Advertisement

Left Main Coronary Artery Intervention

  • Giovanni Luigi De Maria
  • Adrian Paul Banning
Chapter

Abstract

The left main coronary artery (LMCA) supplies the majority of blood to the left ventricle. This fact alone explains why untreated obstructive LMCA disease is associated with a poor prognosis. Coronary artery bypass grafting (CABG) has a clear indication with a proven mortality benefit and it has been conventionally regarded as the gold standard treatment for LMCA disease. However, thanks to evolving technologies and technique, trials have progressively supported the alternative use of coronary stents in certain patient subsets with LMCA disease. In left main disease particularly, stringent technique is essential to obtain an optimal and durable result. Rigorous procedural planning, application of appropriate procedural imaging and lesion preparation together with careful patient-selection, are crucial in LMCA intervention. The aim of this chapter is to guide the reader through the main aspects that need attention when dealing with LMCA disease and provides a practical algorithm to apply in the catheterization laboratory.

Keywords

Left main coronary artery Coronary artery bypass grafting Percutaneous coronary intervention Left main bifurcation Intravascular ultrasound (IVUS) Optical coherence tomography (OCT) Proximal optimization technique SYNTAX score 

References

  1. 1.
    Giannoglou GD, Antoniadis AP, Chatzizisis YS, Damvopoulou E, Parcharidis GE, Louridas GE. Prevalence of narrowing >or=50% of the left main coronary artery among 17,300 patients having coronary angiography. Am J Cardiol. 2006;98:1202–5.CrossRefPubMedGoogle Scholar
  2. 2.
    Patel N, De Maria GL, Kassimis G, et al. Outcomes after emergency percutaneous coronary intervention in patients with unprotected left main stem occlusion: the BCIS national audit of percutaneous coronary intervention 6-year experience. JACC Cardiovasc Interv. 2014;7:969–80.CrossRefPubMedGoogle Scholar
  3. 3.
    Lefèvre T, Girasis C, Lassen JF. Differences between the left main and other bifurcations. EuroIntervention. 2015;11 Suppl:106–10.CrossRefGoogle Scholar
  4. 4.
    Wykrzykowska JJ, Mintz GS, Garcia-Garcia HM, et al. Longitudinal distribution of plaque burden and necrotic core-rich plaques in nonculprit lesions of patients presenting with acute coronary syndromes. JACC Cardiovasc Imaging. 2012;5(3 Suppl):10–8.CrossRefGoogle Scholar
  5. 5.
    Mercado N, Moe TG, Pieper M, et al. Tissue characterisation of atherosclerotic plaque in the left main: an in vivo intravascular ultrasound radiofrequency data analysis. EuroIntervention. 2011;7:347–52.CrossRefPubMedGoogle Scholar
  6. 6.
    Chaitman BR, Fisher LD, Bourassa MG, et al. 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;48:765–77.CrossRefPubMedGoogle Scholar
  7. 7.
    Shah PJ, Durairaj M, Gordon I, et al. Factors affecting patency of internal thoracic artery graft: clinical and angiographic study in 1434 symptomatic patients operated between 1982 and 2002. Eur J Cardiothorac Surg. 2004;26:118–24.CrossRefPubMedGoogle Scholar
  8. 8.
    Buszman PE, Buszman PP, Kiesz RS, et al. Early and long-term results of unprotected left main coronary artery stenting: the LE MANS (Left Main Coronary Artery Stenting) registry. J Am Coll Cardiol. 2009;54:1500–11.CrossRefPubMedGoogle Scholar
  9. 9.
    Morice MC, Serruys PW, Kappetein AP, et al. Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation. 2010;121:2645–53.CrossRefPubMedGoogle Scholar
  10. 10.
    Boudriot E, Thiele H, Walther T, et al. Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis. J Am Coll Cardiol. 2011;57:538–45.CrossRefPubMedGoogle Scholar
