the primary therapy for left main stem coronary stenosis.

References (27)

SH Stertzer et al.
Evaluation of transluminal coronary angioplasty in left main coronary artery stenosis
Am J Cardiol
(1981)
WL Proudfit et al.
Natural history of obstructive coronary artery disease: ten year study of 601 nonsurgical cases
Prog Cardiovasc Dis
(1978)
SH Rahimtoola
Coronary arterigraphy in symptomatic patients after myocardial infarction: the need to distinguish between clinical investigation and clinical care
Chest
(1980)
BR Chaitman
Effect of coronary bypass surgery on survival patterns in subsets of patients with left main coronary artery disease
Report of the collaborative study in coronary artery surgery (CASS)
Am J Cardiol
(1981)
A Oberman
The surgical vs medical treatment in disease of the left main coronary artery
Lancet
(1976)
KM Kent
Percutaneous transluminal coronary angioplasty: report from the registry of the National Heart, Lung and Blood Institute
Am J Cardiol
(1982)
HP Krayenbuehl et al.
Percutaneous transluminal coronary angioplasty
AR Gruentzig et al.
Nonoperative dilatation of coronary artery stenosis: percutaneous transluminal coronary angioplasty
N Eng J Med
(1979)
AR Gruentzig
Percutaneous transluminal coronary angioplasty. A cooperative study
Am J Cardiol
(1979)
RK Myler et al.
Coronary angioplasty

AR Gruentzig

Transluminal dilatation of coronary artery stenosis

Lancet

(1978)

P Angelini et al.

Early experience of transluminal angioplasty (TCA) by the brachial artery (the Sones technique in transluminal angioplasty)

Catheterization Cardiovasc Diagn

(1981)

G Dorros et al.

The brachial artery method of transluminal coronary angioplasty

Catherization Cardiovasc Diagn

(1982)

Cited by (66)

