Left main intervention: Difference between revisions

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{{CMG}}; '''Associate Editors-In-Chief:''' Neil M. Gheewala, M.D.
{{CMG}}; '''Associate Editors-In-Chief:''' Neil M. Gheewala, M.D.


==Overview==
==Left Main Intervention==
The left main coronary artery provides blood flow to two of the main coronary arteries (the [[left anterior descending artery]] as well as the [[circumflex coronary artery]]), and approximately 5% of all patients undergoing coronary angiography have significant (> 50%) [[left main coronary artery|left main coronary artery (LMCA)]] [[stenosis]].  
===Diagnosis===
The [[left main coronary artery]] provides blood flow to two of the main [[coronary artery|coronary arteries]] (the [[left anterior descending artery]] as well as the [[circumflex coronary artery]]), and approximately 5% of all patients undergoing [[coronary angiography]] have significant (> 50%) [[left main coronary artery|left main coronary artery (LMCA)]] [[stenosis]]. Assessment of the [[LMCA|left main]] is associated with the greatest amount of inter and intraobserver variability in [[angiography]]. The [[LMCA|left main]] is short, and is often [[disease]]d with asymmetric [[lesion]]s making its assessment on [[angiography]] difficult. There may be [[diffuse]] [[disease]] which may cause an underestimation of the extent of involvement on [[angiography]]. While [[lumen|luminal]] encroachment is defined as a minimum [[lumen]] area less than 4 mm² in the [[epicardial]] [[artery|arteries]], a minimum [[lumen]] area less than 6 mm² in the [[LMCA|left main]] is considered to be significant. A minimum [[lumen]] area less than 6 mm² in the [[LMCA|left main]] corresponds with a [[fractional flow reserve]] less than 0.75. A minimum [[lumen]] area less than 6 mm² also corresponds to a minimum [[lumen]] area less than 4 mm² in either the [[LAD]] or the [[circumflex artery|circumflex arteries]]. In interrogating [[ostia]]l [[lesion]]s, it is critical to disengage the guide so that the guide is not mistaken for the [[lumen]] of the [[artery]].


==Diagnosis==
===Treatment===
Assessment of the left main is associated with the greatest amount of inter and intraobserver variability in angiography.  The left main is short, and is often diseased with asymmetric lesions making its assessment on angiography difficult.  There may be diffuse disease which may cause an underestimation of the extent of involvement on angiography.  While luminal encroachment is defined as a minimum lumen area less than 4 mm² in the epicardial arteries, a minimum lumen area less than 6 mm² in the left main is considered to be significant.  A minimum lumen area less than 6 mm² in the left main corresponds with a [[fractional flow reserve]] less than 0.75.  A minimum lumen area less than 6 mm² also corresponds to a minimum lumen area less than 4 mm² in either the LAD or the circumflex arteries.  In interrogating ostial lesions is critical to disengage the guide so the guide is not mistaken for the lumen of the artery.
The [[ACC]]/[[AHA]] recommends [[CABG|coronary artery bypass grafting (CABG)]] in patients with significant [[LMCA]] [[disease]] who have [[angina]] and [[ACS]]. However, not all patients are operative candidates. [[LMCA|Left main (LM)]] PCI can safely and effectively treat patients in whom [[coronary artery bypass grafting]] ([[CABG]]) is suboptimal, or in patients who have had prior [[CABG]] with a ‘protected’ [[LMCA]]. Protected [[LMCA|left main]] in patients with prior [[CABG]] is defined as having at least one patent [[graft]] to the [[left anterior descending]] or [[circumflex artery]]. The main goal is to provide a treatment option for patients who would otherwise be poor [[surgery|surgical]] candidates, who are declined by [[surgery]], or who refuse [[CABG]]. It is essential to properly select patients based on their [[anatomy]] as to whether they are optimal candidates for [[DES|drug-eluting stents (DES)]] vs [[BMS|bare metal stents (BMS)]] vs [[bifurcation stenting|bifurcation stents]].
 
==Treatment==
The [[ACC]]/[[AHA]] recommends [[CABG|coronary artery bypass grafting (CABG)]] in patients with significant LMCA disease who have [[angina]] and [[ACS]]. However, not all patients are operative candidates. Left main (LM) [[PCI|percutaneous coronary intervention (PCI)]] can safely and effectively treat patients in whom coronary artery bypass grafting (CABG) is suboptimal, or in patients who have had prior CABG with a ‘protected’ LMCA. '''‘Protected’ left main''' in patients with prior CABG is defined as having at least one patent graft to the [[left anterior descending]] or [[circumflex artery]]. The main goal is to provide a treatment option for patients who would otherwise be poor surgical candidates, who are declined by surgery, or who refuse [[CABG]]. It is essential to properly select patients based on their anatomy as to whether they are optimal candidates for [[DES|drug-eluting stents (DES)]] vs [[BMS|bare metal stents (BMS)]] vs bifurcation stents.


===Appropriate Candidate Selection===
===Appropriate Candidate Selection===
[[CABG]] has generally been accepted as the [[standard of care]] for patients with LMCA disease. [[Left main intervention]] is considered a high risk subset of [[PCI]], but it may be necessary for certain patients.   
[[CABG]] has generally been accepted as the [[standard of care]] for patients with [[LMCA]] disease. Left main intervention is considered a high risk subset of PCI, but it may be necessary for certain patients.   


Candidates for LMCA PCI include:
Candidates for [[LMCA]] PCI include:
*Poor operative candidates
*Poor operative candidates
*Low-risk patients who refuse CABG
*Low-risk patients who refuse [[CABG]]
*Patients with 'protected' left main disease (see above)
*Patients with 'protected' [[LMCA|left main disease]] (see above)
*Syntax score less than or equal to 22 is considered reasonable based on the Syntax trial (remains subject to debate)
*[[SYNTAX score|Syntax score]] less than or equal to 22 is considered reasonable based on the [[SYNTAX|Syntax]] trial (remains subject to debate)


High-risk features in patients with [[left main disease]] [[PCI]] include:
High-risk features in patients with left main disease PCI include:
*Absence of [[internal mammary artery]], [[radial artery]], or [[saphenous vein grafts]] distally leading to an ‘unprotected’ left main.   
*Absence of [[internal mammary artery]], [[radial artery]], or [[saphenous vein grafts]] distally leading to an ‘unprotected’ [[LMCA|left main]].   
*Concomitant [[RCA|right coronary artery (RCA)]] disease and/or lack of [[collaterals]] from RCA
*Concomitant [[RCA|right coronary artery (RCA)]] disease and/or lack of [[collaterals]] from [[RCA]]
*[[Left ventricular dysfunction]]
*[[Left ventricular dysfunction]]


==Technical Aspects of Performing PCI in the Left Main==
===Technical Aspects of Performing PCI in the Left Main===
===Hemodynamic Monitoring and Support===
====Hemodynamic Monitoring and Support====
[[Hemodynamic]] support is not mandatory, but it should be considered for high-risk patients who have refractory [[angina]] or are awaiting [[CABG]] with persistent angina on maximal medical therapy. Options include an [[IABP|intra-aortic balloon pump (IABP)]], Impella, and Tandom Heart. Also, [[Pulmonary artery|pulmonary artery (PA)]] line monitoring may be helpful.
[[Hemodynamic]] support is not mandatory, but it should be considered for high-risk patients who have refractory [[angina]] or are awaiting [[CABG]] with persistent [[angina]] on maximal medical [[therapy]]. Options include an [[IABP|intra-aortic balloon pump (IABP)]], Impella, and Tandom Heart. Also, [[Pulmonary artery|pulmonary artery (PA)]] line monitoring may be helpful.
 
