Left main intervention

(Redirected from Left Main Intervention)
Jump to navigation Jump to search

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [12]; Associate Editors-In-Chief: Sudarshan Srivats, M.D., M.P.H.[13], Neil M. Gheewala, M.D.

Percutaneous coronary intervention Microchapters

Home

Patient Information

Overview

Risk Stratification and Benefits of PCI

Preparation of the Patient for PCI

Equipment Used During PCI

Pharmacotherapy to Support PCI

Vascular Closure Devices

Recommendations for Perioperative Management–Timing of Elective Noncardiac Surgery in Patients Treated With PCI and DAPT

Post-PCI Management

Risk Reduction After PCI

Post-PCI follow up

Hybrid coronary revascularization

PCI approaches

PCI Complications

Factors Associated with Complications
Vessel Perforation
Dissection
Distal Embolization
No-reflow
Coronary Vasospasm
Abrupt Closure
Access Site Complications
Peri-procedure Bleeding
Restenosis
Renal Failure
Thrombocytopenia
Late Acquired Stent Malapposition
Loss of Side Branch
Multiple Complications

PCI in Specific Patients

Cardiogenic Shock
Left Main Coronary Artery Disease
Refractory Ventricular Arrhythmia
Severely Depressed Ventricular Function
Sole Remaining Conduit
Unprotected Left Main Patient
Adjuncts for High Risk PCI

PCI in Specific Lesion Types

Classification of the Lesion
The Calcified Lesion
The Ostial Lesion
The Angulated or Tortuous Lesion
The Bifurcation Lesion
The Long Lesion
The Bridge Lesion
Vasospasm
The Chronic Total Occlusion
The Left Internal Mammary Artery
Multivessel Disease
Distal Anastomotic Lesions
Left Main Intervention
The Thrombotic Lesion

Left main intervention On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Left main intervention

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Left main intervention

CDC on Left main intervention

Left main intervention in the news

Blogs on Left main intervention

Directions to Hospitals Treating Percutaneous coronary intervention

Risk calculators and risk factors for Left main intervention

Overview

The left main coronary artery (LMCA) supplies approximately 84% of left ventricular blood flow in a right-dominant circulation. A significant left main lesion (≥50% diameter stenosis) therefore places the largest single coronary territory at risk and carries more prognostic weight than any other single coronary lesion. Significant left main disease is found in approximately 5%–7% of diagnostic coronary angiograms. Untreated, hemodynamically significant disease has historically carried a 3-year mortality approaching 50%. Angiography is unreliable for judging left main severity, so lesions of indeterminate severity require intravascular ultrasound (IVUS) and/or fractional flow reserve (FFR). Coronary artery bypass grafting (CABG) remains the Class I standard to improve survival. Percutaneous coronary intervention (PCI) with drug-eluting stents is a guideline-supported alternative in selected patients with low anatomic complexity, high surgical risk, or an informed preference for PCI. Compared with CABG, PCI gives similar long-term mortality but more spontaneous myocardial infarction and repeat revascularization. Contemporary left main PCI has four core features: heart-team patient selection, intracoronary-imaging guidance, a provisional single-stent default for the distal bifurcation, and individualized dual antiplatelet therapy. Routine surveillance stress testing and surveillance angiography are no longer recommended. High-risk unprotected left main PCI and cardiogenic shock are covered in PCI in the unprotected left main patient.

Lesion Assessment

Angiography

Angiographic assessment of the left main has the highest inter- and intraobserver variability of any coronary segment. Several features make it difficult:[1][2]

  • The segment is short and has no normal reference segment.
  • Disease is often diffuse and eccentric, so severity is frequently underestimated.
  • Views are prone to foreshortening, vessel overlap, and contrast streaming at the ostium.

When interrogating ostial lesions, disengage the guide catheter so that it is not mistaken for the arterial lumen. Any lesion of indeterminate severity, or with discordant appearance between projections, should be interrogated with intracoronary imaging and/or physiology.

Intravascular Ultrasound

IVUS is the reference modality for ambiguous left main disease. Using IVUS to define the severity of intermediate left main stenosis is Class 2a (LOE B-NR) in the 2021 ACC/AHA/SCAI revascularization guideline.[3][4][5] The validated minimum lumen area (MLA) thresholds derive from Murray's law: a left main MLA below 6 mm² corresponds to an MLA below 4 mm² in the left anterior descending artery (LAD) or left circumflex artery (LCx). When imaging the distal left main, begin the pullback in the daughter vessel with the least angulated take-off, which is usually the LAD.

Left main MLA (IVUS) Interpretation Suggested action
<6.0 mm² Anatomically significant; corresponds to FFR of about 0.75–0.80 Revascularization if clinically indicated
6.0–7.5 mm² Gray zone; deferral is generally safe at ≥6.0 mm², but some operators use ≥7.5 mm² as the deferral threshold Confirm with FFR
>7.5 mm² Not significant Defer revascularization
~4.5–4.8 mm² Alternative cutoff derived in Korean cohorts; applicable to patients of Asian descent or smaller-caliber vessels[6][7] Apply population-appropriate threshold

Physiology

  • An FFR ≤0.80 identifies functionally significant left main disease, and deferral above this value is well supported. This replaces the older 0.75 threshold.[8]
  • Use IV adenosine so that the guide can be disengaged from the ostium without losing hyperemia. This avoids pressure damping and a falsely significant value.[8]
  • Record pressure with the wire in both the LAD and the LCx, because downstream disease in either branch confounds the result. If both branches are significantly diseased, use intracoronary imaging instead.[8]
  • Nonhyperemic pressure ratios (iFR, dPR, RFR) are less reliable in the left main.[8][9]
    • Concordance with FFR is only about 80%.
    • In iLITRO-EPIC07, 46% of iFR-negative lesions had an MLA <6 mm².
    • FFR is therefore preferred for intermediate left main lesions.
  • Because the left main subtends a large myocardial mass, the optimal angiographic cutoff for functional significance is only about 43% diameter stenosis.[10]