  11. 11.
    Park SJ, Kim YH, Park DW, et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med. 2011;364:1718–27.CrossRefPubMedGoogle Scholar
  12. 12.
    Kappetein AP, Feldman TE, Mack MJ, et al. Comparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three-vessel disease: 3-year follow-up of the SYNTAX trial. Eur Heart J. 2011;32:2125–34.CrossRefPubMedGoogle Scholar
  13. 13.
    Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014;35:2541–619.CrossRefPubMedGoogle Scholar
  14. 14.
    Campos CM, Christiansen EH, Stone GW, Serruys PW. The EXCEL and NOBLE trials: similarities, contrasts and future perspectives for left main revascularisation. EuroIntervention. 2015;11(Suppl V):115–9.CrossRefGoogle Scholar
  15. 15.
    Mäkikallio T, Holm NR, Lindsay M, et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet. 2016;388:2743–52.CrossRefPubMedGoogle Scholar
  16. 16.
    Stone GW, Sabik JF, Serruys PW, et al. Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med. 2016;375:2223–35.CrossRefPubMedGoogle Scholar
  17. 17.
    Giacoppo D, Colleran R, Cassese S, Frangieh AH, Wiebe J, Joner M, Schunkert H, Kastrati A, Byrne RA. Percutaneous coronary intervention vs coronary artery bypass grafting in patients with left main coronary artery stenosis: a systematic review and meta-analysis. JAMA Cardiol. 2017;2:1079–88.CrossRefPubMedGoogle Scholar
  18. 18.
    Ruel M, Verma S, Bhatt DL. What is the optimal revascularization strategy for left main coronary stenosis? JAMA Cardiol. 2017;2:1061–2.CrossRefPubMedGoogle Scholar
  19. 19.
    Delhaye C, Sudre A, Lemesle G, et al. Hybrid revascularization, comprising coronary artery bypass graft with exclusive arterial conduits followed by early drug-eluting stent implantation, in multivessel coronary artery disease. Arch Cardiovasc Dis. 2010;103:502–11.CrossRefPubMedGoogle Scholar
  20. 20.
    Kappetein AP, Head SJ. CABG, stents, or hybrid procedures for left main disease? EuroIntervention. 2015;11(Suppl V):111–4.CrossRefGoogle Scholar
  21. 21.
    Capodanno D, Di Salvo ME, Cincotta G, Miano M, Tamburino C, T C. Usefulness of the SYNTAX score for predicting clinical outcome after percutaneous coronary intervention of unprotected left main coronary artery disease. Circ Cardiovasc Interv. 2009;2:302–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Garg S, Stone GW, Kappetein AP, JFrd S, Simonton C, Serruys PW. Clinical and angiographic risk assessment in patients with left main stem lesions. JACC Cardiovasc Interv. 2010;3:891–901.CrossRefPubMedGoogle Scholar
  23. 23.
    Roques F, Nashef SA, Michel P, et al. Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg. 1999;15:816–22.CrossRefPubMedGoogle Scholar
  24. 24.
    Mehta RH, Grab JD, O'Brien SM, et al. Bedside tool for predicting the risk of postoperative dialysis in patients undergoing cardiac surgery. Circulation. 2006;114:2208–16.CrossRefPubMedGoogle Scholar
  25. 25.
    Farooq V, van Klaveren D, Steyerberg EW, et al. Anatomical and clinical characteristics to guide decision making between coronary artery bypass surgery and percutaneous coronary intervention for individual patients: development and validation of SYNTAX score II. Lancet. 2013;381:639–50.CrossRefPubMedGoogle Scholar
  26. 26.
    Campos CM, van Klaveren D, Farooq V, et al. Long-term forecasting and comparison of mortality in the Evaluation of the Xience Everolimus Eluting Stent vs. Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial: prospective validation of the SYNTAX Score II. Eur Heart J. 2015;36:1231–41.CrossRefPubMedGoogle Scholar
  27. 27.
