S tenting of unprotected left main coronary artery in patients with low preoperative risk
of coronary artery bypass grafting
D
Daarriiuusszz DDuuddeekk,, GGrrzzeeggoorrzz HHeebbaa,, DDaawwiidd GGiisszztteerroowwiicczz,, ŁŁuukkaasszz RRzzeesszzuuttkkoo,, JJaacceekk LLeegguuttkkoo,, SSttaanniissłłaaww BBaarrttuuśś,, MMiicchhaałł CChhyyrrcchheell,, JJaacceekk SS.. DDuubbiieell
2ndDepartment of Cardiology, Institute of Cardiology, Collegium Medicum, Jagiellonian University, Kraków, Poland
Address for correspondence:
Dr. Dariusz Dudek, II Klinika Kardiologii Instytutu Kardiologii, Collegium Medicum UJ, ul. Kopernika 17, 31-501 Kraków, tel.: +48 12 424 71 85, fax: +48 12 424 71 84, e-mail: mcdudek@cyf_kr.edu.pl
R
Reecceeiivveedd:: 13 June 2005. AAcccceepptteedd:: 12 April 2006.
A b s t r a c t
IInnttrroodduuccttiioonn:: Available data indicate that stenting of the left main coronary artery (LMN) is safe and effective. Restenosis remains the main factor limiting the effectiveness of percutaneous coronary intervention (PCI).
A
Aiimm:: To evaluate immediate and long-term results of treatment of patients with LMN disease and low preoperative risk of coronary artery bypass grafting.
M
Meetthhooddss:: Coronary stents were implanted into LMN in 64 patients. The following strategy was applied: drug eluting stent (DES) for LMN diameter ≤3.5 mm (28 subjects) and bare metal stent (BMS) for LMN diameter >3.5 mm (36 subjects). Patients enrolled in the study underwent clinical evaluation and coronary angiography. Immediate effect of the procedure and main adverse cardiac events were assessed: death, myocardial infarction and additional target lesion or non-target lesion revascularization.
R
Reessuullttss:: Angiographic and clinical effectiveness of the interventions was 100%. Full revascularisation of ischaemic regions of the myocardium was performed. Mean clinical follow-up period was 9.4±4.0 months. Neither death nor myocardial infarction occurred. Additional PCIs were performed in 11 (17.2%) patients; however, target vessel revascularisation (TVR) rate within LMN was 9.4% (i.e. 6 subjects with BMS), and non-TVR rate was 7.8% (5 subjects).
C
Coonncclluussiioonnss:: LMN stenting is associated with high effectiveness of PCI in patients with low operative risk. Long-term follow-up revealed low incidence of major adverse cardiac events. Strategy of selective use of DESs in the study group produced good clinical outcome. Multivessel disease with LMN stenosis was associated with high rate of additional revascularisation of other vessels. Further improvement of treatment results may be obtained by more common use of DES for multivessel disease and LMN diameters larger than 4.0 mm.
K
Keeyy wwoorrddss:: left main coronary artery, stenting, outcome
Kardiol Pol 2006; 64: 929-936
Introduction
The recommended method of treatment of ischaemic heart disease with critical stenosis of the left main coronary artery (LMN) is surgical revascularisation, i.e. coronary artery bypass grafting (CABG). However, in patients who are not optimal candidates for CABG, the possibility of percutaneous treatment has also been approved (class II B according to the American Heart Association) [1]. Percutaneous treatment of isolated
stenosis of LMN uses both bare metal stents (BMS) and drug eluting stents (DES) [2]. Despite a lack of randomised trials, the available data [3] indicate that stenting of LMN is safe and effective. Restenosis still remains the key factor limiting the long-term effectiveness of percutaneous coronary intervention (PCI) and is associated with poor outcome [4].
The present study aimed to evaluate immediate and long-term effects of treatment of 64 patients
with LMN disease undergoing PCI and insertion of BMS or DES, who had low preoperative risk of CABG.