Revascularization Strategy: PCI Versus CABG

CABG remains the Class I standard to improve survival in significant left main disease. PCI is an alternative in selected patients in whom it can achieve revascularization equivalent to surgery, which in practice means low anatomic complexity.[3][11][10] No randomized trial has compared PCI with medical therapy alone in left main disease, and medical therapy alone is inadequate for significant disease.[12] In observational registry data, deferring revascularization of >50% left main stenosis was associated with higher 5-year mortality and more acute coronary syndrome than PCI or CABG.[13]

Guideline Recommendations by Anatomic Complexity

SYNTAX score Guideline Recommendation Class of recommendation Level of evidence
≤22 (low) ESC/EACTS 2018 CABG and PCI equally recommended I (CABG); I (PCI) A
≤22 (low) ACC/AHA/SCAI 2021 PCI reasonable as an alternative to CABG 1 (CABG); 2a (PCI) B (CABG); B-NR (PCI)
23–32 (intermediate) ESC/EACTS 2018 CABG preferred over PCI I (CABG); IIa (PCI) A (CABG); A (PCI)
23–32 (intermediate) ACC/AHA/SCAI 2021 CABG preferred for high-complexity CAD 1 B-R
≥33 (high) ESC/EACTS 2018 CABG recommended; PCI not recommended I (CABG); III (PCI) A (CABG); B (PCI)
≥33 (high) ACC/AHA/SCAI 2021 CABG preferred 1 B-R
Any complexity ESC 2024 CABG overall preferred; PCI an alternative only for low complexity (SYNTAX ≤22) when equivalent completeness of revascularization is achievable I (CABG); — (PCI) A (CABG)

The 2024 ESC guideline no longer uses the 2018 per-tier grid.[10]

  • Its pooled analysis found similar mortality with PCI and CABG overall.
  • There was a non-significant trend toward higher mortality with PCI at SYNTAX >32 (HR 1.30, 95% CI 0.92–1.84).

Table adapted from Davidson et al. (2018 ESC/EACTS and 2021 ACC/AHA/SCAI rows) and the 2024 ESC guideline.[14][10]

Randomized Trial Evidence

Four randomized trials compared PCI and CABG in left main disease: SYNTAX, PRECOMBAT, NOBLE, and EXCEL.

  • Mortality
    • In the individual-patient-data meta-analysis of all four trials, 5-year all-cause death did not differ significantly: 11.2% with PCI vs 10.2% with CABG (HR 1.10, 95% CI 0.91–1.32).[15]
    • A Bayesian analysis in the same study suggested a probable small survival advantage for CABG of less than 0.2% per year.[15]
    • A 2026 reconstructed-IPD meta-analysis of five trials, including LE MANS, found no difference in 10-year mortality (HR 1.02, 95% CI 0.89–1.17; about 23% in both arms).[16]
  • Spontaneous MI and repeat revascularization are consistently higher with PCI.[15]
  • Stroke is similar overall but lower with PCI in the first year after revascularization.[15]
  • NOBLE used biodegradable-polymer stents. At 5 years, CABG was superior for the composite endpoint, driven by nonprocedural MI and repeat revascularization.[17]
  • EXCEL used everolimus-eluting stents in patients with SYNTAX ≤32. PCI was noninferior for the 3-year composite endpoint.[14]
    • Controversy over EXCEL's periprocedural-MI definition contributed to the European Association for Cardio-Thoracic Surgery (EACTS) withdrawing its endorsement of the 2018 ESC revascularization guideline.[14]
  • All contemporary trials used drug-eluting stents; bare-metal stents have no role in left main PCI.[15]

SYNTAX Score and Heart Team Evaluation

  • Anatomic complexity, measured by the SYNTAX score, predicts death and MACE after PCI but not after CABG.[18][19][20][21]
  • SYNTAX Score II 2020 adds clinical variables and discriminates better for individualized PCI-versus-CABG decisions.[22][23]
  • A SYNTAX score ≤22 is not an absolute PCI threshold. Integrate anatomic complexity with clinical risk, including the Society of Thoracic Surgeons (STS) score, and with heart-team judgment.
  • A multidisciplinary heart team is recommended when the optimal strategy is unclear.[14][10]
  • ESC suggests the following volume thresholds, and higher operator volume is associated with better outcomes:[14][10]
    • Left main PCI by operators performing ≥25 left main PCIs per year.
    • CABG at institutions performing ≥200 cases per year.

Candidates for Left Main PCI

  • Low-complexity left main disease (SYNTAX ≤22) in which PCI can achieve revascularization equivalent to CABG
  • High surgical risk, or patients declined for surgery
  • Patients who prefer PCI after informed shared decision-making
  • Protected left main: prior CABG with at least one patent graft to the LAD or LCx
  • For PCI of an unprotected left main culprit lesion in acute coronary syndrome, see PCI in the unprotected left main patient.