====Pre-interventional Preparation: Clearly Define Relevant Anatomy====
===Pre-interventional Preparation: Clearly Define Relevant Anatomy===
Characterizing the patient's [[anatomy]] may reduce [[complication]]s and the duration of the intervention. This can be done through several different methods:
Characterizing the patient's anatomy may reduce complications and the duration of the intervention. This can be done through several different methods:
*[[Intravascular ultrasound|Intravascular ultrasound (IVUS)]]: The extent of the [[plaque]], as well as any [[calcification]], can be characterized by [[IVUS]].
*'''Intravascular ultrasound (IVUS):''' The extent of the [[plaque]], as well as any [[calcification]], can be characterized by IVUS.
*Multiple [[angiographic]] views: A layout of the [[anatomy]] can help characterize any disease in the [[LMCA]] [[ostium]], the [[distal]]/ [[Bifurcation Lesion|bifurcation lesion]], as well as the extent of the [[lesion]].
*'''Multiple [[angiographic]] views:''' A layout of the anatomy can help characterize any disease in the [[LMCA]] ostium, the distal/bifurcation lesion, as well as the extent of the lesion.
*Guiding catheter selection: Larger guiding catheters (i.e.: 7 or 8 French) can be used in the event that [[distal]] [[bifurcation stenting|bifurcation intervention]] becomes necessary, as they provide good support and do not occlude the [[ostium]]. If necessary, side hole guiding catheters can be utilized.
*'''Guiding catheter selection:'''  Larger guiding catheters (i.e.: 7 or 8 French) can be used in the event that distal bifurcation intervention becomes necessary, as they provide good support and do not occlude the ostium. If necessary, side hole guiding catheters can be utilized.
 
In addition to characterizing the patient's anatomy, it is essential to have all stents and balloons on the table, prepped, and ready to be deployed so that no time is wasted.


===Antiplatelet Regimen===
In addition to characterizing the patient's [[anatomy]], it is essential to have all [[stent]]s and balloons on the table, prepped, and ready to be deployed so that no time is wasted.
* A pre-PCI loading dose of non-enteric coated [[Aspirin]] is essential.   
====Antiplatelet Regimen====
* A pre-PCI loading dose of 600 mg of [[Clopidogrel]] should be administered, then 150 mg PO qd should be administered for one week, and then 75 mg should be given daily for the rest of the patient's life. [[Prasugrel]] could alternatively be administered if the patient is under age 75, over 60 kg, has no history of [[stroke]] or [[TIA]], and is at low risk of bleeding. Patients should be told not to discontinue their thienopyridine unlesss they have spoken with their cardiologist.
* A pre-PCI [[loading dose]] of non-[[enteric coating|enteric coated]] [[Aspirin]] is essential.   
* A pre-PCI [[loading dose]] of 600 mg of [[Clopidogrel]] should be administered, then 150 mg PO qd should be administered for one week, and then 75 mg should be given daily for the rest of the patient's life. [[Prasugrel]] could alternatively be administered if the patient is under age 75, over 60 kg, has no history of [[stroke]] or [[TIA]], and is at low risk of [[bleeding]]. Patients should be told not to discontinue their [[thienopyridine]] unless they have spoken with their [[cardiologist]].
* [[GP IIb/IIIa inhibitors]] are typically used to prevent [[thrombotic]] closure.
* [[GP IIb/IIIa inhibitors]] are typically used to prevent [[thrombotic]] closure.


===Reduce Ischemic Time===
====Reduce Ischemic Time====
Besides selecting and prepping the equipment in advance, other methods can be employed to reduce [[ischemic]] time:
Besides selecting and prepping the equipment in advance, other methods can be employed to reduce [[ischemic]] time:
* A rapid exchange system may be used
* A rapid exchange system may be used
* The contrast in the indeflator should be diluted with saline to allow for faster deflation.  
* The [[contrast]] in the deflator should be diluted with [[saline]] to allow for faster deflation.  
* For conventional angioplasty balloon inflations, a perfusion balloon can be utilized in the [[left anterior descending artery]] (if this is the dominant territory).
* For conventional [[angioplasty]] balloon inflations, a [[perfusion]] balloon can be utilized in the [[left anterior descending artery]] (if this is the dominant territory).
 
====Appropriate Stent Selection====
Consider using a [[BMS]] if the left main diameter is 3.5 mm or greater, and consider using a [[DES]] if the [[LMCA|left main]] diameter is small or if the lesion is long. If there is an [[ostium|ostia]]l [[lesion]], the operator should assure that the [[aorta|aorto]]-[[ostium|ostial]] region is covered by a [[stent]].
 
There is increasing evidence for better [[PCI]] outcomes using [[DES]] instead of [[BMS]] because of lower [[angiographic]] rates of [[restenosis]] and significant reductions in major adverse events<ref name="pmid16487858">{{cite journal |author=Price MJ, Cristea E, Sawhney N, ''et al.'' |title=Serial angiographic follow-up of sirolimus-eluting stents for unprotected left main coronary artery revascularization |journal=J. Am. Coll. Cardiol. |volume=47 |issue=4 |pages=871–7 |year=2006 |month=February |pmid=16487858 |doi=10.1016/j.jacc.2005.12.015 |url=}}</ref>. There are unclear benefits of using one [[DES]] over another based on their design (open/closed cell, modular), strut thickness/radial strength, and type of drug/[[polymer]].
 
====Approach Dictated by Lesion Morphology====
Outcome differences have been observed according to the location of the [[LMCA]] [[stenosis]]. For instance, [[distal]] [[LMCA|left main]] involvement (~75%) [[lesion]]s have worse outcomes compared to more [[proximal]] [[lesion]]s.
 