Methods Patients
Between August 2002 and September 2004 LMN stenting was performed in 64 consecutive patients at the Second Department of Cardiology of the Institute of Cardiology, Collegium Medicum, Jagiellonian University. All patients gave their written consent to participate in the study. The approval of the Ethics Committee was obtained. Risk was estimated for every patient using Euroscore preoperative risk assessment as a sum of 17 factors. Euroscore value >5 is associated with higher 30-day mortality of patients undergoing cardiac surgery [5].
Angiographic evaluation
Baseline (before and at the completion of coronary intervention) and follow-up coronary angiography was performed in at least two perpendicular planes after intracoronary administration of 0.2 mg nitroglycerine.
Baseline angiographic views were also recorded at 2 and 6 months during follow-up coronary angiography.
Angiographic restenosis at long-term follow-up was defined as at least 50% reduction of lumen within the treated region. Quantitative coronary angiography analysis was performed by an independent observer using New Quant32, QCAPlus software (Sanders Data Systems, Palo Alto, CA, USA). Lesions within the distal segments of LMN (bifurcation) were divided into three types according to the Lefevre classification [6].
Coronary stenting procedure
The following approach was applied: sirolimus eluting stent (SES) (Cypher, Cordis, USA) or paclitaxel eluting stent (PES) (Taxus Express 2, Boston Scientific, USA) were used in patients with LMN reference diameter lower than or equal to 3.5 mm and bare metal stent (BMS) in patients with LMN reference diameter greater than 3.5 mm. The diameter of 3.5 mm was imposed by the maximum available DES size throughout the study. For treatment of distal LMN lesions the T-stenting technique was preferred. Patients were given unfractionated heparin (100 U/kg i.v.).
Abciximab administration was operator dependent. All patients received antiplatelet treatment: clopidogrel 300 mg prior to the procedure and then 75 mg in addition to aspirin (75 mg to 150 mg). Patients treated with DES received clopidogrel over 6 to 12 months, and in patients treated with BMS clopidogrel or ticlopidine was used for 1 to 6 months.
Clinical and angiographic follow-up
Patients underwent clinical evaluation after one month and surveillance coronary angiography was performed at 2 and 6 months following stent insertion or at appearance of clinical symptoms. Effectiveness of PCI was defined as residual stenosis within the target lesion below 20% on coronary angiography without major adverse cardiac events (MACE). Major adverse cardiac events were defined as follows: cardiac death, nonfatal myocardial infarction and target vessel revascularisation (TVR) which was defined as revascularization of LMN or proximal segments of the left anterior descending coronary artery or left circumflex coronary artery. Non-target vessel revascularization (non-TVR) was defined as revascularization at any other location.
Statistical analysis
Data are presented as mean ± standard deviation or as patient numbers and percentages. Survival and cumulative risk of MACE were estimated using the Kaplan-Meier method. Continuous variables were compared by means of Student’s t-test for dependent samples. Differences between categorical variables were analysed using Fisher’s exact test. Two-sided tests with p <0.05 confidence level were used.
Results
Study population
Clinical characteristics are presented in Table I. Among 64 patients enrolled in the study, 8 patients had high preoperative risk (Euroscore value >5) while 56 had low preoperative risk as measured with the Euroscore scale (≤5). Urgent interventions were performed in 8 patients (2 subjects from the high risk group and 6 subjects with low preoperative risk). Patients were referred for LMN stenting as they did not consent to CABG (87.5%, 56 patients); urgent indications included LMN dissection (9.4%, 6 patients) and cardiogenic shock secondary to acute coronary syndrome (3.1%, 2 subjects). All interventions were performed on unprotected LMN.
Analysed lesions were located within the ostium of LMN in 17% of cases, mid segment in 8% of cases and distal part in 75% of cases. Mean length of target lesion was 15.4±8.9 mm. De novo lesions were found in 63 subjects and one patient was treated due to restenosis (Euroscore scale <5).
Immediate treatment results
Stents were successively deployed in all 64 participants – 36 subjects received BMS, 13 received SES and 15 received PES. Angiographic and clinical effectiveness of the interventions was 100%. In 20 (31%)
patients PCI was also performed within another vessel (left anterior descending branch – 48%, right coronary artery – 38% and left circumflex branch – 14%).