Procedural Technique

Planning, Access, and Guide Selection

  • Radial access is feasible for most cases.
  • Use a 7–8 Fr guide when a planned 2-stent technique or atherectomy is anticipated. The larger guide gives more support and accommodates two balloons or stents.
  • Pre-procedural intracoronary imaging defines plaque burden, calcification, vessel size, and distal bifurcation anatomy.[24]
  • Calcified left main: imaging-based assessment of calcium burden guides whether lesion preparation is needed before stenting. Options include rotational atherectomy, orbital atherectomy, and intravascular lithotripsy.[24][25]

Intracoronary Imaging Guidance

  • Guideline status
    • 2024 ESC: intracoronary imaging (IVUS or optical coherence tomography) to guide left main, true-bifurcation, and long-lesion PCI is Class I, LOE A.[10]
    • 2021 ACC/AHA/SCAI: IVUS or OCT guidance is Class 2a (LOE B-R). OCT is a reasonable alternative to IVUS except in ostial left main disease, where IVUS is preferred.[3][14]
  • Outcomes: imaging guidance is associated with lower target-lesion failure, stent thrombosis, and reintervention after left main PCI.[25][26]
    • Most left main–specific data come from registries (e.g., ROCK II and pooled registry analyses) and from left main subgroups of broader randomized trials.
    • ULTIMATE was an all-comers IVUS-guidance trial, not a dedicated left main trial.
  • Practical use: the 2026 EAPCI/EBC consensus statement details imaging-based planning, stent sizing, and post-deployment optimization. Mean left main diameter is about 5 mm (range 3.5–6 mm).[24]

Ostial and Shaft Lesions

Ostial and shaft lesions are technically more straightforward and have lower restenosis rates than distal bifurcation disease. Position the stent precisely to cover the aorto-ostial junction completely, and confirm coverage and expansion with IVUS.[24][3]

Distal Bifurcation Lesions

The distal bifurcation is involved in about 80% of left main PCI. Commit to the strategy before placing the first stent.

  • Provisional single-stent (crossover from left main to LAD) is the default.
    • EBC-MAIN randomized 467 patients with true left main bifurcation lesions to stepwise provisional or systematic dual stenting.[27]
    • The 3-year composite of death, MI, or target-lesion revascularization (TLR) did not differ significantly: 23.5% vs 29.5% (HR 0.75, 95% CI 0.53–1.07).[27]
    • Clinically driven TLR was significantly lower with provisional stenting: 8.3% vs 15.6% (HR 0.50, 95% CI 0.29–0.86).[27]
    • Provisional stenting also required shorter procedures and less contrast. Its benefit was greatest when the side vessel was <3.25 mm and the side-branch lesion was <10 mm long.[27]
    • In a meta-analysis of 8,377 patients, provisional stenting reduced 3-year MACE (OR 0.64), mainly through less TLR.[28]
  • Planned 2-stent technique is warranted for true bifurcation lesions (Medina 1,1,1 or 0,1,1) with a large, significantly diseased LCx. Examples include LCx disease extending >5 mm beyond the carina, threatened LCx closure, or anticipated difficult re-access.[29]
    • DK-crush is the preferred 2-stent technique. In DKCRUSH-V (482 patients with true distal left main bifurcation lesions), DK-crush reduced 1-year target-lesion failure compared with provisional stenting: 5.0% vs 10.7% (HR 0.42).[30]
    • The benefit was sustained at 3 years: 8.3% vs 16.9%.[31]
    • Network meta-analyses rank DK-crush highest among bifurcation techniques.[32][33][34]
  • Proximal optimization technique (POT) should be performed routinely after main-vessel stenting. It corrects proximal–distal size mismatch, improves apposition, and helps the side-branch wire recross through the optimal stent cell.[35][29]
  • Final kissing-balloon inflation (KBI)[35][29][36]
    • Mandatory after every 2-stent technique, and a marker of procedural quality.
    • After a single-stent crossover, it reduces angiographic side-branch restenosis but has no proven hard-outcome benefit.

Strategy selection for distal left main bifurcation PCI

 
 
 
Distal left main bifurcation lesion
(imaging-guided assessment)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
True bifurcation (Medina 1,1,1 or 0,1,1)
with large, significantly diseased LCx?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
Provisional stent (LM to LAD) + POT;
treat LCx only if compromised
 
 
 
 
Yes
Planned 2-stent (DK-crush preferred)
+ POT + mandatory final KBI

Hemodynamic Support

Routine mechanical circulatory support (MCS) is not required. It has not improved outcomes in randomized trials: BCIS-1 was neutral and PROTECT II was stopped for futility.[3][37]

  • Guideline status: elective MCS is Class 2b in the 2021 ACC/AHA/SCAI guideline, and "should be considered" in selected high-risk cases per ESC.[3][10]
  • High-risk features that may justify MCS:
    • Severe LV dysfunction (LVEF ≤35%) with an unprotected left main or a last remaining conduit
    • Concomitant disease of the right coronary artery or a dominant LCx
    • Planned atherectomy
  • Device choice: Impella provides greater hemodynamic support than an intra-aortic balloon pump, but a mortality benefit is unproven pending PROTECT IV.[38][37]

Antiplatelet Therapy

Agent Loading dose Maintenance dose Key cautions
Clopidogrel 600 mg 75 mg daily Not preferred for ACS when ticagrelor or prasugrel can be used
Prasugrel 60 mg 10 mg daily (5 mg daily if weight <60 kg or age ≥75 years) Contraindicated after prior stroke or TIA
Ticagrelor 180 mg 90 mg twice daily Use with aspirin maintenance ≤100 mg daily
  • Duration: default DAPT duration is 6 months for chronic coronary disease and 12 months for ACS, individualized to ischemic versus bleeding risk.[39][42]
    • Short DAPT (1–3 months) followed by P2Y12-inhibitor monotherapy is increasingly used, particularly in high-bleeding-risk patients.
    • After abbreviated DAPT, clopidogrel monotherapy is not recommended for ACS (STOPDAPT-2 ACS).
  • After a left main 2-stent procedure: stopping DAPT before 1 year was associated with markedly higher target-lesion failure and thrombotic events. Maintaining DAPT for at least 12 months is therefore prudent. This interaction was not seen after single-stent left main PCI.[43]
  • Glycoprotein IIb/IIIa inhibitors are no longer used routinely. Reserve them for bailout situations: large thrombus burden, no-reflow, or thrombotic complications.[39]