[[Distal]] [[Bifurcation Lesion|bifurcation]] involvement has poorer results when treated with a two [[stent]] approach (i.e. kissing [[stent]]s, culotte, T, etc). The approach is similar to other [[Bifurcation Lesion|bifurcation]] [[therapy|therapies]], but it has a higher risk with:
*Directional [[coronary artery|coronary]] [[atherectomy]] (DCA) alone
*[[atherectomy|DCA]] plus [[stent]]ing of the principal [[vessel]]
*[[Stent]]ing of the principal [[vessel]] (which is usually the [[LAD]]) and rescuing [[circumflex]]. [[Bifurcation stenting]] (Crush, Culotte, T) have been shown to be non-inferior to each other and yield reasonable [[angiographic]] and clinical outcomes.
 
[[Calcification|Calcified]] lesions can be treated with rotational [[atherectomy]] or [[stent]]ing.
 
Bulky [[plaque]] can be treated with directional [[atherectomy]] and [[stent]]ing, or [[stent]]ing alone.
 
===Follow-Up Care===
====Exercise Tolerance Test Screening====
There is a consensus opinion that it is important to aggressively screen for [[restenosis]]. [[Left main]] [[restenosis]] may unfortunately present as [[sudden cardiac death]] rather than recurrent [[angina]]. It is therefore recommended that repeat [[angiography]] be performed 2-3 months following the procedure, even in the absence of [[symptom]]s. Some operators also recommend additional [[angiography]] at 6 months to identify late [[restenosis]].
 
====Use of and Indwelling EKG Electrode and Alarming Device====
In countries where it is available, implantation of an [[ischemia]] monitoring device, such as the AngelMed Guardian device<ref name="pmid19631947">{{cite journal |author=Hopenfeld B, John MS, Fischell DR, Medeiros P, Guimarães HP, Piegas LS |title=The Guardian: an implantable system for chronic ambulatory monitoring of acute myocardial infarction |journal=J Electrocardiol |volume=42 |issue=6 |pages=481–6 |year=2009 |pmid=19631947 |doi=10.1016/j.jelectrocard.2009.06.017 |url=}}</ref>, may permit ongoing surveillance for early detection of [[ischemia]] in these high risk patients.


===Appropriate Stent Selection===
====Risk Factor Modification====
Consider using a [[BMS]] if the left main diameter is 3.5 mm or greater, and consider using a [[DES]] if the left main diameter is small or if the lesion is long.  If there is an [[ostial lesion]], the operator should assure that the aorto-ostial region is covered by a stent.
Treating a patient with non-[[surgery|surgical]] methods include [[smoking cessation]] and [[cardiac risk factors|cardiac risk factor]] modification.


There is increasing evidence for better [[PCI]] outcomes using [[DES]] instead of [[BMS]] because of lower angiographic rates of [[restenosis]] and significant reductions in major adverse events<ref name="pmid16487858">{{cite journal |author=Price MJ, Cristea E, Sawhney N, ''et al.'' |title=Serial angiographic follow-up of sirolimus-eluting stents for unprotected left main coronary artery revascularization |journal=J. Am. Coll. Cardiol. |volume=47 |issue=4 |pages=871–7 |year=2006 |month=February |pmid=16487858 |doi=10.1016/j.jacc.2005.12.015 |url=}}</ref>.  There are unclear benefits of using one DES over another based on their design (open/closed cell, modular), strut thickness/radial strength, and type of drug/polymer.
====Dual Antiplatelet Therapy====
If a [[stent]] is placed, the patient should placed on prolonged [[dual antiplatelet therapy]]. Either [[clopidogrel]] or [[Prasugrel]] for the rest of the patient's life are suitable choices.


===Approach Dictated by Lesion Morphology===
==2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)<ref name="pmid22070837">{{cite journal |author=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 |title=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 |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=24 |pages=2550–83 |year=2011 |month=December|pmid=22070837|doi=10.1016/j.jacc.2011.08.006|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0|accessdate=2011-12-08|url=http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf|PDF}}</ref>==
Outcome differences have been observed according to the location of the [[LMCA]] [[stenosis]].  For instance, distal left main involvement (~75%) lesions have worse outcomes compared to more proximal lesions.
===Revascularization to Improve Survival in Left Main Coronary Artery Disease (DO NOT EDIT)<ref name="pmid22070837">{{cite journal |author=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|title=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|journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=24 |pages=2550–83 |year=2011|month=December|pmid=22070837|doi=10.1016/j.jacc.2011.08.006|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0|accessdate=2011-12-08|url=http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf|PDF}}</ref>===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[CABG]] to improve survival is recommended for patients with significant (≥50% diameter [[stenosis]]) [[left main coronary artery]] [[stenosis]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


Distal bifurcation involvement has poorer results when treated with a two stent approach (i.e. kissing stents, culotte, T, etc). The approach is similar to other bifurcation therapies, but it has a higher risk with:
{|class="wikitable"
*Directional coronary [[atherectomy]] (DCA) alone
|-
*DCA plus stenting of the principal vessel
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
*Stenting of the principal vessel (which is usually the [[LAD]]) and rescuing [[circumflex]]. Bifurcation stenting (Crush, Culotte, T) have been shown to be non-inferior to each other and yield reasonable angiographic and clinical outcomes.  
|-
|bgcolor="LightCoral"|
<nowiki>"</nowiki>'''1.''' [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] to improve survival should not be performed in [[chronic stable angina definition|stable]] patients with significant (greater than or equal to 50% diameter [[stenosis]]) [[PCI in the unprotected left main patient|unprotected left main CAD]] who have unfavorable [[anatomy]] for [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] and who are good candidates for [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]]. <ref name="pmid21256999">Chakravarty T, Buch MH, Naik H, White AJ, Doctor N, Schapira J et al. (2011)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21256999 Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization.] ''Am J Cardiol'' 107 (3):360-6. [http://dx.doi.org/10.1016/j.amjcard.2010.09.029 DOI:10.1016/j.amjcard.2010.09.029] PMID:[http://pubmed.gov/21256999 21256999]</ref><ref name="pmid20630454">Kim YH, Park DW, Kim WJ, Lee JY, Yun SC, Kang SJ et al. (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20630454 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.[http://dx.doi.org/10.1016/j.jcin.2010.04.004 DOI:10.1016/j.jcin.2010.04.004] PMID:[http://pubmed.gov/20630454 20630454]</ref><ref name="pmid20530001">Morice MC, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A et al. (2010)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20530001 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.[http://dx.doi.org/10.1161/CIRCULATIONAHA.109.899211 DOI:10.1161/CIRCULATIONAHA.109.899211] PMID:[http://pubmed.gov/20530001 20530001]</ref><ref name="pmid7729018">Caracciolo EA, Davis KB, Sopko G, Kaiser GC, Corley SD, Schaff H et al. (1995) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7729018 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: [http://pubmed.gov/7729018 7729018]</ref><ref name="pmid7025604">Chaitman BR, Fisher LD, Bourassa MG, Davis K, Rogers WJ, Maynard C et al. (1981)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7025604 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:[http://pubmed.gov/7025604 7025604]</ref><ref name="pmid11431667">Dzavik V, Ghali WA, Norris C, Mitchell LB, Koshal A, Saunders LD et al. (2001)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11431667 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 (1):119-26. [http://dx.doi.org/10.1067/mhj.2001.116072 DOI:10.1067/mhj.2001.116072] PMID:[http://pubmed.gov/11431667 11431667]</ref><ref name="pmid791537">Takaro T, Hultgren HN, Lipton MJ, Detre KM (1976) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=791537 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: [http://pubmed.gov/791537 791537]</ref><ref name="pmid6979435">Takaro T, Peduzzi P, Detre KM, Hultgren HN, Murphy ML, van der Bel-Kahn J et al. (1982) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=6979435 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: [http://pubmed.gov/69794356979435]</ref><ref name="pmid2785870">Taylor HA, Deumite NJ, Chaitman BR, Davis KB, Killip T, Rogers WJ (1989) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=2785870 Asymptomatic left main coronary artery disease in the Coronary Artery Surgery Study (CASS) registry.] ''Circulation'' 79 (6):1171-9. PMID:[http://pubmed.gov/2785870 2785870]</ref><ref name="pmid7914958">Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW et al. (1994) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7914958 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: [http://pubmed.gov/79149587914958]</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