Full revascularisation of ischaemic regions of the myocardium was obtained in all subjects. In 43 (67%) subjects, direct stenting of LMN was performed, and 21 (33%) subjects had previous predilation with a balloon catheter. In 56 (88%) patients deployment of stents was followed balloon post-dilatation. In the study group an intraaortic balloon pump was urgently required in 3 patients and abciximab was administered in 24 (38%) subjects, including 8 cases of urgent use.
Angiographic data and PCI characteristics are presented in Tables II and III. Periprocedural myocardial
Age 58±9.5
Gender – males 80% (51)
Stable angina pectoris 70% (45)
Unstable angina pectoris 27% (17)
Acute myocardial infarction 3% (2)
CCS class
I 11% (7)
II 39% (25)
III 27% (17)
IV 23% (15)
Arterial hypertension 73% (47)
Diabetes mellitus 8% (5)
Nicotinism 38% (24)
Hypercholesterolaemia 73% (47)
BMI >30 kg/m2 16% (10)
Chronic renal failure 1.6% (1)
Chronic obstructive pulmonary disease 1.6% (1)
Peripheral atherosclerosis 6% (4)
Past myocardial infarction 39% (25)
Heart failure 0
Past CABG 0
Past PCI 30% (19)
Coronary angioplasty 6% (4)
Past insertion of coronary stents 23% (15) Intracoronary brachytherapy in the past 1.6% (1)
LVEF 58 ± 10.1%
Elective indications for PCI of LMN 87.5% (56) Urgent indications for PCI of LMN 12.5% (8) High risk patients – Euroscore >5 12.5% (8) Low risk patients – Euroscore <5 87.5% (56)
T
Taabbllee II.. Baseline patient characteristics (n=64).
Number of patients is given in brackets
LLooccaattiioonn ooff lleessiioonn
Proximal part 17% (11)
Mid part 8% (5)
Distal part 75% (48)
Calcifications 8% (5)
Eccentric lesions 58% (37)
De novo lesion 98% (63)
Restenosis 2% (1)
N
Nuummbbeerr ooff aaffffeecctteedd vveesssseellss
1 vessel 27% (17)
2 vessels 40% (26)
3 vessels 20% (13)
Isolated LMN lesion 13% (8)
LLMMNN wwiitthh bbiiffuurrccaattiioonn lleessiioonn ((nn==4499))
Type 1 33% (16)
Type 2 53% (26)
Type 3 14% (7)
B
Baasseelliinnee QQCCAA ((nn==3300))
Reference vessel (mm) 3.06±0.45
MLD (mm) 1.41±0.44
%DS 53.8±15.2
Lesion length (mm) 15.4±8.9
Q
QCCAA ppoosstt PPCCII ((nn==2222))
Reference vessel (mm) 3.61±0.43
MLD (mm) 3.05±0.36
%DS 15.4±9.7
Immediate increase of luminal diameter (mm) 1.69±0.60 FFoollllooww--uupp aannggiiooggrraapphhyy aatt mmoonntthh 22 ((nn==1199))
Reference vessel (mm) 3.42±0.41
MLD (mm) 2.71±0.51
%DS 21.6±10.3
Long-term increase of luminal diameter (mm) 0.42±0.37 FFoollllooww--uupp aannggiiooggrraapphhyy aatt mmoonntthh 66 ((nn==1177))
Reference vessel (mm) 3.31±0.38
MLD (mm) 2.61±0.56
%DS 22.7±12.1
Long-term increase of luminal diameter (mm) 0.51±0.48 LLMMNN rreesstteennoossiiss 99%% ((66))
Ostium 3% (2)
Mid part 0
Distal part 6% (4)
T
Taabbllee IIII.. Angiographic characteristics
Abbreviations: QCA – quantitative coronary angiography, DS – degree of reduction of vessel diameter at the site of lesion, MLD – minimal luminal diameter
infarction was observed in one patient who underwent urgent deployment of stent for LMN dissection and imminent occlusion of the artery. All patients were discharged home without angina. Example LMN stenting procedure is shown in Figure 1.