Follow-Up and Secondary Prevention

  • Routine surveillance stress testing in asymptomatic patients after multivessel or left main PCI is Class 3. In the POST-PCI trial, it did not improve outcomes.[44][11]
  • Routine surveillance angiography is not recommended; the earlier Class IIa recommendation has been removed from guidelines.[1]
    • Systematic angiographic follow-up does detect clinically silent in-stent restenosis: about 10% at 8 months, mostly asymptomatic, with diabetes mellitus and chronic kidney disease as predictors.
    • For this reason, some programs individualize surveillance in high-risk subgroups.[45]
  • Secondary prevention remains essential, including high-intensity statin therapy, blood pressure control, smoking cessation, diabetes management, and cardiac rehabilitation.[11]

Summary of Contemporary Guideline Recommendations

Recommendation Guideline Class of recommendation Level of evidence
Heart-team evaluation when the optimal revascularization strategy is unclear ACC/AHA/SCAI 2021; ESC 2024 I —
CABG to improve survival in significant left main stenosis ACC/AHA/SCAI 2021 1 B
PCI as an alternative to CABG in selected patients in whom PCI can achieve equivalent revascularization (low anatomic complexity) ACC/AHA/SCAI 2021 2a B-NR
IVUS to define severity of intermediate left main stenosis ACC/AHA/SCAI 2021 2a B-NR
Intracoronary imaging (IVUS or OCT) to guide left main, true-bifurcation, and long-lesion PCI ESC 2024 I A
IVUS or OCT guidance of stent implantation (OCT reasonable alternative except in ostial left main) ACC/AHA/SCAI 2021 2a B-R
Elective mechanical circulatory support in selected high-risk PCI ACC/AHA/SCAI 2021 2b —
Routine surveillance stress testing in asymptomatic patients after multivessel or left main PCI (not recommended) AHA/ACC 2023 Chronic Coronary Disease 3 —

Levels of evidence for the ACC/AHA/SCAI 2021 rows are as reported by Davidson et al.[14]

Areas of Uncertainty

  • Transatlantic disagreement: the NOBLE/EXCEL discordance, the EXCEL periprocedural-MI controversy, and the EACTS withdrawal mean US and European guidance are not fully harmonized at intermediate SYNTAX scores.[14]
  • High-complexity disease
    • The 2018 ESC/EACTS guideline classified PCI at SYNTAX ≥33 as Class III, a recommendation EACTS later contested.[14]
    • The 2024 ESC guideline frames CABG as the overall preferred modality and endorses PCI only for low-complexity (SYNTAX ≤22) disease.[10]
    • Some real-world data in surgically ineligible patients with high-complexity disease are supportive, but randomized evidence is lacking.[23][12]
  • Nonhyperemic physiology (iFR/dPR) is insufficiently validated in the left main.[8]
  • One versus two stents for true bifurcations: EBC-MAIN supports provisional stenting as the default, while DKCRUSH-V favored DK-crush in complex true bifurcations. Optimal patient selection between the two remains unsettled.[27][31]
  • Mechanical circulatory support: benefit in high-risk left main PCI is unproven.[37]
  • IVUS thresholds vary with ethnicity and vessel size (6.0 mm² general; 4.5–4.8 mm² in Asian populations).[5][6]
  • Selective angiographic surveillance in diabetic or CKD patients remains debated.[45]

Pearls and Pitfalls

  • Do not rely on the angiogram alone; the left main is the most error-prone severity call in the catheterization laboratory.
  • A pseudo-lesion from the guide catheter or pressure damping can mimic ostial disease or distort FFR. Disengage the guide and use IV adenosine.
  • Interpreting left main FFR in the presence of downstream LAD or LCx disease without measuring both branches gives misleading results.
  • Skipping POT leaves the proximal stent malapposed, and omitting KBI after a 2-stent technique leaves a compromised LCx.
  • Converting a failing provisional strategy to an unplanned bailout second stent is associated with worse outcomes than an upfront, well-executed 2-stent plan.[46]
  • Keep DAPT for at least 12 months after a 2-stent left main procedure.[43]
  • Avoid routine surveillance stress testing or angiography in asymptomatic patients, and avoid routine MCS in stable, preserved-EF left main PCI.

Historical Guideline Recommendations

The 2011 ACCF/AHA/SCAI recommendations below are preserved for historical reference. They are superseded by the 2021 ACC/AHA/SCAI revascularization guideline, the 2023 AHA/ACC chronic coronary disease guideline, and the 2024 ESC guideline summarized above.

