Drug-eluting stents in unprotected left main coronary artery disease

Abstract

Though coronary bypass graft surgery (CABG) has traditionally been the cornerstone of therapy in patients with unprotected left main coronary artery (ULMCA) disease, recent evidence supports the use of percutaneous coronary intervention in appropriate patients. Indeed in patients with ULMCA disease, drug-eluting stents (DES) have shown similar incidence of hard end points, fewer periprocedural complications and lower stroke rates compared with CABG, though at the cost of increased revascularization with time. Furthermore, the availability of newer efficacious and safer DES as well as improvements in diagnostic tools, percutaneous techniques and, importantly, a better patient selection, allowed percutaneous coronary intervention a viable alternative to CABG of left main-patients with low disease complexity; however, even in this interventional era characterized by efficacious DES, patients with ULMCA disease remain a challenging high-risk population where outcomes strongly depend on clinical characteristics, anatomical disease complexity and extension and operator’s experience. This review summarizes the role of DES in ULMCA disease patients.

Keywords::

• coronary stents
• drug-eluting stents
• left main
• outcomes
• percutaneous coronary intervention
• unprotected left main coronary artery disease

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Erratum

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Significant unprotected left main coronary artery (ULMCA) disease represents a unique high-risk condition associated with the highest mortality of any coronary lesion because of the jeopardized myocardium at risk. Furthermore, significant ULMCA stenosis usually coexists with multivessel disease.

• Apart the anatomical complexity of the left main disease itself and of the associated coronary artery disease, patients with ULMCA stenosis often show multiple comorbidities, making coronary revascularization in this patient subset more difficult.

• Revascularization in these patients is the preferred therapeutic option due to a significantly higher mortality rate in those treated medically.

• With the advent of drug-eluting stents, the outcomes of patients treated with ULMCA-PCI have improved reaching a substantial equipoise on safety end points (death, MI) when compared with those treated with coronary bypass graft surgery.

• ULMCA-PCI is still associated with higher repeated revascularizations because of patient’s high-risk profiles and complex coronary lesion characteristics.

• A better patient selection together with improvements in the PCI technique and availability of safer and more effective new drug-eluting stents demonstrated promising results in the percutaneous treatment of ULMCA, especially in some select subgroup of patients.

• For patients with lower coronary artery disease complexity who can undergo PCI at an acceptable risk and with reasonable probability for success, PCI may be an acceptable or even preferred option. Best practice is engagement of Heart Team for SYNTAX score <32 and when feasible, coronary bypass graft surgery for SYNTAX score >33.

• In this setting, the bioabsorbable stents with their temporary scaffolding are a very attractive option in the percutaneous treatment of ULMCA disease. However, to date it still remains an ‘in utero’ treatment.

Notes