Drug-eluting versus bare-metal stents in unprotected left main coronary artery stenosis: A meta-analysis
2010, JACC: Cardiovascular Interventions
We undertook a meta-analysis to assess outcomes for drug-eluting stents (DES) and bare-metal stents (BMS) in percutaneous coronary intervention for unprotected left main coronary artery (ULMCA) stenosis.
Uncertainty exists regarding the relative performance of DES versus BMS in percutaneous coronary intervention for unprotected left main coronary stenosis.
Of a total of 838 studies, 44 met inclusion criteria (n = 10,342). The co-primary end points were mortality, myocardial infarction (MI), target vessel/lesion revascularization (TVR/TLR), and major adverse cardiac events (MACE: mortality, MI, TVR/TLR).
Event rates for DES and BMS were calculated at 6 to 12 months, at 2 years, and at 3 years. Crude event rates at 3 years were mortality (8.8% and 12.7%), MI (4.0% and 3.4%), TVR/TLR (8.0% and 16.4%), and MACE (21.4% and 31.6%). Nine studies were included in a comparative analysis (n = 5,081). At 6 to 12 months the adjusted odds ratio (OR) for DES versus BMS were: mortality 0.94 (95% confidence interval [CI]: 0.06 to 15.48; p = 0.97), MI 0.64 (95% CI: 0.19 to 2.17; p = 0.47), TVR/TLR 0.10 (95% CI: 0.01 to 0.84; p = 0.01), and MACE 0.34 (95% CI: 0.15 to 0.78; p = 0.01). At 2 years, the OR for DES versus BMS were: mortality 0.42 (95% CI: 0.28 to 0.62; p < 0.01), MI 0.16 (95% CI: 0.01 to 3.53; p = 0.13), and MACE 0.31 (95% CI: 0.15 to 0.66; p < 0.01). At 3 years, the OR for DES versus BMS were: mortality 0.70 (95% CI: 0.53 to 0.92; p = 0.01), MI 0.49 (95% CI: 0.26 to 0.92; p = 0.03), TVR/TLR 0.46 (95% CI: 0.30 to 0.69; p < 0.01), and MACE 0.78 (95% CI: 0.57 to 1.07; p = 0.12).
Our meta-analysis suggests that DES is associated with favorable outcomes for mortality, MI, TVR/TLR, and MACE as compared to BMS in percutaneous coronary intervention for unprotected left main coronary artery stenosis.
Outcome After Surgery and Percutaneous Intervention for Cardiogenic Shock and Left Main Disease
2008, Annals of Thoracic Surgery
Citation Excerpt :
However, very few patients undergo CABG for cardiogenic shock complicating myocardial infarction [15]. Acute occlusion of the LMCA can result in severe circulatory decompensation within minutes and often manifests with fatal consequences [16–19]. Wong and associates [20] reported that the mortality was particularly high when the LMCA was the infarct-related artery (78.6%).
The ideal revascularization strategy (bypass surgery versus percutaneous coronary intervention [PCI]) for patients with cardiogenic shock in the setting of left main coronary artery disease is unknown.
The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock Trial and Registry included 164 patients with left main disease who underwent revascularization. Although the standard of care at the time and the trial protocol recommended coronary artery bypass graft surgery for patients with left main disease, the revascularization strategy (79 coronary artery bypass graft surgery and 85 PCI) was individualized for each patient by site investigators.
The median time from myocardial infarction to revascularization was 24.3 hours (interquartile range, 8.7 to 82.5 hours) in the surgical group and 7.4 hours (interquartile range, 3.7 to 19.5 hours) in the PCI group (p < 0.05). Overall 30-day survival with surgery in this setting was 54% (95% confidence interval, 0.43 to 0.69) and was significantly superior to the 14% (95% confidence interval, 0.09 to 0.35) in the PCI group (p ≤ 0.001). When the left main was the infarct-related artery, the 30-day survival rate was 40% in the surgical group (n = 6) and 16% in the PCI group (n = 15; p = 0.03). Coronary artery bypass graft surgery (hazard ratio, 0.41; 95% confidence interval, 0.22 to 0.77; p = 0.006) and age (per 10 years, hazard ratio, 1.04; 95% confidence interval, 1.01 to 1.08; p = 0.02) were independently associated with 30-day survival.
Coronary artery bypass graft surgery appeared to provide a survival advantage over PCI at 30-day follow-up in patients with left main coronary artery disease. The impact of current PCI strategies on this subgroup is undetermined.
Unprotected Left Main Intervention. Patient Selection, Operator Technique, and Clinical Outcomes
2008, JACC: Cardiovascular Interventions
In the 1980s, early attempts at balloon angioplasty of the unprotected left main coronary artery (UPLM) were associated with poor early outcomes because of coronary dissection, abrupt closure, and restenosis. Mortality rates as high as 30% at 1 year were reported. In the 1990s, bare-metal stents helped reduce acute complications, but high rates of repeat revascularization (20% to 30%) were observed because of restenosis. In the early 2000s, the introduction of drug-eluting stents (DES), with the promise of vastly reduced rates of restenosis, raised the possibility of improved late outcomes for UPLM patients receiving stents. Although use of DES for UPLM is currently a class III indication in patients who are candidates for coronary artery bypass graft (CABG), many patients are currently undergoing this procedure. Published registries indicate the procedural and in-hospital risks are acceptable and seem to be the same or lower than the procedural risks of CABG. Unprotected left main ostial and midshaft lesions have excellent early and midterm outcomes that will likely (although not yet proven) be similar to those of CABG. Distal left main lesions involving the bifurcation are technically more challenging and associated with a higher rate of late revascularization. Early registry data have not found excess mortality in patients receiving DES for UPLM when compared with historical bypass surgery data, even when the distal bifurcation is stented. However, current follow-up of stented patients is limited to 1 year or less. Over the next few years, the results of randomized trials will expand the evidence base available to clinicians caring for this challenging patient group.