2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[47]

Revascularization to Improve Survival in Left Main Coronary Artery Disease (DO NOT EDIT)[47]

Class I
"1. CABG to improve survival is recommended for patients with significant (≥50% diameter stenosis) left main coronary artery stenosis. (Level of Evidence: B)"
Class III (Harm)

"1. PCI to improve survival should not be performed in stable patients with significant (greater than or equal to 50% diameter stenosis) unprotected left main CAD who have unfavorable anatomy for PCI and who are good candidates for CABG. [48][49][50][51][52][53][54][55][56][57] (Level of Evidence: B)"

Class IIa

"1. PCI to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (greater than or equal to 50% diameter stenosis) unprotected left main CAD with:

a. Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (e.g., a low SYNTAX score [lower than or equal to 22], ostial or trunk left main CAD); and (Level of Evidence: B)
b. Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., Society of Thoracic Surgeons–predicted risk of operative mortality 5%). [48][49][50][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74][75] (Level of Evidence: B)"

"2. PCI to improve survival is reasonable in patients with UA/NSTEMI when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG. [50][64][76][66][67][72][73][74][75][77] (Level of Evidence: B)"

"3. PCI to improve survival is reasonable in patients with acute STEMI when an unprotected left main coronary artery is the culprit lesion, distal coronary flow is less than TIMI (Thrombolysis In Myocardial Infarction) grade 3, and PCI can be performed more rapidly and safely than CABG. [61][78][79] (Level of Evidence: C)"

Class IIb

"1. PCI to improve survival may be reasonable as an alternative to CABG in selected stable patients with significant (greater than or equal to 50% diameter stenosis) unprotected left main CAD with:

a. Anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (e.g., low-intermediate SYNTAX score of lower than 33, bifurcation left main CAD); and (Level of Evidence: B)
b. Clinical characteristics that predict an increased risk of adverse surgical outcomes (e.g., moderate-severe chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; Society of Thoracic Surgeons– predicted risk of operative mortality greater than 2%). [48][49][50][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][80] (Level of Evidence: B)"