Long-term outcomes
Mean clinical follow-up period was 9.2±4.2 months (range from 6 to 18 months) and no death or myocardial infarction was reported. No in-stent thrombosis was observed (Table IV). Six (9.4%) patients with BMS inserted at baseline underwent TLR (3 patients required urgent treatment and among patients treated electively two had low and one had high preoperative risk). Four of those patients remained under clinical surveillance (from 1 to 13 months) without presenting angina; 2 of them underwent PCI and were finally selected for CABG due to another restenosis. Evaluation also included the incidence of non- TVR, which was 7.8% (5 patients). Triple-vessel disease
was confirmed in three of those patients and two-vessel disease in the remaining two. Additional PCIs were carried out in a total of 11 (17.2%) patients. Patient characteristics, detailed anatomical location of restenosis and time to revascularization are listed in Table V. Figure 2 shows Kaplan-Meier revascularisation free (88%) and TVR free survival curves (96%).
Subgroup analysis (Table VI) revealed significant differences of TVR rate in patients in whom DES was deployed (n=36) in comparison to patients treated with BMS (n=28) (0% vs 21.4%, p <0.006, respectively), and between the subgroup of patients treated for urgent indications and subjects treated electively – 50% vs 1.7%
(p <0.002, respectively). Furthermore, in the subgroup with distal LMN stenosis significantly lower incidence of MACE (i.e. TVR and non-TVR) was recorded in patients treated using the kissing balloon technique compared to subjects treated with a different method (6.7% vs 38.9%, respectively, p <0.009). Follow-up coronary angiography at 6 months (mean 8.9±4.9 months) was performed in 52 of 64 patients (81%).
Discussion
The majority of participants (78.1%) had low operative risk and indications for elective coronary revascularization as well as preserved left ventricular ejection fraction. Therefore, expected long-term clinical outcome in this group after LMN stenting should be good. Stenting of LMN in patients with high preoperative risk is associated with urgent indications for myocardial
Angiographic effectiveness 100%
Clinical effectiveness of the procedure 100%
Inserted stent
Sirolimus eluting stent (SES) 13 patients Paclitaxel eluting stent (PES) 15 patients
Proximal location 1
Mid location 1
Distal location 26
Bare metal stent (BMS) 36 patients
Proximal location 10
Mid location 4
Distal location 22
Mean stent diameter 3.6±0.4 mm
Mean stent length 18.5±7.4 mm
Number of stents per patient 1.1
Total treatment of lesions in other vessels 33% (21)
Administration of abciximab 38% (24)
IVUS guidance 25% (16)
Max inflation pressure 13±2.2 atm
Max balloon diameter 4.1±0.37 mm
Direct stenting 67% (43)
Stenting with predilation 33% (21)
Postdilation 88%(56)
Intraaortic balloon pump 5% (3)
Stenting of LMN only 25% (16)
Stenting of bifurcation lesion 75% (48) T
Taabbllee IIIIII.. Percutaneous coronary intervention characteristics (n=64)
IInn--hhoossppiittaall aaddvveerrssee eevveennttss
Death 0
CABG 0
Myocardial infarction 1.6% (1)
TVR 0
Total MACE 1.6% (1)
LLoonngg--tteerrmm ffoollllooww--uupp
Death 0
Myocardial infarction 0
TVR 9.4% (6)
Non-TVR 7.8% (5)
CABG 3.1% (2)
(in patients with previous TLR) Total MACE (TVR + nonTVR + MI + death) 17.2% (11)
