Optimizing Interventional Strategies For Left Main Bifurcation

Percutaneous coronary intervention (PCI) for left main coronary stenosis using second-generation drug-eluting stents (DES) is safe and the outcomes are comparable with those with CABG, according to a review of current studies by Tanveer Rab, MD, and colleagues, presented March 17 as an oral abstract at ACC.17 in Washington, DC, and simultaneously published in JACC: Interventions. Target lesion revascularization (TLR), however, remains an issue, they found.

In patients whose SYNTAX score is low or intermediate, PCI has been established as a safe alternative to coronary artery bypass grafting (CABG), and this has been supported by the recent results from the EXCEL and NOBLE studies, state the authors. They conducted this review to provide guidance on patient selection, risk scoring, intracoronary imaging, vessel preparation, and selection of the stenting technique. A single-stent provisional approach was found to be the preferred strategy.

Left main bifurcation is present in more than 80 percent of left main stenoses, and drivers of the choice of the stent technique are potential complications to left circumflex and TLR. Among the challenges for PCI of the left main bifurcation are the need for larger stents, an understanding of the stent platform to expand, and identifying diffuse left main disease.

A heart team approach for elective PCI is recommended by the authors, and facilities that have intravascular ultrasound or optical coherence and the capacity to assess coronary physiology, as well as access to atherectomy and mechanical circulatory support. Pre-procedure assessment and planning is critical to success, and includes using the Medina angiographic classification of the complexity of the bifurcation lesion and imaging and functional assessment.

An algorithm for the management of left main bifurcation is provided by the authors, along with a scheme of treatment options for left main disease that incorporates the guideline recommendations. The authors also provide insights on hemodynamic support for high-risk PCI, lesion classification, and stenting technique for simple and complex lesions.

"Neither of the two trials studied outcomes beyond five years," said Kim A. Eagle, MD, MACC, editor-in-chief of ACC.org. "Therefore, further studies are needed to assess the long term durability of each approach."

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery

Keywords: ACC17, ACC Annual Scientific Session, Algorithms, Atherectomy, Constriction, Pathologic, Coronary Artery Bypass, Coronary Stenosis, Drug-Eluting Stents, Hemodynamics, Patient Selection, Percutaneous Coronary Intervention, Stents

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