    Tiroch K, Mehilli J, Byrne RA, et al. Impact of coronary anatomy and stenting technique on long-term outcome after drug-eluting stent implantation for unprotected left main coronary artery disease. JACC Cardiovasc Interv. 2014;7:29–36.CrossRefPubMedGoogle Scholar
  28. 28.
    Bing R, Yong AS, Lowe HC. Percutaneous transcatheter assessment of the left main coronary artery current status and future directions. JACC Cardiovasc Interv. 2015;8:1529–39.CrossRefPubMedGoogle Scholar
  29. 29.
    Kang SJ, Ahn JM, Kim WJ, et al. Functional and morphological assessment of side branch after left main coronary artery bifurcation stenting with cross-over technique. Catheter Cardiovasc Interv. 2014;83:545–52.CrossRefPubMedGoogle Scholar
  30. 30.
    Nam CW, Hur SH, Koo BK, et al. Fractional flow reserve versus angiography in left circumflex ostial intervention after left main crossover stenting. Korean Circ J. 2011;41:304–7.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Nissen SE, Yock P. Intravascular ultrasound: novel pathophysiological insights and current clinical applications. Circulation. 2001;103:604–16.CrossRefPubMedGoogle Scholar
  32. 32.
    Jasti V, Ivan E, Yalamanchili V, Wongpraparut N, Leesar MA. Correlations between fractional flow reserve and intravascular ultrasound in patients with an ambiguous left main coronary artery stenosis. Circulation. 2004;110:2831–6.CrossRefPubMedGoogle Scholar
  33. 33.
    de la Torre Hernandez JM, Hernández Hernandez F, Alfonso F, et al. Prospective application of pre-defined intravascular ultrasound criteria for assessment of intermediate left main coronary artery lesions results from the multicenter LITRO study. J Am Coll Cardiol. 2011;58:351–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Kang SJ, Lee JY, Ahn JM, et al. Intravascular ultrasound-derived predictors for fractional flow reserve in intermediate left main disease. JACC Cardiovasc Interv. 2011;4:1168–74.CrossRefPubMedGoogle Scholar
  35. 35.
    Park SJ, Ahn JM, Kang SJ, et al. Intravascular ultrasound-derived minimal lumen area criteria for functionally significant left main coronary artery stenosis. JACC Cardiovasc Interv. 2014;7:868–74.CrossRefPubMedGoogle Scholar
  36. 36.
    Oviedo C, Maehara A, Mintz GS, et al. Intravascular ultrasound classification of plaque distribution in left main coronary artery bifurcations: where is the plaque really located? Circ Cardiovasc Interv. 2010;3:105–12.CrossRefPubMedGoogle Scholar
  37. 37.
    Kang SJ, Ahn JM, Song H, et al. Comprehensive intravascular ultrasound assessment of stent area and its impact on restenosis and adverse cardiac events in 403 patients with unprotected left main disease. Circ Cardiovasc Interv. 2011;4:562–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Park SJ, Kim YH, Park DW, et al. Impact of intravascular ultrasound guidance on long-term mortality in stenting for unprotected left main coronary artery stenosis. Circ Cardiovasc Interv. 2009;2:167–77.CrossRefPubMedGoogle Scholar
  39. 39.
    de la Torre Hernandez JM, Baz Alonso JA, Gómez Hospital JA, et al. Clinical impact of intravascular ultrasound guidance in drug-eluting stent implantation for unprotected left main coronary disease: pooled analysis at the patient-level of 4 registries. JACC Cardiovasc Interv. 2014;7:244–54.CrossRefPubMedGoogle Scholar
  40. 40.
    Lowe HC, Narula J, Fujimoto J, Jang IK. Intracoronary optical diagnostics: current status, limitations and potential. J Am Coll Cardiol Interv. 2011;4:1257–70.CrossRefGoogle Scholar
  41. 41.
    Fujino Y, Bezerra HG, Attizzani GF, et al. Frequency-domain optical coherence tomography assessment of unprotected left main coronary artery disease-a comparison with intravascular ultrasound. Catheter Cardiovasc Interv. 2013;82:173–83.CrossRefGoogle Scholar