T
Taabbllee IIVV.. Clinical follow-up
CABG – coronary artery bypass grafting, MI – myocardial infarction, TVR – target lesion revascularization, Non-target TVR – non-target lesion revascularization, MACE – major adverse cardiac events
FFiigguurree 11.. Examples of LMN stenting. AA – proximal LMN stenosis. AA11 – reference vessel diameter >3.5 mm, A
A22 – BMS 4.0 x 16 mm stenting after predilatation with balloon catheter, AA33 – control angiography after 12 months. BB – Distal LMN stenosis. BB11 – reference vessel diameter >3.5 mm, BB22 – BMS 4.0 x 20 mm stenting in LMN and LAD with kissing balloon technique, BB33 – control angiography after 6 months
A A
B B
11 22 33
11 22 33
A
Aggee,, ggeennddeerr FFoollllooww--uupp LLeessiioonn llooccaattiioonn RReesstteennoossiiss ((RR)) BBiiffuurrccaattiioonn SStteenntt ttyyppee TTrreeaattmmeenntt a
annggiiooggrraapphhyy vvss lleessiioonn ((BBMMSS vvss DDEESS)) ((mmoonntthhss)) PPrrooggrreessssiioonn ((PP))
61 m 6 TV (PLM) R Yes BMS PCI (balloon)
54 m 4 TV (DLM) R Yes BMS PCI (balloon)
54 f 5 TV (DLM)-ost Cx R Yes BMS PCI (stent)
67 f 2 TV (DLM) R Yes BMS PCI (balloon)
65 m 3 TV (DLM)-ostLAD R No BMS PCI (stent)
59 f 2 TV (DLM)-ostCx R Yes BMS PCI (balloon)
73 m 5 NTV (RCA) R No DES PCI (balloon)
62 m 4 NTV (LADmid) R No DES PCI (balloon)
61 m 2 NTV (LADmid) P No DES PCI (balloon)
47 m 11 NTV (LADprox) R No DES PCI (stent)
61 m 2 NTV (LADprox) P Yes DES PCI (stent)
T
Taabbllee VV.. Adverse events
1PLM – proximal part of LMN, DLM – distal part of LMN, LAD prox – LAD mid-proximal and mid part of the left anterior descending branch, TV – target vessel, NTL – non-target vessel, DES – drug eluting stent, BMS – bare metal stent
revascularisation such as acute myocardial infarction, cardiogenic shock or comorbidities that considerably increase the risk of cardiac surgery. In the study group 8 (12.5%) patients had high preoperative risk as assessed
with the Euroscore scale. Two MACE occurred in this group: one TVR after previous BMS deployment and one non-TVR. No significant differences regarding MACE were observed during long-term follow-up between low
S
Suubbggrroouupp ((nn)) TTVVRR %% ((nn)) PP NNoonn--TTVVRR %% ((nn)) PP MMAACCEE %% ((nn)) PP drug eluting stent (36) vs bare metal stent (28) 0% (0) vs 21.4% (6) 0.006 14.3% (5) vs 0% (0) NS 14.3% (5) vs 21.4% (6) NS urgent (6) vs elective (58) 50% (3) vs 1.7% (1) 0.002 16.7% (1) vs 1.7% (1) NS 66.7% (4) vs 3.4% (2) 0.005 high operative risk (8) vs low operative risk (56) 12.5% (1) vs 8.9% (5) NS 12.5% (1) vs 7.2% (4) NS 25% (2) vs 16.1% (9) NS acute coronary syndrome (19) 15.8% (3) vs 6.7% (3) NS 5.3% (1) vs 8.9% (4) NS 21.1% (4) vs 15.6% (7) NS vs stable angina pectoris (45)
distal lesion (48) vs proximal or mid lesion (16) 8.3% (4) vs 2.5% (2) NS 6.3% (3) vs 12.5% (2) NS 14.6% (7) vs 25% (4) NS kissing balloon technique (30) 3.3% (1) vs 22.2% (4) NS 3.3% (1) vs 16.7% (3) NS 6.7% (2) vs 38.9% (7) 0.009 vs other technique (18)
patients with multivessel disease (39) 10.2% (4) vs 8% (2) NS 12.8% (5) vs 4% (1) NS 23.1% (9) vs 12% (3) NS vs patients with single vessel disease (25)
T
Taabbllee VVII.. Analysis of results in patient subgroups
and high preoperative risk groups, which most probably resulted from the low number of high risk patients.