[[Calcification|Calcified]] lesions can be treated with rotational [[atherectomy]] or stenting.
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''1.''' [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] to improve survival is reasonable as an alternative to [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]] in selected [[chronic stable angina|stable]] patients with significant (greater than or equal to 50% diameter [[stenosis]]) [[PCI in the unprotected left main patient|unprotected left main CAD]] with:


Bulky [[plaque]] can be treated with directional [[atherectomy]] and stenting, or stenting alone.
:'''a.''' Anatomic conditions associated with a low risk of [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] procedural [[complication]]s and a high likelihood of good long-term outcome (e.g., a low [[SYNTAX]] score [lower than or equal to 22], [[ostium|ostial]] or trunk [[left main]] [[CAD]]); and ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


==Follow-Up Care==
:'''b.''' Clinical characteristics that predict a significantly increased risk of adverse [[surgery|surgical]] outcomes (e.g., Society of Thoracic Surgeons–predicted risk of operative [[mortality]] 5%). <ref name="pmid21256999">Chakravarty T, Buch MH, Naik H, White AJ, Doctor N, Schapira J et al. (2011)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21256999 Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization.] ''Am J Cardiol'' 107 (3):360-6. [http://dx.doi.org/10.1016/j.amjcard.2010.09.029 DOI:10.1016/j.amjcard.2010.09.029] PMID:[http://pubmed.gov/21256999 21256999]</ref><ref name="pmid20630454">Kim YH, Park DW, Kim WJ, Lee JY, Yun SC, Kang SJ et al. (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20630454 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.[http://dx.doi.org/10.1016/j.jcin.2010.04.004 DOI:10.1016/j.jcin.2010.04.004] PMID:[http://pubmed.gov/20630454 20630454]</ref><ref name="pmid20530001">Morice MC, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A et al. (2010)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20530001 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.[http://dx.doi.org/10.1161/CIRCULATIONAHA.109.899211 DOI:10.1161/CIRCULATIONAHA.109.899211] PMID:[http://pubmed.gov/20530001 20530001]</ref><ref name="pmid21697170">Kappetein AP, Feldman TE, Mack MJ, Morice MC, Holmes DR, Ståhle E et al. (2011)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21697170 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. [http://dx.doi.org/10.1093/eurheartj/ehr213DOI:10.1093/eurheartj/ehr213] PMID: [http://pubmed.gov/21697170 21697170]</ref><ref name="pmid21435606">Capodanno D, Caggegi A, Miano M, Cincotta G, Dipasqua F, Giacchi G et al. (2011)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21435606 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. [http://dx.doi.org/10.1016/j.jcin.2010.10.013 DOI:10.1016/j.jcin.2010.10.013]PMID: [http://pubmed.gov/21435606 21435606]</ref><ref name="pmid18216353">Hannan EL, Wu C, Walford G, Culliford AT, Gold JP, Smith CR et al. (2008)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18216353 Drug-eluting stents vs. coronary-artery bypass grafting in multivessel coronary disease.] ''N Engl J Med'' 358 (4):331-41.[http://dx.doi.org/10.1056/NEJMoa071804 DOI:10.1056/NEJMoa071804] PMID: [http://pubmed.gov/1821635318216353]</ref><ref name="pmid9403609">Ellis SG, Tamai H, Nobuyoshi M, Kosuga K, Colombo A, Holmes DR et al. (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9403609 Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994-1996.]''Circulation'' 96 (11):3867-72. PMID: [http://pubmed.gov/9403609 9403609]</ref><ref name="pmid18215597">Biondi-Zoccai GG, Lotrionte M, Moretti C, Meliga E, Agostoni P, Valgimigli M et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18215597 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.[http://dx.doi.org/10.1016/j.ahj.2007.10.009 DOI:10.1016/j.ahj.2007.10.009] PMID:[http://pubmed.gov/18215597 18215597]</ref><ref name="pmid21272743">Boudriot E, Thiele H, Walther T, Liebetrau C, Boeckstegers P, Pohl T et al. (2011)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21272743 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.[http://dx.doi.org/10.1016/j.jacc.2010.09.038 DOI:10.1016/j.jacc.2010.09.038] PMID:[http://pubmed.gov/21272743 21272743]</ref><ref name="pmid18178401">Brener SJ, Galla JM, Bryant R, Sabik JF, Ellis SG (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18178401 Comparison of percutaneous versus surgical revascularization of severe unprotected left main coronary stenosis in matched patients.] ''Am J Cardiol'' 101 (2):169-72. [http://dx.doi.org/10.1016/j.amjcard.2007.08.054DOI:10.1016/j.amjcard.2007.08.054] PMID: [http://pubmed.gov/18178401 18178401]</ref><ref name="pmid18237682">Buszman PE, Kiesz SR, Bochenek A, Peszek-Przybyla E, Szkrobka I, Debinski M et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18237682 Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization.] ''J Am Coll Cardiol'' 51 (5):538-45.[http://dx.doi.org/10.1016/j.jacc.2007.09.054 DOI:10.1016/j.jacc.2007.09.054] PMID:[http://pubmed.gov/18237682 18237682]</ref><ref name="pmid16717151">Chieffo A, Morici N, Maisano F, Bonizzoni E, Cosgrave J, Montorfano M et al. (2006)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16717151 Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience.]''Circulation'' 113 (21):2542-7. [http://dx.doi.org/10.1161/CIRCULATIONAHA.105.595694DOI:10.1161/CIRCULATIONAHA.105.595694] PMID: [http://pubmed.gov/16717151 16717151]</ref><ref name="pmid16487857">Lee MS, Kapoor N, Jamal F, Czer L, Aragon J, Forrester J et al. (2006)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16487857 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. [http://dx.doi.org/10.1016/j.jacc.2005.09.072DOI:10.1016/j.jacc.2005.09.072] PMID: [http://pubmed.gov/16487857 16487857]</ref><ref name="pmid18608116">Mäkikallio TH, Niemelä M, Kervinen K, Jokinen V, Laukkanen J, Ylitalo I et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18608116 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. [http://dx.doi.org/10.1080/07853890701879790 DOI:10.1080/07853890701879790]PMID: [http://pubmed.gov/18608116 18608116]</ref><ref name="pmid19695542">Naik H, White AJ, Chakravarty T, Forrester J, Fontana G, Kar S et al. (2009)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19695542 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. [http://dx.doi.org/10.1016/j.jcin.2009.05.020DOI:10.1016/j.jcin.2009.05.020] PMID: [http://pubmed.gov/19695542 19695542]</ref><ref name="pmid16784920">Palmerini T, Marzocchi A, Marrozzini C, Ortolani P, Saia F, Savini C et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16784920 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.[http://dx.doi.org/10.1016/j.amjcard.2006.01.070 DOI:10.1016/j.amjcard.2006.01.070] PMID:[http://pubmed.gov/16784920 16784920]</ref><ref name="pmid20451344">Park DW, Seung KB, Kim YH, Lee JY, Kim WJ, Kang SJ et al. (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20451344 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. [http://dx.doi.org/10.1016/j.jacc.2010.04.004DOI:10.1016/j.jacc.2010.04.004] PMID: [http://pubmed.gov/20451344 20451344]</ref><ref name="pmid19029471">Rodés-Cabau J, Deblois J, Bertrand OF, Mohammadi S, Courtis J, Larose E et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19029471 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.