Long-Term Results of Stenting in Patients with Hemodynamically Significant Lesions of the Left Main Coronary Artery

Olena V. Levchyshyna; Sergii V. Salo; Yevhenii V. Aksonov; Mykola S. Kyba

doi:10.30702/ujcvs/23.31(04)/LS066-2633

Olena V. Levchyshyna National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine https://orcid.org/0000-0003-0276-4533
Sergii V. Salo National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine https://orcid.org/0000-0001-5456-1418
Yevhenii V. Aksonov National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine https://orcid.org/0000-0003-0808-1813
Mykola S. Kyba National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine https://orcid.org/0009-0007-7390-5969

DOI: https://doi.org/10.30702/ujcvs/23.31(04)/LS066-2633

Keywords: ischemic heart disease, percutaneous coronary intervention, single-stent technique, double-stent technique, TAP, culotte, DK crush, coronary artery bypass grafting

Abstract

The aim. To study the long-term results of stenting in patients with coronary artery disease with hemodynamically significant left main coronary artery (LMCA) stenoses.

Materials and methods. The study included 67 patients (56 men, 11 women) with a mean age of 63 ± 2.1 years.

Results. Among the 67 patients included in the study, 29 patients (43.3%) underwent percutaneous coronary inter-vention using a single-stent technique. These were patients with ostial LMCA lesions, lesions of the middle third of the LMCA and some patients with Medina 1.1.0; 1.0.1; 1.0.0; 0.1.0; 0.0.1 lesions of the distal part of the LMCA. The median follow-up was 2 years. Using a questionnaire, we managed to establish contact with 25 patients (86.2%). Among these, 1 patient (3.4%) died of non-cardiac causes and 7 patients (24.1%) had a recurrence of angina within 2 years. The causes of angina recurrence in 2 cases (6.9%) were restenosis in the stent with transition to the mouth of the side branch, which required repeated stenting of the LMCA with transition to the left circumflex artery. In 5 patients (17.2%), angina recur-rence was associated with progression of coronary atherosclerosis of another localization.

Among 67 patients with LMCA stenting, the two-stent technique was used in 38 patients (56.7%). These were pa-tients with Medina 1.1.0; 1.0.1; 1.0.0; 0.1.0; 0.0.1 lesions of the distal part of the LMCA. The median follow-up was 2 years. Using a questionnaire, we managed to contact 35 patients (92.1%). Among these, 4 patients (10.5%) died, but only one of them due to cardiac causes (2.6%), and 3 patients (7.9%) had recurrent angina within 2 years, two of whom underwent stenting by the T and protrusion (TAP) technique and one by culotte. The first two patients underwent angioplasty of restenosis in stents using balloons with a therapeutic coating. In the last patient, stent recoil in the left circumflex artery mouth was observed due to severe calcification, so this patient underwent re-implantation of the stent system in the recoil zone.

Conclusions. The problem of choosing a method of revascularization for patients with hemodynamically significant LMCA lesions remains controversial to this day, despite the wide range of evidence. Doctors should jointly decide on the choice of treatment methodology solely in the interests of the patient, taking into account all the factors that may affect the patient’s quality of life in the long term.

References

Ragosta M, Dee S, Sarembock IJ, Lipson LC, Gimple LW, Powers ER. Prevalence of unfavorable angiographic characteristics for percutaneous intervention in patients with unprotected left main coronary artery disease. Catheter Cardiovasc Interv. 2006;68(3):357-362. https://doi.org/10.1002/ccd.20709
Taggart DP, Kaul S, Boden WE, Ferguson TB Jr, Guyton RA, Mack MJ, et al. Revascularization for Unprotected Left Main Stem Coronary Artery Stenosis: Stenting or Surgery. J Am Coll Cardiol. 2008;51(9):885-892. https://doi.org/10.1016/j.jacc.2007.09.067
Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al.; SYNTAX Investigators. Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease. N Engl J Med. 2009;360(10):961-972. https://doi.org/10.1056/NEJMoa0804626
Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al.; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87-165. https://doi.org/10.1093/eurheartj/ehy394
Byrne RA, Fremes S, Capodanno D, Czerny M, Doenst T, Emberson JR, et al. 2022 Joint ESC/EACTS review of the 2018 guideline recommendations on the revascularization of left main coronary artery disease in patients at low surgical risk and anatomy suitable for PCI or CABG. Eur Heart J. 2023;44(41):4310-4320. https://doi.org/10.1093/eurheartj/ehad476
Medina A, Suárez de Lezo J, Pan M. Una clasificación simple de las lesiones coronarias en bifurcación [A New Classification of Coronary Bifurcation Lesions]. Rev Esp Cardiol. 2006 Feb;59(2):183. Spanish.
Raphael CE, O’Kane PD. Contemporary approaches to bifurcation stenting. JRSM Cardiovasc Dis. 2021 Feb24;10:2048004021992190.https://doi.org/10.1177/2048004021992190
Hildick-Smith D, Behan MW, Lassen JF, Chieffo A, Lefèvre T, Stankovic G, et al. The EBC TWO Study (European Bifurcation Coronary TWO): A Randomized Comparison of Provisional T-Stenting Versus a Systematic 2 Stent Culotte Strategy in Large Caliber True Bifurcations. Circ Cardiovasc Interv. 2016 Sep;9(9):e003643. https://doi.org/10.1161/CIRCINTERVENTIONS.115.003643
Banning AP, Lassen JF, Burzotta F, Lefèvre T, Darremont O, Hildick-Smith D, et al. Percutaneous coronary intervention for obstructive bifurcation lesions: the 14th consensus document from the European Bifurcation Club. EuroIntervention. 2019;15(1):90-98. https://doi.org/10.4244/EIJ-D-19-00144
Burzotta F, Lassen JF, Louvard Y, Lefèvre T, Banning AP, Daremont O, et al. European Bifurcation Club white paper on stenting techniques for patients with bifurcated coronary artery lesions. Catheter Cardiovasc Interv. 2020;96(5):1067-1079. https://doi.org/10.1002/ccd.29071
Di Gioia G, Sonck J, Ferenc M, Chen SL, Colaiori I, Gallinoro E, et al. Clinical Outcomes Following Coronary Bifurcation PCI Techniques: A Systematic Review and Network Meta-Analysis Comprising 5,711 Patients. JACC Cardiovasc Interv. 2020;13(12):1432-1444. https://doi.org/10.1016/j.jcin.2020.03.054