References

  1. ↑ 1.0 1.1 Teirstein PS, Price MJ. J Am Coll Cardiol. 2012.
  2. ↑ Zengin et al. Int J Cardiovasc Imaging. 2026.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Lawton JS, Tamis-Holland JE, Bangalore S; et al. (2022). "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006.
  4. ↑ Patel MR, Calhoon JH, Dehmer GJ; et al. (2017). "ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease". J Am Coll Cardiol. 69 (17): 2212–2241. doi:10.1016/j.jacc.2017.02.001.
  5. ↑ 5.0 5.1 Cortese et al. Catheter Cardiovasc Interv. 2022.
  6. ↑ 6.0 6.1 Park SJ, Ahn JM, Kang SJ; et al. (2014). "Intravascular Ultrasound-Derived Minimal Lumen Area Criteria for Functionally Significant Left Main Coronary Artery Stenosis". JACC Cardiovasc Interv. 7 (8): 868–874. doi:10.1016/j.jcin.2014.02.015.
  7. ↑ Kang SJ, Lee JY, Ahn JM; et al. (2011). "Intravascular Ultrasound-Derived Predictors for Fractional Flow Reserve in Intermediate Left Main Disease". JACC Cardiovasc Interv. 4 (11): 1168–1174. doi:10.1016/j.jcin.2011.08.009.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 Bangalore S, Fearon WF, Fugar S; et al. (2025). "Evidence-Based Practices in the Cardiac Catheterization Laboratory: Invasive Epicardial Coronary Physiologic Assessment: A Scientific Statement From the American Heart Association". Circulation. doi:10.1161/CIR.0000000000001389.
  9. ↑ Demirtakan et al. Am J Cardiol. 2025.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 Vrints C, Andreotti F, Koskinas KC; et al. (2024). "2024 ESC Guidelines for the Management of Chronic Coronary Syndromes". Eur Heart J. 45 (36): 3415–3537. doi:10.1093/eurheartj/ehae177.
  11. ↑ 11.0 11.1 11.2 Virani SS, Newby LK, Arnold SV; et al. (2023). "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease". J Am Coll Cardiol. 82 (9): 833–955. doi:10.1016/j.jacc.2023.04.003.
  12. ↑ 12.0 12.1 Khalid U, Kayani W, Alam M, Denktas AE (2023). "Revascularization Options for Left Main Disease: What Clinicians Need to Know". Curr Atheroscler Rep. 25 (6): 267–273. doi:10.1007/s11883-023-01105-2.
  13. ↑ Bröchner MM, Christiansen EH, Kragholm K; et al. (2026). "Unprotected Left Main Disease: Clinical Outcomes Following Deferral, Coronary Artery Bypass Grafting, or Percutaneous Coronary Intervention". Catheter Cardiovasc Interv. doi:10.1002/ccd.70905.
  14. ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 14.7 14.8 Davidson LJ, Cleveland JC, Welt FG; et al. (2022). "A Practical Approach to Left Main Coronary Artery Disease: JACC State-of-the-Art Review". J Am Coll Cardiol. 80 (22): 2119–2134. doi:10.1016/j.jacc.2022.09.034.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 Sabatine MS, Bergmark BA, Murphy SA; et al. (2021). "Percutaneous Coronary Intervention With Drug-Eluting Stents Versus Coronary Artery Bypass Grafting in Left Main Coronary Artery Disease: An Individual Patient Data Meta-Analysis". Lancet. 398 (10318): 2247–2257. doi:10.1016/S0140-6736(21)02334-5.
  16. ↑ Koeckerling D, Reddy RK, Howard JP; et al. (2026). "Long-Term Mortality After PCI or CABG for Left Main Stem Disease: Updated Meta-Analysis of Randomized Trials Using Reconstructed Individual-Participant Survival Data". J Am Coll Cardiol. 87 (16): 2180–2183. doi:10.1016/j.jacc.2026.01.079.
  17. ↑ Holm et al. [NOBLE 5-year outcomes]. Lancet. 2020.
  18. ↑ Yoon et al. JACC Cardiovasc Interv. 2020.
  19. ↑ Lee et al. [Extended PRECOMBAT follow-up]. J Am Heart Assoc. 2021.
  20. ↑ Thuijs et al. [SYNTAX 10-year follow-up]. Lancet. 2019.
  21. ↑ Mohr FW, Morice MC, Kappetein AP; et al. (2013). "Coronary Artery Bypass Graft Surgery Versus Percutaneous Coronary Intervention in Patients With Three-Vessel Disease and Left Main Coronary Disease: 5-Year Follow-Up of the Randomised, Clinical SYNTAX Trial". Lancet. 381 (9867): 629–638. doi:10.1016/S0140-6736(13)60141-5.
  22. ↑ Takahashi et al. [SYNTAX Score II 2020]. Lancet. 2020.
  23. ↑ 23.0 23.1 Sung WT, Chuang MJ, Tsai YL; et al. (2024). "Impacts of the SYNTAX score I, II and SYNTAX score II 2020 on left main revascularization". Sci Rep. 14 (1): 1073. doi:10.1038/s41598-024-51192-7.
  24. ↑ 24.0 24.1 24.2 24.3 Johnson TW, Gonzalo N, de la Torre Hernandez JM; et al. (2026). "Intracoronary Imaging for Left Main Percutaneous Coronary Intervention: A Clinical Consensus Statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the European Bifurcation Club (EBC)". Eur Heart J. 47 (37): 5247–5265. doi:10.1093/eurheartj/ehag353.
  25. ↑ 25.0 25.1 Padda I, Atwal H, Bharaj I; et al. (2026). "Multimodal imaging in left main and bifurcation revascularization: contemporary evidence and comparative modalities review". Int J Cardiovasc Imaging. 42 (9): 1647–1666. doi:10.1007/s10554-026-03710-z.
  26. ↑ Truesdell et al. J Am Coll Cardiol. 2023.
  27. ↑ 27.0 27.1 27.2 27.3 27.4 Arunothayaraj S, Egred M, Banning AP; et al. (2025). "Stepwise Provisional Versus Systematic Dual-Stent Strategies for Treatment of True Left Main Coronary Bifurcation Lesions". Circulation. 151 (9): 612–622. doi:10.1161/CIRCULATIONAHA.124.071153. PMID 39907022 Check |pmid= value (help).
  28. ↑ Bhogal S, Zhang C, Aladin AI, Mintz GS, Waksman R (2022). "Provisional Versus Dual Stenting of Left Main Coronary Artery Bifurcation Lesions (From a Comprehensive Meta-Analysis)". Am J Cardiol. 185: 10–17. doi:10.1016/j.amjcard.2022.09.012.
  29. ↑ 29.0 29.1 29.2 Paradies V, Banning A, Cao D; et al. (2023). "Provisional Strategy for Left Main Stem Bifurcation Disease: A State-of-the-Art Review of Technique and Outcomes". JACC Cardiovasc Interv. 16 (7): 743–758. doi:10.1016/j.jcin.2022.12.022.