Clinical outcome of patients with PCI of LMN is not as beneficial as for subjects with other coronary arteries treated. Recently published data [3, 4] regarding elective LMN stenting indicate that inhospital mortality ranges from 0% to 4% for elective procedures and increases to 13.7% for urgent interventions. Incidence of MACE reported in the above mentioned trials was 6.8% to 16%
for TLR, 0% to 2.6% for myocardial infarction and 0.7%
to 11% for mortality during 7.3- to 36-month long-term follow-up. Neither death nor myocardial infarction occurred during long-term follow-up in the present study, overall survival was 100% and MACE free survival was 88%; these results remain compatible with the available data for low risk populations [7, 8]. In our study restenosis occurred within up to 6 months following the procedure which is similar to data reports in literature.
The only MACE observed during 6 month clinical follow- up were additional revascularisations with the
frequency of 17.2%, including non-TVR in patients with known multivessel disease, which totalled 7.8%.
In this study increased rate of additional revascularisations of non-target vessels was observed in the subgroup of subjects treated for urgent indications (p <0.002) compared to elective patients. In contrast to our results, the findings published by Lee et al. refer to 31-month clinical follow-up free of cardiac events in 10 patients treated with urgent stenting for LMN dissection [9]. On the other hand, available data involving larger numbers of patients treated with urgent insertion of stent for imminent occlusion (studies did not refer to PCI of LMN) indicate a considerable percentage of events during follow-up, in particular in-hospital complications [10]. A similarly high percentage of adverse events was reported in patients with myocardial infarction treated with LMN stenting [11].
Use of DES seems to be critical for improvement of long-term results of management of patients with LMN disease. Insertion of DES was associated with a decrease in the restenosis rate and the need for additional revascularisations that were proven in a number of randomised clinical trials [12]. The strategy of treatment of patients with LMN disease applied in this study made the procedure technique dependent on LMN anatomy – the use of BMS for arteries with greater diameters (>3.5 mm) was justified by the risk of restenosis following insertion of stents in such lesions [13]. There is also a possibility of DES polymer damage during deployment of stent in LMN with diameters above 3.5 mm (drug eluting stent diameters of 4 mm and above were unavailable for the duration of the study).
Both SES and PES were used and their effectiveness and safety over BMS were confirmed in randomised clinical trials [14]. The most important conclusion of this reference publication was the lack of deaths during long-term follow- up and low frequency of additional revascularisation (0% and 2% at 6 and 12 months of follow-up). In the
1.0
0.8
0.6
0.4
0.2
0.0
3 6 9 12 15 18 T
Tiimmee ((mmoonntthhss))
EEvveenntt FFrreeee SSuurrvviivvaall
FFiigguurree 22.. Kaplan-Meier curves. Any revascula- risation free survival (dotted line) and target lesion revascularisation free survival (solid line)
present study TVR did not occur in the DES group (p <0.006), which demonstrates the value of DES for treatment of complex high risk lesions.
Bifurcation stenoses are typical lesions associated with negative prognosis while treated with PCI. The preferred approach at our site is a provisional T-stenting strategy which involves deployment of stent into the parent vessel with subsequent balloon angioplasty of the side branch (kissing balloon technique) and stenting of the side branch in case of suboptimal angioplasty effect [15]. For coronary arteries, insertion of BMS into the parent artery and its side branch shows no advantage over a provisional T-stenting approach [16]. A similar relationship seems to apply also for the use of DES [17].
Thus, in clinical practice concurrent insertion of two stents was avoided. Only 4 patients required bifurcation reconstruction using two stents. In the majority of patients stent was deployed within LMN and the left anterior descending coronary artery. Progression of atherosclerosis in the side branch may become a difficult therapeutic problem and a significant limitation of the technique. According to the results for lesions located in other coronary arteries, also in our study a lower number of MACE was recorded (both TVR and nonTVR) for stent insertion into the parent artery with subsequent balloon angioplasty of the side branch using the kissing balloon technique [18].
Conclusions
1. Stenting of the unprotected left main coronary artery is safe clinically, as well as angiographically effective in patients with low operative risk and elective indications for intervention.