Left Main Coronary Artery Stenosis: State-of-the-Art
2007, Current Problems in Cardiology
Citation Excerpt :
The high concentration of elastic fibers in the aorto-ostial lesions and subsequent marked recoil has been proposed as possible causes of the high restenosis rate after conventional balloon angioplasty. Due to these limitations of balloon angioplasty, elective percutaneous revascularization of unprotected LMCA stenosis was truncated201 even though the early results were good.200,202,203 In humans, observational IVUS data204 indicate that a larger plaque burden leads to a higher rate of late lumen loss after stenting.
Patients with stenosis of the left main coronary artery present difficult challenges. The risks associated with this lesion have been known since the early days of angiography when patients were found to have increased mortality during follow-up. This information led to the general guidelines that surgical revascularization should be considered the treatment of choice in patients with significant left main coronary artery stenosis.
Current advances in invasive cardiology have brought important information to the field. Intravascular ultrasound is now used routinely to evaluate angiographically indeterminate lesions with criteria now set forward as to what constitutes an indication for revascularization. Stents have even further dramatically changed the landscape. There are substantial issues, however, that need to addressed. These include the following: (1) the effect of specific lesion location on outcome—it is known that patients with distal bifurcation left main disease have worse outcome; (2) the potential for subacute thrombosis of the left main coronary artery; (3) the impact of left ventricular function and patient comorbidities irrespective of the degree and location of left main coronary artery stenosis; and (4) the risk–benefit ratio of stenting versus coronary artery bypass graft surgery.
These issues are currently being addressed in two seminally important trials including the SYNTAX trial, which randomizes patients with left main and/or three-vessel disease to either coronary artery bypass graft surgery or a TAXUS drug-eluting stent. This trial is in the final stages of patient recruitment and will have important implications for the field. The other trial is the COMBAT trial, which is focused exclusively on left main coronary artery stenosis and randomizes patients with left main coronary artery disease either to a Sirolimus-eluting stent (Cypher, Johnson and Johnson Cordis, USA) or to coronary artery bypass graft surgery.
The field of left main coronary artery disease continues to expand in terms of the evidence available for optimal patient evaluation and selection of treatment modalities.
Unprotected left main coronary artery stenting: Immediate and medium-term outcomes of 140 elective procedures
2000, Journal of the American College of Cardiology
OBJECTIVES
We sought to evaluate immediate and late outcomes after stenting for left main coronary artery (LMCA) stenosis.
BACKGROUND
Conventional percutaneous transluminal coronary angioplasty (PTCA), for which coronary artery bypass grafting (CABG) has been the gold standard therapy for years, has yielded poor results in unprotected LMCA lesions. The development of coronary stents, together with their dramatic patency improvement provided by new antiplatelet regimens and their validation against restenosis, warrants a reappraisal of angioplasty in LMCA stenosis.
METHODS
From January 1993 to September 1998, 140 consecutive unselected patients with unprotected LMCA stenosis underwent elective stenting. Group I included 47 high-CABG-risk patients, and group II included 93 low-CABG-risk patients. Ticlopidine without aspirin was routinely started at least 72 h before the procedure and continued for one month. Patients were reevaluated monthly. A follow-up angiography was requested after six months.
RESULTS
The procedure success rate was 100%. One-month mortality was 9% (4/47) in group I and 0% in group II. A follow-up angiography was obtained in 82% of cases, and target lesion revascularization was required in 17.4%. One-year actuarial survival was 89% in the first 29 group I patients and 97.5% in the first 63 group II patients.
CONCLUSIONS
Stenting of unprotected LMCA stenosis provided excellent immediate results, particularly in good CABG candidates. Medium-term results were good, with a restenosis rate of 23%, similar to that seen after stenting at other coronary sites. Stenting deserves to be considered a safe and effective alternative to CABG in institutions performing large numbers of PTCAs.
Interventional revascularization of left main coronary artery stenosis with new devices: Two cases of 'unprotected' left main stenosis treated with atherectomy and stenting
2000, American Journal of the Medical Sciences

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Original studyPercutaneous transluminal coronary angioplasty in left main stem coronary stenosis: a five-year appraisal

Abstract

Am J Cardiol

Prog Cardiovasc Dis

Chest

Am J Cardiol

Lancet

Am J Cardiol