  42. 42.
    Capodanno D, Prati F, Pawlowsky T, et al. Comparison of optical coherence tomography and intravascular ultrasound for the assessment of in-stent tissue coverage after stent implantation. EuroIntervention. 2009;5:538–43.CrossRefPubMedGoogle Scholar
  43. 43.
    Kubo T, Akasaka T, Shite J, et al. OCT compared with IVUS in a coronary lesion assessment: the OPUS-CLASS study. JACC Cardiovasc Imaging. 2013;6:1095–104.CrossRefPubMedGoogle Scholar
  44. 44.
    Burzotta F, Dato I, Trani C, et al. Frequency domain optical coherence tomography to assess non-ostial left main coronary artery. EuroIntervention. 2015;10:e1.CrossRefPubMedGoogle Scholar
  45. 45.
    Ng J, Foin N, Ang HY, et al. Over-expansion capacity and stent design model: an update with contemporary DES platforms. Int J Cardiol. 2016;221:171–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Park SJ, Ahn JM, Foin N, Louvard Y. When and how to perform the provisional approach for distal LM stenting. EuroIntervention. 2015;11(Suppl V):120–4.CrossRefGoogle Scholar
  47. 47.
    Mylotte D, Routledge H, Harb T, et al. Provisional side branch-stenting for coronary bifurcation lesions: evidence of improving procedural and clinical outcomes with contemporary techniques. Catheter Cardiovasc Interv. 2013;82:437–45.Google Scholar
  48. 48.
    Okamura T, Onuma Y, Yamada J, et al. 3D optical coherence tomography: new insights into the process of optimal rewiring of side branches during bifurcational stenting. EuroIntervention. 2014;10:907–15.CrossRefPubMedGoogle Scholar
  49. 49.
    Lassen JF, Holm NR, Banning A, et al. Percutaneous coronary intervention for coronary bifurcation disease: 11th consensus document from the European Bifurcation Club. EuroIntervention. 2016;12:38–46.CrossRefPubMedGoogle Scholar
  50. 50.
    Niemelä M, Kervinen K, Erglis A, et al. Randomized comparison of final kissing balloon dilatation versus no final kissing balloon dilatation in patients with coronary bifurcation lesions treated with main vessel stenting: the Nordic-Baltic Bifurcation Study III. Circulation. 2011;123:79–86.CrossRefPubMedGoogle Scholar
  51. 51.
    Gao Z, Xu B, Yang YJ, et al. Effect of final kissing balloon dilatation after one-stent technique at left-main bifurcation: a single center data. Chin Med J. 2015;128:733–9.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Derimay F, Souteyrand G, Motreff P, et al. Sequential proximal optimizing technique in provisional bifurcation stenting with Everolimus-eluting bioresorbable vascular scaffold: fractal coronary bifurcation bench for comparative test between absorb and XIENCE Xpedition. JACC Cardiovasc Interv. 2016;9:1397–406.CrossRefPubMedGoogle Scholar
  53. 53.
    Chen SL, Xu B, Han YL, et al. Comparison of double kissing crush versus Culotte stenting for unprotected distal left main bifurcation lesions: results from a multicenter, randomized, prospective DKCRUSH-III study. J Am Coll Cardiol. 2013;61:1482–8.CrossRefPubMedGoogle Scholar
  54. 54.
    Roh JH, Santoso T, Kim YH. Which technique for double stenting in unprotected left main bifurcation coronary lesions? EuroIntervention. 2015;11(Suppl V):125–8.CrossRefGoogle Scholar
  55. 55.
    Siotia A, Morton AC, Malkin CJ, Raina T, Gunn J. Simultaneous kissing drug-eluting stents to treat unprotected left main stem bifurcation disease: medium term outcome in 150 consecutive patients. EuroIntervention. 2012;8:691–700.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Giovanni Luigi De Maria
    • 1
  • Adrian Paul Banning
    • 1
  1. 1.Oxford Heart Centre, John Radcliffe HospitalOxford University Hospital NHS TrustOxfordUK

Personalised recommendations