  30. ↑ Chen SL, Zhang JJ, Han Y; et al. (2017). "Double Kissing Crush Versus Provisional Stenting for Left Main Distal Bifurcation Lesions: DKCRUSH-V Randomized Trial". J Am Coll Cardiol. 70 (21): 2605–2617. doi:10.1016/j.jacc.2017.09.1066.
  31. ↑ 31.0 31.1 Chen X, Li X, Zhang JJ; et al. (2019). "3-Year Outcomes of the DKCRUSH-V Trial Comparing DK Crush With Provisional Stenting for Left Main Bifurcation Lesions". JACC Cardiovasc Interv. 12 (19): 1927–1937. doi:10.1016/j.jcin.2019.04.056.
  32. ↑ Chiabrando JG, Lombardi M, Vescovo GM; et al. (2021). "Stenting techniques for coronary bifurcation lesions: Evidence from a network meta-analysis of randomized clinical trials". Catheter Cardiovasc Interv. 97 (3): E306–E318. doi:10.1002/ccd.29097.
  33. ↑ Di Gioia et al. JACC Cardiovasc Interv. 2020.
  34. ↑ Bujak et al. EuroIntervention. 2023.
  35. ↑ 35.0 35.1 Giustino G, Sharma SK, Kini A (2024). "Systematic Proximal Optimization Technique During Bifurcation Stenting: Where Is the Evidence?". JACC Cardiovasc Interv. 17 (6): 801–806. doi:10.1016/j.jcin.2024.01.071.
  36. ↑ Burzotta et al. [European Bifurcation Club white paper]. 2020.
  37. ↑ 37.0 37.1 37.2 Salter et al. Nat Rev Cardiol. 2023.
  38. ↑ Parikh et al. J Am Coll Cardiol. 2021.
  39. ↑ 39.0 39.1 39.2 39.3 39.4 Kumbhani DJ, Gibson CM, Kinlay S; et al. (2026). "Antiplatelet Therapy in the Management of Atherosclerotic Cardiovascular Disease: 2026 ACC Scientific Statement: A Report of the American College of Cardiology". J Am Coll Cardiol. 88 (11): 1284–1313. doi:10.1016/j.jacc.2026.05.037.
  40. ↑ Effient (prasugrel) prescribing information. U.S. Food and Drug Administration.
  41. ↑ Brilinta (ticagrelor) prescribing information. U.S. Food and Drug Administration.
  42. ↑ Capodanno et al. J Am Coll Cardiol. 2018.
  43. ↑ 43.0 43.1 Rhee TM, Park KW, Kim CH; et al. (2018). "Dual Antiplatelet Therapy Duration Determines Outcome After 2- But Not 1-Stent Strategy in Left Main Bifurcation Percutaneous Coronary Intervention". JACC Cardiovasc Interv. 11 (24): 2453–2463. doi:10.1016/j.jcin.2018.09.020.
  44. ↑ Lee JM, Kim H, Park YS; et al. (2024). "Surveillance Stress Testing After Percutaneous Intervention for Patients With Multivessel or Left Main Coronary Disease". J Am Coll Cardiol. 83 (9): 890–900. doi:10.1016/j.jacc.2023.12.027.
  45. ↑ 45.0 45.1 Massussi et al. Coron Artery Dis. 2025.
  46. ↑ Wang J, Guan C, Chen J; et al. (2020). "Validation of bifurcation DEFINITION criteria and comparison of stenting strategies in true left main bifurcation lesions". Sci Rep. 10 (1): 10461. doi:10.1038/s41598-020-67369-9. PMID 32587331 Check |pmid= value (help).
  47. ↑ 47.0 47.1 Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions" (PDF). Journal of the American College of Cardiology. 58 (24): 2550–83. doi:10.1016/j.jacc.2011.08.006. PMID 22070837. Retrieved 2011-12-08. Text "PDF" ignored (help); Unknown parameter |month= ignored (help)
  48. ↑ 48.0 48.1 48.2 Chakravarty T, Buch MH, Naik H, White AJ, Doctor N, Schapira J et al. (2011)Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization. Am J Cardiol 107 (3):360-6. DOI:10.1016/j.amjcard.2010.09.029 PMID:21256999
  49. ↑ 49.0 49.1 49.2 Kim YH, Park DW, Kim WJ, Lee JY, Yun SC, Kang SJ et al. (2010) Validation of SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score for prediction of outcomes after unprotected left main coronary revascularization. JACC Cardiovasc Interv 3 (6):612-23.DOI:10.1016/j.jcin.2010.04.004 PMID:20630454
  50. ↑ 50.0 50.1 50.2 50.3 Morice MC, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A et al. (2010)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 121 (24):2645-53.DOI:10.1161/CIRCULATIONAHA.109.899211 PMID:20530001
  51. ↑ Caracciolo EA, Davis KB, Sopko G, Kaiser GC, Corley SD, Schaff H et al. (1995) Comparison of surgical and medical group survival in patients with left main coronary artery disease. Long-term CASS experience. Circulation 91 (9):2325-34. PMID: 7729018
  52. ↑ Chaitman BR, Fisher LD, Bourassa MG, Davis K, Rogers WJ, Maynard C et al. (1981)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 48 (4):765-77. PMID:7025604
  53. ↑ Dzavik V, Ghali WA, Norris C, Mitchell LB, Koshal A, Saunders LD et al. (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 J142 (1):119-26. DOI:10.1067/mhj.2001.116072 PMID:11431667
  54. ↑ Takaro T, Hultgren HN, Lipton MJ, Detre KM (1976) The VA cooperative randomized study of surgery for coronary arterial occlusive disease II. Subgroup with significant left main lesions.Circulation 54 (6 Suppl):III107-17. PMID: 791537
  55. ↑ Takaro T, Peduzzi P, Detre KM, Hultgren HN, Murphy ML, van der Bel-Kahn J et al. (1982) Survival in subgroups of patients with left main coronary artery disease. Veterans Administration Cooperative Study of Surgery for Coronary Arterial Occlusive Disease. Circulation 66 (1):14-22. PMID: [1]
  56. ↑ Taylor HA, Deumite NJ, Chaitman BR, Davis KB, Killip T, Rogers WJ (1989) Asymptomatic left main coronary artery disease in the Coronary Artery Surgery Study (CASS) registry. Circulation 79 (6):1171-9. PMID:2785870
  57. ↑ Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW et al. (1994) Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 344 (8922):563-70. PMID: [2]
  58. ↑ 58.0 58.1 Kappetein AP, Feldman TE, Mack MJ, Morice MC, Holmes DR, Ståhle E et al. (2011)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 32 (17):2125-34. [3] PMID: 21697170
  59. ↑ 59.0 59.1 Capodanno D, Caggegi A, Miano M, Cincotta G, Dipasqua F, Giacchi G et al. (2011)Global risk classification and clinical SYNTAX (synergy between percutaneous coronary intervention with TAXUS and cardiac surgery) score in patients undergoing percutaneous or surgical left main revascularization. JACC Cardiovasc Interv 4 (3):287-97. DOI:10.1016/j.jcin.2010.10.013PMID: 21435606
