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Treatment of unprotected left main coronary artery disease with drug-eluting stents: is it time for a randomized trial?

Nature Clinical Practice Cardiovascular Medicine volume 2, pages 396–400 (2005)Cite this article

Abstract

The treatment of unprotected left main coronary artery disease by percutaneous intervention represents a considerable challenge for interventional cardiologists. The American College of Cardiology/ American Heart Association guidelines currently recommend surgical revascularization for this disorder and percutaneous interventions have thus far been performed only in exceptional cases, albeit with positive results in some patients. Technical limitations, however, including stent restenosis, limit the application of this technique at present. The availability of drug-eluting stents, which are associated with a reduction in angiographic restenosis, might change this situation. Preliminary results show that the implantation of drug-eluting stents for unprotected left main coronary artery lesions is a feasible and safe approach. Randomized clinical trials comparing the use of drug-eluting stents with coronary artery bypass surgery for unprotected left main coronary artery disease are the next step, but can such trials be contemplated at this stage? In this review we present an overview of the findings to date and discuss the direction that research should now take.

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Figure 1: Angiographic 5-month follow-up performed in an asymptomatic patient with negative stress test showing focal restenosis in a sirolimus-eluting stent at the ostium of circumflex artery.

References

  1. Ellis SG et al. (1997) Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994–1996. Circulation 96: 3867–3872

    Article  CAS  Google Scholar 

  2. Tan WA et al. (2001) Long-term clinical outcomes after unprotected left main trunk percutaneous revascularization in 279 patients. Circulation 104: 1609–1614

    Article  CAS  Google Scholar 

  3. Park SJ et al. (2001) Elective stenting of unprotected left main coronary artery stenosis: effect of debulking before stenting and intravascular ultrasound guidance. J Am Coll Cardiol 38: 1054–1060

    Article  CAS  Google Scholar 

  4. Takagi T et al. (2002) Results and long-term predictors of adverse clinical events after elective percutaneous interventions on unprotected left main coronary artery. Circulation 106: 698–702

    Article  Google Scholar 

  5. Black A et al. (2001) Unprotected left main coronary artery stenting: correlates of midterm survival and impact of patient selection. J Am Coll Cardiol 37: 832–838

    Article  CAS  Google Scholar 

  6. Park SJ et al. (2003) Long-term (three-year) outcomes after stenting of unprotected left main coronary artery stenosis in patients with normal left ventricular function. Am J Cardiol 91: 12–16

    Article  Google Scholar 

  7. Caracciolo EA et al. (1995) Comparison of surgical and medical group survival in patients with left main coronary artery disease. Long-term CASS experience. Circulation 91: 2325–2334

    Article  CAS  Google Scholar 

  8. d'Allonnes FR et al. (2002) Isolated left main coronary artery stenosis: long term follow up in 106 patients after surgery. Heart 87: 544–548

    Article  Google Scholar 

  9. Holm F et al. (2004) Main clinical and surgical determinants of in-hospital mortality after surgical revascularization of left main coronary artery stenosis: 2 year retrospective study (1998–1999). J Mal Vasc 29: 89–93

    Article  CAS  Google Scholar 

  10. Eagle KA et al. (2004) ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation 110: 1168–1176

    Article  Google Scholar 

  11. Dzavik V et al.; Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators (2001) Long-term survival in 11,661 patients with multivessel coronary artery disease in the era of stenting: a report from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators. Am Heart J 142: 119–126

  12. Morice MC et al. (2002) A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med 346: 1773–1780

    Article  CAS  Google Scholar 

  13. Moses JW et al. (2003) Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med 349: 1315–1323

    Article  CAS  Google Scholar 

  14. Colombo A et al. (2003) Randomized study to assess the effectiveness of slow- and moderate-release polymer-based paclitaxel-eluting stents for coronary artery lesion. Circulation 108: 788–794

    Article  CAS  Google Scholar 

  15. Stone GW et al. (2004) A polymer-based, paclitaxel-eluting stent in patients with coronary artery disease. N Engl J Med 350: 221–231

    Article  CAS  Google Scholar 

  16. Orlic D et al. (2004) Treatment of multivessel coronary artery disease with sirolimus-eluting stent implantation: immediate and mid-term results. J Am Coll Cardiol 43: 1154–1160

    Article  CAS  Google Scholar 

  17. Lemos PA et al. (2004) Unrestricted utilization of sirolimus-eluting stents compared with conventional bare stent implantation in the “real world”: the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry. Circulation 109: 190–195

    Article  CAS  Google Scholar 

  18. Arampatzis CA et al. (2004) Elective sirolimus-eluting stent implantation for left main coronary artery disease: six-month angiographic follow-up and 1-year clinical outcome. Catheter Cardiovasc Interv 62: 292–296

    Article  Google Scholar 

  19. Valgimigli M et al. (2005) Short- and long-term clinical outcome after drug-eluting stent implantation for the percutaneous treatment of left main coronary artery disease: insights from the Rapamycin-Eluting and Taxus Stent Evaluated At Rotterdam Cardiology Hospital registries (RESEARCH and T-SEARCH). Circulation 111: 1383–1389

    Article  Google Scholar 

  20. de Lezo JS et al. (2004) Rapamycin-eluting stents for the treatment of unprotected left main coronary disease. Am Heart J 148: 481–485

    Article  Google Scholar 

  21. Park SJ et al. (2005) Sirolimus-eluting stent implantation for unprotected left main coronary artery stenosis: comparison with bare metal stent implantation. J Am Coll Cardiol 45: 351–356

    Article  CAS  Google Scholar 

  22. Chieffo A et al. (2005) Early and mid-term results of drug-eluting stent implantation in unprotected left main. Circulation 111: 791–795

    Article  CAS  Google Scholar 

  23. Lefèe T et al. (2005) Preliminary Results of The Left Main TAXUS Pilot Study. Presented at the Scientific Sessions of the American College of Cardiology: 2005 March 6–9; Orlando

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Acknowledgements

We thank Dr Pierfrancesco Agostoni for his help in the preparation of Figure 1.

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Authors and Affiliations

  1. San Raffaele Hospital,

    Alaide Chieffo & Antonio Colombo

  2. San Raffaele and Columbus Hospitals, Milan, Italy

    Alaide Chieffo & Antonio Colombo

Authors
  1. Alaide Chieffo
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  2. Antonio Colombo
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Correspondence to Antonio Colombo.

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The authors declare no competing financial interests.

Glossary

PARSONNET CLASSIFICATION

A scoring system, based on patient-related factors, for the prediction of mortality within 30 days of cardiac surgery

EUROSCORE

In accordance with the EuroSCORE classification, a scoring system for the prediction of early mortality in cardiac surgical patients based on objective risk factors

OCULOSTENOTIC REFLEX

The practice of treating narrowing in a coronary artery with an intervention based on the severity of stenosis alone, without seeking evidence of ischemia

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Chieffo, A., Colombo, A. Treatment of unprotected left main coronary artery disease with drug-eluting stents: is it time for a randomized trial?. Nat Rev Cardiol 2, 396–400 (2005). https://doi.org/10.1038/ncpcardio0272

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