[http://dx.doi.org/10.1161/CIRCULATIONAHA.107.727099 DOI:10.1161/CIRCULATIONAHA.107.727099] PMID:[http://pubmed.gov/19029471 19029471]</ref><ref name="pmid17826380">Sanmartín M, Baz JA, Claro R, Asorey V, Durán D, Pradas G et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17826380 Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease.] ''Am J Cardiol'' 100 (6):970-3.[http://dx.doi.org/10.1016/j.amjcard.2007.04.037 DOI:10.1016/j.amjcard.2007.04.037] PMID:[http://pubmed.gov/17826380 17826380]</ref><ref name="pmid18378517">Seung KB, Park DW, Kim YH, Lee SW, Lee CW, Hong MK et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18378517 Stents versus coronary-artery bypass grafting for left main coronary artery disease.] ''N Engl J Med'' 358 (17):1781-92.[http://dx.doi.org/10.1056/NEJMoa0801441 DOI:10.1056/NEJMoa0801441] PMID:[http://pubmed.gov/18378517 18378517]</ref><ref name="pmid19463306">White AJ, Kedia G, Mirocha JM, Lee MS, Forrester JS, Morales WC et al. (2008)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19463306 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. [http://dx.doi.org/10.1016/j.jcin.2008.02.007DOI:10.1016/j.jcin.2008.02.007] PMID: [http://pubmed.gov/19463306 19463306]</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
===Exercise Tolerance Test Screening===
|-
There is a consensus opinion that it is important to aggressively screen for [[restenosis]]. [[Left main]] restenosis may unfortunately present as [[sudden cardiac death]] rather than recurrent [[angina]]. It is therefore recommended that repeat angiography be performed 2-3 months following the procedure, even in the absence of symptoms. Some operators also recommend additional angiography at 6 months to identify late [[restenosis]].
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''2.''' [[Unstable angina / non ST elevation myocardial infarction recommendations for PCI|PCI]] to improve survival is reasonable in patients with [[UA|UA/NSTEMI]] when an [[PCI in the unprotected left main patient|unprotected left main coronary artery]] is the [[culprit lesion]] and the patient is not a candidate for [[Unstable angina / non ST elevation myocardial infarction recommendations for CABG|CABG]]. <ref name="pmid20530001">Morice MC, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A et al. (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20530001 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.[http://dx.doi.org/10.1161/CIRCULATIONAHA.109.899211 DOI:10.1161/CIRCULATIONAHA.109.899211] PMID:[http://pubmed.gov/20530001 20530001]</ref><ref name="pmid18178401">Brener SJ, Galla JM, Bryant R, Sabik JF, Ellis SG (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18178401 Comparison of percutaneous versus surgical revascularization of severe unprotected left main coronary stenosis in matched patients.] ''Am J Cardiol'' 101 (2):169-72. [http://dx.doi.org/10.1016/j.amjcard.2007.08.054DOI:10.1016/j.amjcard.2007.08.054] PMID: [http://pubmed.gov/18178401 18178401]</ref><ref name="pmid20630452">Chieffo A, Magni V, Latib A, Maisano F, Ielasi A, Montorfano M et al. (2010)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20630452 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. [http://dx.doi.org/10.1016/j.jcin.2010.03.014 DOI:10.1016/j.jcin.2010.03.014] PMID:[http://pubmed.gov/20630452 20630452]</ref><ref name="pmid16717151">Chieffo A, Morici N, Maisano F, Bonizzoni E, Cosgrave J, Montorfano M et al. (2006)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16717151 Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience.]''Circulation'' 113 (21):2542-7. [http://dx.doi.org/10.1161/CIRCULATIONAHA.105.595694DOI:10.1161/CIRCULATIONAHA.105.595694] PMID: [http://pubmed.gov/16717151 16717151]</ref><ref name="pmid16487857">Lee MS, Kapoor N, Jamal F, Czer L, Aragon J, Forrester J et al. (2006)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16487857 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. [http://dx.doi.org/10.1016/j.jacc.2005.09.072DOI:10.1016/j.jacc.2005.09.072] PMID: [http://pubmed.gov/16487857 16487857]</ref><ref name="pmid19029471">Rodés-Cabau J, Deblois J, Bertrand OF, Mohammadi S, Courtis J, Larose E et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19029471 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.[http://dx.doi.org/10.1161/CIRCULATIONAHA.107.727099 DOI:10.1161/CIRCULATIONAHA.107.727099] PMID:[http://pubmed.gov/19029471 19029471]</ref><ref name="pmid17826380">Sanmartín M, Baz JA, Claro R, Asorey V, Durán D, Pradas G et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17826380 Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease.] ''Am J Cardiol'' 100 (6):970-3.[http://dx.doi.org/10.1016/j.amjcard.2007.04.037 DOI:10.1016/j.amjcard.2007.04.037] PMID:[http://pubmed.gov/17826380 17826380]</ref><ref name="pmid18378517">Seung KB, Park DW, Kim YH, Lee SW, Lee CW, Hong MK et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18378517 Stents versus coronary-artery bypass grafting for left main coronary artery disease.] ''N Engl J Med'' 358 (17):1781-92.[http://dx.doi.org/10.1056/NEJMoa0801441 DOI:10.1056/NEJMoa0801441] PMID:[http://pubmed.gov/18378517 18378517]</ref><ref name="pmid19463306">White AJ, Kedia G, Mirocha JM, Lee MS, Forrester JS, Morales WC et al. (2008)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19463306 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. [http://dx.doi.org/10.1016/j.jcin.2008.02.007DOI:10.1016/j.jcin.2008.02.007] PMID: [http://pubmed.gov/19463306 19463306]</ref><ref name="pmid19720640">Montalescot G, Brieger D, Eagle KA, Anderson FA, FitzGerald G, Lee MS et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19720640 Unprotected left main revascularization in patients with acute coronary syndromes.] ''Eur Heart J'' 30 (19):2308-17.[http://dx.doi.org/10.1093/eurheartj/ehp353 DOI:10.1093/eurheartj/ehp353] PMID:[http://pubmed.gov/19720640 19720640]</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''3.''' [[ST elevation myocardial infarction primary percutaneous coronary intervention|PCI]] to improve survival is reasonable in patients with [[STEMI|acute STEMI]] when an [[PCI in the unprotected left main patient|unprotected left main coronary artery]] is the [[culprit lesion]], [[distal]] [[coronary blood flow|coronary flow]] is less than [[TIMI|TIMI (Thrombolysis In Myocardial Infarction)]] [[TIMI flow grade|grade 3]], and [[ST elevation myocardial infarction primary percutaneous coronary intervention|PCI]] can be performed more rapidly and safely than [[ST elevation myocardial infarction coronary artery bypass grafting|CABG]]. <ref name="pmid9403609">Ellis SG, Tamai H, Nobuyoshi M, Kosuga K, Colombo A, Holmes DR et al. (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9403609 Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994-1996.]''Circulation'' 96 (11):3867-72. PMID: [http://pubmed.gov/9403609 9403609]</ref><ref name="pmid18573394">Lee MS, Tseng CH, Barker CM, Menon V, Steckman D, Shemin R et al. (2008)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18573394 Outcome after surgery and percutaneous intervention for cardiogenic shock and left main disease.] ''Ann Thorac Surg'' 86 (1):29-34.[http://dx.doi.org/10.1016/j.athoracsur.2008.03.019 DOI:10.1016/j.athoracsur.2008.03.019] PMID:[http://pubmed.gov/18573394 18573394]</ref><ref name="pmid20723848">Lee MS, Bokhoor P, Park SJ, Kim YH, Stone GW, Sheiban I et al. (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20723848 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.[http://dx.doi.org/10.1016/j.jcin.2010.06.005 DOI:10.1016/j.jcin.2010.06.005] PMID:[http://pubmed.gov/20723848 20723848]</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