  60. ↑ 60.0 60.1 Hannan EL, Wu C, Walford G, Culliford AT, Gold JP, Smith CR et al. (2008)Drug-eluting stents vs. coronary-artery bypass grafting in multivessel coronary disease. N Engl J Med 358 (4):331-41.DOI:10.1056/NEJMoa071804 PMID: [4]
  61. ↑ 61.0 61.1 61.2 Ellis SG, Tamai H, Nobuyoshi M, Kosuga K, Colombo A, Holmes DR et al. (1997) Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994-1996.Circulation 96 (11):3867-72. PMID: 9403609
  62. ↑ 62.0 62.1 Biondi-Zoccai GG, Lotrionte M, Moretti C, Meliga E, Agostoni P, Valgimigli M et al. (2008) A collaborative systematic review and meta-analysis on 1278 patients undergoing percutaneous drug-eluting stenting for unprotected left main coronary artery disease. Am Heart J 155 (2):274-83.DOI:10.1016/j.ahj.2007.10.009 PMID:18215597
  63. ↑ 63.0 63.1 Boudriot E, Thiele H, Walther T, Liebetrau C, Boeckstegers P, Pohl T et al. (2011)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 57 (5):538-45.DOI:10.1016/j.jacc.2010.09.038 PMID:21272743
  64. ↑ 64.0 64.1 64.2 Brener SJ, Galla JM, Bryant R, Sabik JF, Ellis SG (2008) Comparison of percutaneous versus surgical revascularization of severe unprotected left main coronary stenosis in matched patients. Am J Cardiol 101 (2):169-72. [5] PMID: 18178401
  65. ↑ 65.0 65.1 Buszman PE, Kiesz SR, Bochenek A, Peszek-Przybyla E, Szkrobka I, Debinski M et al. (2008) Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization. J Am Coll Cardiol 51 (5):538-45.DOI:10.1016/j.jacc.2007.09.054 PMID:18237682
  66. ↑ 66.0 66.1 66.2 Chieffo A, Morici N, Maisano F, Bonizzoni E, Cosgrave J, Montorfano M et al. (2006)Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience.Circulation 113 (21):2542-7. [6] PMID: 16717151
  67. ↑ 67.0 67.1 67.2 Lee MS, Kapoor N, Jamal F, Czer L, Aragon J, Forrester J et al. (2006)Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease. J Am Coll Cardiol 47 (4):864-70. [7] PMID: 16487857
  68. ↑ 68.0 68.1 Mäkikallio TH, Niemelä M, Kervinen K, Jokinen V, Laukkanen J, Ylitalo I et al. (2008) Coronary angioplasty in drug eluting stent era for the treatment of unprotected left main stenosis compared to coronary artery bypass grafting. Ann Med 40 (6):437-43. DOI:10.1080/07853890701879790PMID: 18608116
  69. ↑ 69.0 69.1 Naik H, White AJ, Chakravarty T, Forrester J, Fontana G, Kar S et al. (2009)A meta-analysis of 3,773 patients treated with percutaneous coronary intervention or surgery for unprotected left main coronary artery stenosis.JACC Cardiovasc Interv 2 (8):739-47. [8] PMID: 19695542
  70. ↑ 70.0 70.1 Palmerini T, Marzocchi A, Marrozzini C, Ortolani P, Saia F, Savini C et al. (2006) Comparison between coronary angioplasty and coronary artery bypass surgery for the treatment of unprotected left main coronary artery stenosis (the Bologna Registry). Am J Cardiol 98 (1):54-9.DOI:10.1016/j.amjcard.2006.01.070 PMID:16784920
  71. ↑ 71.0 71.1 Park DW, Seung KB, Kim YH, Lee JY, Kim WJ, Kang SJ et al. (2010) Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry. J Am Coll Cardiol 56 (2):117-24. [9] PMID: 20451344
  72. ↑ 72.0 72.1 72.2 Rodés-Cabau J, Deblois J, Bertrand OF, Mohammadi S, Courtis J, Larose E et al. (2008) Nonrandomized comparison of coronary artery bypass surgery and percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease in octogenarians. Circulation 118 (23):2374-81.DOI:10.1161/CIRCULATIONAHA.107.727099 PMID:19029471
  73. ↑ 73.0 73.1 73.2 Sanmartín M, Baz JA, Claro R, Asorey V, Durán D, Pradas G et al. (2007) Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease. Am J Cardiol 100 (6):970-3.DOI:10.1016/j.amjcard.2007.04.037 PMID:17826380
  74. ↑ 74.0 74.1 74.2 Seung KB, Park DW, Kim YH, Lee SW, Lee CW, Hong MK et al. (2008) Stents versus coronary-artery bypass grafting for left main coronary artery disease. N Engl J Med 358 (17):1781-92.DOI:10.1056/NEJMoa0801441 PMID:18378517
  75. ↑ 75.0 75.1 75.2 White AJ, Kedia G, Mirocha JM, Lee MS, Forrester JS, Morales WC et al. (2008)Comparison of coronary artery bypass surgery and percutaneous drug-eluting stent implantation for treatment of left main coronary artery stenosis.JACC Cardiovasc Interv 1 (3):236-45. [10] PMID: 19463306
  76. ↑ Chieffo A, Magni V, Latib A, Maisano F, Ielasi A, Montorfano M et al. (2010)5-year outcomes following percutaneous coronary intervention with drug-eluting stent implantation versus coronary artery bypass graft for unprotected left main coronary artery lesions the Milan experience. JACC Cardiovasc Interv 3 (6):595-601. DOI:10.1016/j.jcin.2010.03.014 PMID:20630452
  77. ↑ Montalescot G, Brieger D, Eagle KA, Anderson FA, FitzGerald G, Lee MS et al. (2009) Unprotected left main revascularization in patients with acute coronary syndromes. Eur Heart J 30 (19):2308-17.DOI:10.1093/eurheartj/ehp353 PMID:19720640
  78. ↑ Lee MS, Tseng CH, Barker CM, Menon V, Steckman D, Shemin R et al. (2008)Outcome after surgery and percutaneous intervention for cardiogenic shock and left main disease. Ann Thorac Surg 86 (1):29-34.DOI:10.1016/j.athoracsur.2008.03.019 PMID:18573394
  79. ↑ Lee MS, Bokhoor P, Park SJ, Kim YH, Stone GW, Sheiban I et al. (2010) Unprotected left main coronary disease and ST-segment elevation myocardial infarction: a contemporary review and argument for percutaneous coronary intervention. JACC Cardiovasc Interv 3 (8):791-5.DOI:10.1016/j.jcin.2010.06.005 PMID:20723848
  80. ↑ Park SJ, Kim YH, Park DW, Yun SC, Ahn JM, Song HG et al. (2011)Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med 364 (18):1718-27.DOI:10.1056/NEJMoa1100452 PMID:[11]
Retrieved from "https://www.wikidoc.org/index.php?title=Left_main_intervention&oldid=1746820"