2. Long-term follow-up shows high survival rate and low incidence of major cardiac adverse events in these patients.
3. The strategy of selective use of drug eluting stents in the described population produces good clinical outcomes; however, further improvement of the effectiveness will most likely be possible after the use of drug eluting stents for stenting of larger vessels (diameter above 4 mm).
R
Reeffeerreenncceess
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2. Park SJ, Park SW, Hong MK, et al. Stenting of unprotected left main coronary artery stenoses: immediate and late outcomes.
J Am Coll Cardiol 1998; 31: 37-42.
3. Silvestri M, Barragan P, Sainsous J, et al. Unprotected left main coronary artery stenting: immediate and medium-term outcomes of 140 elective procedures. J Am Coll Cardiol 2000; 35: 1543-50.
4. Takagi T, Stankovic G, Finci L, et al. Results and long-term predictors of adverse clinical events after elective percutaneous interventions on unprotected left main coronary artery.
Circulation 2002; 106: 698-702.
5. Nashef SA, Roques F, Michel P, et al. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999; 16: 9-13.
6. Lefevre T, Louvard Y, Morice MC, et al. Stenting of bifurcation lesions: classification, treatments, and results. Catheter Cardiovasc Interv 2000; 49: 274-83.
7. Tan WA, Tamai H, Park SJ, et al. Long-term clinical outcomes after unprotected left main trunk percutaneous revascularization in 279 patients. Circulation 2001; 104: 1609-14.
8. Takagi T, Stankovic G, Finci L, et al. Results and long-term predictors of adverse clinical events after elective percutaneous interventions on unprotected left main coronary artery.
Circulation 2002; 106: 698-702.
9. Lee SW, Hong MK, Kim YH, et al. Bail-out stenting for left main coronary artery dissection during catheter-based procedure:
acute and long-term results. Clin Cardiol 2004; 27: 393-5.
10. Witkowski A, Chmielak Z, Dąbrowski M, et al. High-Pressure bail-out coronary stenting without anticoagulation: early outcome and follow-up results. J Invasive Cardiol 1998; 10: 83-8.
11. Lee SW, Hong MK, Lee CW, et al. Early and late clinical outcomes after primary stenting of the unprotected left main coronary artery stenosis in the setting of acute myocardial infarction. Int J Cardiol 2004; 97: 73-6.
12. Saia F, Degertekin M, Lemos PA, et al. Drug-eluting stents:
from randomized trials to the real world. Minerva Cardioangiol 2004; 52: 349-63.
13. Cutlip DE, Chauhan MS, Baim DS, et al. Clinical restenosis after coronary stenting: perspectives from multicenter clinical trials.
J Am Coll Cardiol 2002; 40: 2082-9.
14. Arampatzis CA, Lemos PA, Tanabe K, et al. Effectiveness of sirolimus-eluting stent for treatment of left main coronary artery disease. Am J Cardiol 2003; 92: 327-9.
15. Yamashita T, Nishida T, Adamian MG, et al. Bifurcation lesions:
two stents versus one stent-immediate and follow-up results.
J Am Coll Cardiol 2000; 35: 1145-51.
16. Al Suwaidi J, Berger PB, Rihal CS, et al. Immediate and long- term outcome of intracoronary stent implantation for true bifurcation lesions. J Am Coll Cardiol 2000; 35: 929-36.
17. Pan M, de Lezo JS, Medina A, et al. Rapamycin-eluting stents for the treatment of bifurcated coronary lesions: a randomized comparison of a simple versus complex strategy. Am Heart J 2004; 148: 857-64.
18. Lefevre T, Louvard Y, Morice MC, et al. Stenting of bifurcation lesions: a rational approach. J Interv Cardiol 2001; 14: 573-85.