===Use of and Indwelling EKG Electrode and Alarming Device===
{|class="wikitable"
In countries where it is available, implantation of an ischemia monitoring device, such as the AngelMed Guardian device<ref name="pmid19631947">{{cite journal |author=Hopenfeld B, John MS, Fischell DR, Medeiros P, Guimarães HP, Piegas LS |title=The Guardian: an implantable system for chronic ambulatory monitoring of acute myocardial infarction |journal=J Electrocardiol |volume=42 |issue=6 |pages=481–6 |year=2009 |pmid=19631947 |doi=10.1016/j.jelectrocard.2009.06.017 |url=}}</ref>, may permit ongoing surveillance for early detection of [[ischemia]] in these high risk patients.
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|
<nowiki>"</nowiki>'''1.''' [[Chronic stable angina revascularization percutaneous coronary intervention|PCI]] to improve survival may be reasonable as an alternative to [[Chronic stable angina revascularization coronary artery bypass grafting|CABG]] in selected [[chronic stable angina definition|stable]] patients with significant (greater than or equal to 50% diameter [[stenosis]]) [[PCI in the unprotected left main patient|unprotected left main CAD]] with:


===Risk Factor Modification===
:'''a.''' [[Anatomy|Anatomic]] conditions associated with a low to intermediate risk of [[Chronic stable angina revascularization complications of percutaneous coronary intervention|PCI procedural complications]] and an intermediate to high likelihood of good long-term outcome (e.g., low-intermediate [[SYNTAX|SYNTAX score]] of lower than 33, [[Bifurcation Lesion|bifurcation]] [[left main]] [[CAD]]); and ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
Treating a patient with non-surgical methods include [[smoking cessation]] and [[cardiac risk factor]] modification.


