Unprotected left main disease managed with drug-eluting stents: long-term outcome of 100 patients with increased surgical risk.

OBJECTIVES: The purpose of this study was to determine long-term clinical outcomes in high surgical risk patients (pts) with unprotected left main (ULM) disease who were managed with drug-eluting stents (DES). BACKGROUND: The long-term efficacy of unprotected left main (ULM) stenting with DES remains uncertain. METHODS: From June 2003 to December 2005, 100 pts with increased surgical risk underwent ULM stenting with DES. Patient risk was estimated by EuroSCORE. Disease was confined to the ostium/main stem in Group A (31 pts) and involved the bifurcation in Group B (69 pts). Study endpoints were MI, TVR, and death. RESULTS: Mean age was 68 +/- 1 years, EF 52 +/- 1%. Mean EuroSCORE was 5.2 +/- 0.4, and 41% pts had a EuroSCORE of >6. In Group A, 87% of lesions were directly stented. In Group B, 61% of pts received one stent and 39% received two stents. Primary success was 95%. Follow-up data (mean 28 +/- 1 months) were obtained in all patients. Restenosis occurred at the proximal stent margin in 5/9 pts. There were 12 cardiac deaths (88% cardiac survival) and 9 noncardiac deaths (79% total survival). In Group B, 5 pts died suddenly: 3 within the first week and 2 additional pts after 1 year. Sudden death did not occur in Group A. All cause event-free survival was 65% in Group A and 67% in Group B. CONCLUSION: A substantial number of late adverse events occurred in both ostial and bifurcation groups with equal frequency. Until definitive data from randomized trials are available, ULM stenting should be performed only in patients with prohibitive surgical risk.

Isolated disease of the ostium left anterior descending or circumflex artery: management using a left main stenting technique. Clinical outcome at 2 years.

BACKGROUND: Ostial disease of the left anterior descending (LAD) or circumflex (LCX) coronary artery is a challenge for the interventionalist. Focal ostial stenting may result in incomplete lesion coverage or plaque shift into the adjacent vessel, creating left main equivalent disease. The purpose of the present study was to address these concerns by using a left main bifurcation strategy with drug-eluting stents (DES) for the treatment of this problem. METHODS: The study population consisted of patients with isolated unprotected ostial stenosis of the LAD or LCX artery. Coronary stenting was performed using a bifurcational technique in which DES were deployed from the distal left main artery across the stenosis into the main branch. Post-deployment kissing balloon inflation with provisional side branch stenting was then performed. Clinical and angiographic follow up was obtained to assess the primary endpoint of death, non-fatal myocardial infarction (MI) or target lesion revascularization (TLR). RESULTS: Thirty-three patients (19 males, 14 females) with a mean age of 67 years were evaluated. Clinical follow up was available in all patients; the mean duration of follow up was 24 months. One cardiac death and 1 non-fatal MI occurred. Protocol-driven follow-up angiography with intravascular ultrasound (IVUS) was obtained at a mean of 11 months in 91% of patients. The incidence of TLR was 15%. CONCLUSION: Main branch stenting with post-stent deployment kissing balloon inflations and provisional side branch stenting may be a reasonable option for the treatment of ostial LAD or LCX disease.