Stentowanie niezabezpieczonego pnia głównego
lewej tętnicy wieńcowej u pacjentów o niskim ryzyku operacji pomostowania aortalno-wieńcowego
D
Daarriiuusszz DDuuddeekk,, GGrrzzeeggoorrzz HHeebbaa,, DDaawwiidd GGiisszztteerroowwiicczz,, ŁŁuukkaasszz RRzzeesszzuuttkkoo,, JJaacceekk LLeegguuttkkoo,, SSttaanniissłłaaww BBaarrttuuśś,, MMiicchhaałł CChhyyrrcchheell,, JJaacceekk SS.. DDuubbiieell
II Klinika Kardiologii, Instytut Kardiologii, Collegium Medicum, Uniwersytet Jagielloński, Kraków
S t r e s z c z e n i e W
Wssttęępp:: Dostępne dane wskazują, że stentowanie pnia głównego lewej tętnicy wieńcowej (PG LTW) jest postępowaniem bezpiecznym i skutecznym. Zjawisko restenozy pozostaje głównym ograniczeniem skuteczności przezskórnych interwencji wieńcowych (percutaneous coronary interventions, PCI).
C
Ceell:: Ocena bezpośrednich oraz długoterminowych wyników leczenia pacjentów z chorobą PG LTW o niskim ryzyku operacji pomostowania aortalno-wieńcowego.
M
Meettooddyy:: U 64 pacjentów implantowano stenty wieńcowe do PG LTW. Przyjęto następującą strategię: użycie stentu pokry- wanego (DES) przy średnicy PG LTW≤3,5 mm (28 chorych) oraz stentu metalowego (BMS) przy średnicy PG LTW >3,5 mm (36 chorych). Pacjenci włączeni do rejestru zostali poddani kontroli klinicznej oraz koronarograficznej. Oceniano bezpośrednią skuteczność zabiegu oraz duże incydenty sercowe: zgon, zawał serca lub ponowną rewaskularyzację – zmiany uprzednio leczo- nej (TLR) oraz progresji miażdżycy (nonTLR).
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Wyynniikkii:: Skuteczność angiograficzna i kliniczna zabiegów wyniosła 100%. Przeprowadzono pełną rewaskularyzację niedokrwio- nych obszarów mięśnia sercowego. Średni okres obserwacji klinicznej wyniósł 9,4±4,0 mies. Nie stwierdzono przypadków zgonu lub zawału serca. Ponowne zabiegi PCI zostały wykonane u 11 pacjentów (17,2%), jednakże częstość powtórnej rewaskularyzacji w zakresie PG LTW wyniosła 9,4% (tj. 6 pacjentów po implantacji BMS), zaś częstość rewaskularyzacji o innej lokalizacji wynio- sła 7,8% (5 chorych).
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Wnniioosskkii:: Stentowanie PG LTW cechuje się wysoką bezpośrednią skutecznością zabiegów PCI u pacjentów o niskim ryzyku operacyjnym. W obserwacji odległej stwierdzono niską częstość dużych incydentów sercowych. Strategia selektywnego zasto- sowania stentów powlekanych w analizowanej grupie pacjentów przyniosła dobre wyniki kliniczne. Choroba wielonaczyniowa towarzysząca zwężeniu PG LTW wiąże się z dużą częstością ponownych rewaskularyzacji w innych naczyniach. Dalszą popra- wę wyników leczenia można osiągnąć przez częste stosowanie stentów powlekanych w chorobie wielonaczyniowej oraz zasto- sowanie stentów powlekanych w PG LTW o średnicy >4,0 mm.
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Słłoowwaa kklluucczzoowwee:: pień główny lewej tętnicy wieńcowej, stentowanie, obserwacja odległa
Kardiol Pol 2006; 64: 929-936
Adres do korespondencji:
dr Dariusz Dudek, II Klinika Kardiologii, Instytut Kardiologii, Collegium Medicum UJ, ul. Kopernika 17, 31-501 Kraków, tel.: +48 12 424 71 85, faks: +48 12 424 71 84, e-mail: mcdudek@cyf_kr.edu.pl
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Prraaccaa wwppłłyynnęęłłaa:: 13.06.2005. ZZaaaakkcceeppttoowwaannaa ddoo ddrruukkuu:: 12.04.2006.