===Dual Antiplatelet Therapy===
:'''b.''' Clinical characteristics that predict an increased risk of adverse [[surgery|surgical]] outcomes (e.g., moderate-severe [[COPD|chronic obstructive pulmonary disease]], [[Stroke rehabilitation|disability from previous stroke]], or previous [[cardiac surgery]]; Society of Thoracic Surgeons– predicted risk of operative [[mortality]] greater than 2%). <ref name="pmid21256999">Chakravarty T, Buch MH, Naik H, White AJ, Doctor N, Schapira J et al. (2011)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21256999 Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization.] ''Am J Cardiol'' 107 (3):360-6. [http://dx.doi.org/10.1016/j.amjcard.2010.09.029 DOI:10.1016/j.amjcard.2010.09.029] PMID:[http://pubmed.gov/21256999 21256999]</ref><ref name="pmid20630454">Kim YH, Park DW, Kim WJ, Lee JY, Yun SC, Kang SJ et al. (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20630454 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.[http://dx.doi.org/10.1016/j.jcin.2010.04.004 DOI:10.1016/j.jcin.2010.04.004] PMID:[http://pubmed.gov/20630454 20630454]</ref><ref name="pmid20530001">Morice MC, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A et al. (2010)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20530001 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.[http://dx.doi.org/10.1161/CIRCULATIONAHA.109.899211 DOI:10.1161/CIRCULATIONAHA.109.899211] PMID:[http://pubmed.gov/20530001 20530001]</ref><ref name="pmid21697170">Kappetein AP, Feldman TE, Mack MJ, Morice MC, Holmes DR, Ståhle E et al. (2011)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21697170 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.[http://dx.doi.org/10.1093/eurheartj/ehr213DOI:10.1093/eurheartj/ehr213] PMID:[http://pubmed.gov/21697170 21697170]</ref><ref name="pmid21435606">Capodanno D, Caggegi A, Miano M, Cincotta G, Dipasqua F, Giacchi G et al. (2011)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21435606 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. [http://dx.doi.org/10.1016/j.jcin.2010.10.013 DOI:10.1016/j.jcin.2010.10.013]PMID: [http://pubmed.gov/21435606 21435606]</ref><ref name="pmid18216353">Hannan EL, Wu C, Walford G, Culliford AT, Gold JP, Smith CR et al. (2008)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18216353 Drug-eluting stents vs. coronary-artery bypass grafting in multivessel coronary disease.] ''N Engl J Med'' 358 (4):331-41.[http://dx.doi.org/10.1056/NEJMoa071804 DOI:10.1056/NEJMoa071804] PMID: [http://pubmed.gov/1821635318216353]</ref><ref name="pmid9403609">Ellis SG, Tamai H, Nobuyoshi M, Kosuga K, Colombo A, Holmes DR et al. (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9403609 Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994-1996.]''Circulation'' 96 (11):3867-72. PMID: [http://pubmed.gov/9403609 9403609]</ref><ref name="pmid18215597">Biondi-Zoccai GG, Lotrionte M, Moretti C, Meliga E, Agostoni P, Valgimigli M et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18215597 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.[http://dx.doi.org/10.1016/j.ahj.2007.10.009 DOI:10.1016/j.ahj.2007.10.009] PMID:[http://pubmed.gov/18215597 18215597]</ref><ref name="pmid21272743">Boudriot E, Thiele H, Walther T, Liebetrau C, Boeckstegers P, Pohl T et al. (2011)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21272743 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.[http://dx.doi.org/10.1016/j.jacc.2010.09.038 DOI:10.1016/j.jacc.2010.09.038] PMID:[http://pubmed.gov/21272743 21272743]</ref><ref name="pmid18178401">Brener SJ, Galla JM, Bryant R, Sabik JF, Ellis SG (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18178401 Comparison of percutaneous versus surgical revascularization of severe unprotected left main coronary stenosis in matched patients.] ''Am J Cardiol'' 101 (2):169-72. [http://dx.doi.org/10.1016/j.amjcard.2007.08.054DOI:10.1016/j.amjcard.2007.08.054] PMID: [http://pubmed.gov/18178401 18178401]</ref><ref name="pmid18237682">Buszman PE, Kiesz SR, Bochenek A, Peszek-Przybyla E, Szkrobka I, Debinski M et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18237682 Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization.] ''J Am Coll Cardiol'' 51 (5):538-45.[http://dx.doi.org/10.1016/j.jacc.2007.09.054 DOI:10.1016/j.jacc.2007.09.054] PMID:[http://pubmed.gov/18237682 18237682]</ref><ref name="pmid16717151">Chieffo A, Morici N, Maisano F, Bonizzoni E, Cosgrave J, Montorfano M et al. (2006)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16717151 Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience.]''Circulation'' 113 (21):2542-7. [http://dx.doi.org/10.1161/CIRCULATIONAHA.105.595694DOI:10.1161/CIRCULATIONAHA.105.595694] PMID: [http://pubmed.gov/16717151 16717151]</ref><ref name="pmid16487857">Lee MS, Kapoor N, Jamal F, Czer L, Aragon J, Forrester J et al. (2006)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16487857 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. [http://dx.doi.org/10.1016/j.jacc.2005.09.072DOI:10.1016/j.jacc.2005.09.072] PMID: [http://pubmed.gov/16487857 16487857]</ref><ref name="pmid18608116">Mäkikallio TH, Niemelä M, Kervinen K, Jokinen V, Laukkanen J, Ylitalo I et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18608116 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. [http://dx.doi.org/10.1080/07853890701879790 DOI:10.1080/07853890701879790]PMID: [http://pubmed.gov/18608116 18608116]</ref><ref name="pmid19695542">Naik H, White AJ, Chakravarty T, Forrester J, Fontana G, Kar S et al. (2009)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19695542 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. [http://dx.doi.org/10.1016/j.jcin.2009.05.020DOI:10.1016/j.jcin.2009.05.020] PMID: [http://pubmed.gov/19695542 19695542]</ref><ref name="pmid16784920">Palmerini T, Marzocchi A, Marrozzini C, Ortolani P, Saia F, Savini C et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16784920 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.[http://dx.doi.org/10.1016/j.amjcard.2006.01.070 DOI:10.1016/j.amjcard.2006.01.070] PMID:[http://pubmed.gov/16784920 16784920]</ref><ref name="pmid20451344">Park DW, Seung KB, Kim YH, Lee JY, Kim WJ, Kang SJ et al. (2010) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=20451344 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. [http://dx.doi.org/10.1016/j.jacc.2010.04.004DOI:10.1016/j.jacc.2010.04.004] PMID: [http://pubmed.gov/20451344 20451344]</ref><ref name="pmid19029471">Rodés-Cabau J, Deblois J, Bertrand OF, Mohammadi S, Courtis J, Larose E et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19029471 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.[http://dx.doi.org/10.1161/CIRCULATIONAHA.107.727099 DOI:10.1161/CIRCULATIONAHA.107.727099] PMID:[http://pubmed.gov/19029471 19029471]</ref><ref name="pmid17826380">Sanmartín M, Baz JA, Claro R, Asorey V, Durán D, Pradas G et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17826380 Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease.] ''Am J Cardiol'' 100 (6):970-3.[http://dx.doi.org/10.1016/j.amjcard.2007.04.037 DOI:10.1016/j.amjcard.2007.04.037] PMID:[http://pubmed.gov/17826380 17826380]</ref><ref name="pmid18378517">Seung KB, Park DW, Kim YH, Lee SW, Lee CW, Hong MK et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18378517 Stents versus coronary-artery bypass grafting for left main coronary artery disease.] ''N Engl J Med'' 358 (17):1781-92.[http://dx.doi.org/10.1056/NEJMoa0801441 DOI:10.1056/NEJMoa0801441] PMID:[http://pubmed.gov/18378517 18378517]</ref><ref name="pmid19463306">White AJ, Kedia G, Mirocha JM, Lee MS, Forrester JS, Morales WC et al. (2008)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19463306 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. [http://dx.doi.org/10.1016/j.jcin.2008.02.007DOI:10.1016/j.jcin.2008.02.007] PMID: [http://pubmed.gov/19463306 19463306]</ref><ref name="pmid21463149">Park SJ, Kim YH, Park DW, Yun SC, Ahn JM, Song HG et al. (2011)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21463149 Randomized trial of stents versus bypass surgery for left main coronary artery disease.] ''N Engl J Med'' 364 (18):1718-27.[http://dx.doi.org/10.1056/NEJMoa1100452 DOI:10.1056/NEJMoa1100452] PMID:[http://pubmed.gov/2146314921463149]</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
If a stent is placed, the patient should placed on prolonged [[dual antiplatelet therapy]]. Either clopidogrel or Prasugrel for the rest of the patient's life are suitable choices.
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Latest revision as of 16:46, 15 January 2013

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

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

Left Main Intervention

Diagnosis

The left main coronary artery provides blood flow to two of the main coronary arteries (the left anterior descending artery as well as the circumflex coronary artery), and approximately 5% of all patients undergoing coronary angiography have significant (> 50%) left main coronary artery (LMCA) stenosis. Assessment of the left main is associated with the greatest amount of inter and intraobserver variability in angiography. The left main is short, and is often diseased with asymmetric lesions making its assessment on angiography difficult. There may be diffuse disease which may cause an underestimation of the extent of involvement on angiography. While luminal encroachment is defined as a minimum lumen area less than 4 mm² in the epicardial arteries, a minimum lumen area less than 6 mm² in the left main is considered to be significant. A minimum lumen area less than 6 mm² in the left main corresponds with a fractional flow reserve less than 0.75. A minimum lumen area less than 6 mm² also corresponds to a minimum lumen area less than 4 mm² in either the LAD or the circumflex arteries. In interrogating ostial lesions, it is critical to disengage the guide so that the guide is not mistaken for the lumen of the artery.

Treatment

The ACC/AHA recommends coronary artery bypass grafting (CABG) in patients with significant LMCA disease who have angina and ACS. However, not all patients are operative candidates. Left main (LM) PCI can safely and effectively treat patients in whom coronary artery bypass grafting (CABG) is suboptimal, or in patients who have had prior CABG with a ‘protected’ LMCA. Protected left main in patients with prior CABG is defined as having at least one patent graft to the left anterior descending or circumflex artery. The main goal is to provide a treatment option for patients who would otherwise be poor surgical candidates, who are declined by surgery, or who refuse CABG. It is essential to properly select patients based on their anatomy as to whether they are optimal candidates for drug-eluting stents (DES) vs bare metal stents (BMS) vs bifurcation stents.

Appropriate Candidate Selection

CABG has generally been accepted as the standard of care for patients with LMCA disease. Left main intervention is considered a high risk subset of PCI, but it may be necessary for certain patients.

Candidates for LMCA PCI include:

  • Poor operative candidates
  • Low-risk patients who refuse CABG
  • Patients with 'protected' left main disease (see above)
  • Syntax score less than or equal to 22 is considered reasonable based on the Syntax trial (remains subject to debate)

High-risk features in patients with left main disease PCI include:

Technical Aspects of Performing PCI in the Left Main

Hemodynamic Monitoring and Support

Hemodynamic support is not mandatory, but it should be considered for high-risk patients who have refractory angina or are awaiting CABG with persistent angina on maximal medical therapy. Options include an intra-aortic balloon pump (IABP), Impella, and Tandom Heart. Also, pulmonary artery (PA) line monitoring may be helpful.

Pre-interventional Preparation: Clearly Define Relevant Anatomy

Characterizing the patient's anatomy may reduce complications and the duration of the intervention. This can be done through several different methods:

In addition to characterizing the patient's anatomy, it is essential to have all stents and balloons on the table, prepped, and ready to be deployed so that no time is wasted.

Antiplatelet Regimen

Reduce Ischemic Time

Besides selecting and prepping the equipment in advance, other methods can be employed to reduce ischemic time:

Appropriate Stent Selection

Consider using a BMS if the left main diameter is 3.5 mm or greater, and consider using a DES if the left main diameter is small or if the lesion is long. If there is an ostial lesion, the operator should assure that the aorto-ostial region is covered by a stent.

There is increasing evidence for better PCI outcomes using DES instead of BMS because of lower angiographic rates of restenosis and significant reductions in major adverse events[1]. There are unclear benefits of using one DES over another based on their design (open/closed cell, modular), strut thickness/radial strength, and type of drug/polymer.

Approach Dictated by Lesion Morphology

Outcome differences have been observed according to the location of the LMCA stenosis. For instance, distal left main involvement (~75%) lesions have worse outcomes compared to more proximal lesions.

Distal bifurcation involvement has poorer results when treated with a two stent approach (i.e. kissing stents, culotte, T, etc). The approach is similar to other bifurcation therapies, but it has a higher risk with:

Calcified lesions can be treated with rotational atherectomy or stenting.

Bulky plaque can be treated with directional atherectomy and stenting, or stenting alone.

Follow-Up Care

Exercise Tolerance Test Screening

There is a consensus opinion that it is important to aggressively screen for restenosis. Left main restenosis may unfortunately present as sudden cardiac death rather than recurrent angina. It is therefore recommended that repeat angiography be performed 2-3 months following the procedure, even in the absence of symptoms. Some operators also recommend additional angiography at 6 months to identify late restenosis.

Use of and Indwelling EKG Electrode and Alarming Device

In countries where it is available, implantation of an ischemia monitoring device, such as the AngelMed Guardian device[2], may permit ongoing surveillance for early detection of ischemia in these high risk patients.

Risk Factor Modification

Treating a patient with non-surgical methods include smoking cessation and cardiac risk factor modification.

Dual Antiplatelet Therapy

If a stent is placed, the patient should placed on prolonged dual antiplatelet therapy. Either clopidogrel or Prasugrel for the rest of the patient's life are suitable choices.

2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[3]

Revascularization to Improve Survival in Left Main Coronary Artery Disease (DO NOT EDIT)[3]

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. [4][5][6][7][8][9][10][11][12][13] (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%). [4][5][6][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] (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. [6][20][32][22][23][28][29][30][31][33] (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. [17][34][35] (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%). [4][5][6][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][36] (Level of Evidence: B)"

References

  1. Price MJ, Cristea E, Sawhney N; et al. (2006). "Serial angiographic follow-up of sirolimus-eluting stents for unprotected left main coronary artery revascularization". J. Am. Coll. Cardiol. 47 (4): 871–7. doi:10.1016/j.jacc.2005.12.015. PMID 16487858. Unknown parameter |month= ignored (help)
  2. Hopenfeld B, John MS, Fischell DR, Medeiros P, Guimarães HP, Piegas LS (2009). "The Guardian: an implantable system for chronic ambulatory monitoring of acute myocardial infarction". J Electrocardiol. 42 (6): 481–6. doi:10.1016/j.jelectrocard.2009.06.017. PMID 19631947.
  3. 3.0 3.1 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)
  4. 4.0 4.1 4.2 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
  5. 5.0 5.1 5.2 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
  6. 6.0 6.1 6.2 6.3 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
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