Treatment of unprotected left main stenoses with Palmaz-Schatz stenting

[Unprotected left main coronary artery stenting: immediate and medium-term outcomes of 24 procedures]

OBJECTIVES

We have examined the immediate and long-term patient outcomes following angioplasty of unprotected left main coronary artery stenoses.

BACKGROUND

Coronary disease of the unprotected left main artery is considered as an absolute contraindication for percutaneous intervention. Recently, several studies have reported good results with unprotected left main coronary artery stenting when surgical revascularization was contraindicated.

METHODS

From October 2004 to June 2006, 24 patients with a contraindication to surgery and with unprotected left main coronary artery stenoses received stents. Patients were surveyed at one, six and 12 months with telephone interviews.

RESULTS

The procedure's success rate was 100%. The percentage of stenosis and minimum lumen diameter (MLD) were respectively 63.4% (+/-15.4) and 1.1mm (+/-0.5) before procedure; 13.8% (+/-10.2) and 3.2mm (+/-0.5) after angioplasty. The size of stents averaged 3.79 mm (+/-0.46) with an average 1.04 stents per patient. During follow up, two deaths occurred (8.3%). No intrastent restenosis was found.

CONCLUSIONS

Stenting of unprotected left main coronary artery stenoses may be a safe and effective alternative to coronary artery bypass especially when surgical revascularization is contraindicated. However, further studies with larger patient populations are needed to assess the late outcome and to clarify the relevance of percutaneous intervention compared to surgery.

Left main coronary artery stenosis: state-of-the-art

Patients with stenosis of the left main coronary artery present difficult challenges. The risks associated with this lesion have been known since the early days of angiography when patients were found to have increased mortality during follow-up. This information led to the general guidelines that surgical revascularization should be considered the treatment of choice in patients with significant left main coronary artery stenosis. Current advances in invasive cardiology have brought important information to the field. Intravascular ultrasound is now used routinely to evaluate angiographically indeterminate lesions with criteria now set forward as to what constitutes an indication for revascularization. Stents have even further dramatically changed the landscape. There are substantial issues, however, that need to addressed. These include the following: (1) the effect of specific lesion location on outcome - it is known that patients with distal bifurcation left main disease have worse outcome; (2) the potential for subacute thrombosis of the left main coronary artery; (3) the impact of left ventricular function and patient comorbidities irrespective of the degree and location of left main coronary artery stenosis; and (4) the risk-benefit ratio of stenting versus coronary artery bypass graft surgery. These issues are currently being addressed in two seminally important trials including the SYNTAX trial, which randomizes patients with left main and/or three-vessel disease to either coronary artery bypass graft surgery or a TAXUS drug-eluting stent. This trial is in the final stages of patient recruitment and will have important implications for the field. The other trial is the COMBAT trial, which is focused exclusively on left main coronary artery stenosis and randomizes patients with left main coronary artery disease either to a Sirolimus-eluting stent (Cypher, Johnson and Johnson Cordis, USA) or to coronary artery bypass graft surgery. The field of left main coronary artery disease continues to expand in terms of the evidence available for optimal patient evaluation and selection of treatment modalities.

Lesion regression after percutaneous coronary intervention for unprotected left main trunk disease

BACKGROUND

Although some studies have documented the six-month angiographic outcomes of percutaneous coronary intervention (PCI) with new devices for unprotected left main trunk disease (ULMTD), a long-term angiographic analysis is mandatory to evaluate the safety and effectiveness of this procedure. This study aims to assess a long-term (one year or more) angiographic analysis after PCI for this lesion.

METHODS

PCI was performed for 225 ULMTD with de novo or restenotic lesions. There were 19 deaths and 12 repeat PCIs during the hospital stay. The remaining 194 lesions were followed, and 126 lesions showed no angiographic restenosis or target lesion revascularization within six months. Finally, long-term quantitative angiographic follow-up was completed in 78 lesions (mean 2.4 years, maximum 7.5 years after PCI).

RESULTS

Minimal lumen diameter increased significantly from 2.46 +/- 0.59 mm to 2.72 +/- 0.65 mm (p < 0.0001) and percent diameter stenosis decreased significantly from 26 +/- 14% to 19 +/- 14% (p < 0.0001) between the six-month and the long-term follow-ups. No additional restenosis or new lesions were found at long-term follow-up, and significant lesion regression was ascertained in each procedure (directional coronary atherectomy, p < 0.005; ballooning, p < 0.005; stenting, p < 0.05).

CONCLUSIONS

These findings support the safety and effectiveness of PCI for ULMTD during the long-term period.

Unprotected left main stenting in acute myocardial infarction

Left main stenosis is a rare cause of acute myocardial infarction. Emergent percutaneous transluminal coronary angioplasty (PTCA) of the left main coronary artery has been shown to have greatly increased procedural and short-term mortality. Stenting decreases the incidence of abrupt closure and has a lower restenosis rate after PTCA. We present a case of a patient presenting in cardiogenic shock due to an acute anterior myocardial infarction who underwent emergent left main coronary artery stenting.

Technical feasibility, safety, and clinical outcome of stenting of unprotected left main coronary artery bifurcation narrowing

This study was performed to evaluate the acute and long-term results of stenting for unprotected left main coronary artery (LMCA) bifurcation lesions. Sixty-three consecutive patients with an unprotected LMCA bifurcation lesion and normal left ventricular function were included. Stenting was performed with (n = 32) or without debulking atherectomy (n = 31) at the operator's discretion. Slotted-tube stents, coil stents, or bifurcation stents were used. The procedural success rate was 100%. In-hospital events including stent thrombosis, Q-wave myocardial infarction, and emergency bypass surgery did not occur in any patients. The angiographic follow-up rate was 86% (43 of the 50 eligible patients), and the restenosis rate was 28% (parent vessel only 14%, side branch only 9%, and both 5%). Restenosis at the parent vessel occurred less frequently in the debulking group than in the nondebulking group (5% vs 33%, respectively, p = 0.02). In multivariate analysis, the debulking procedure was an independent predictive factor of restenosis for the parent vessel (odds ratio 0.10, 95% confidence intervals 0.01 to 0.91, p = 0.04). Clinical follow-up was obtained in all patients at 19.9 +/- 13.7 months. There were 2 deaths (noncardiac origin), but no myocardial infarction during follow-up. Target lesion revascularization was required in 6 patients. The event-free survival rate (death, nonfatal myocardial infarction, and repeat revascularization) was 86% at the end of the follow-up period. In conclusion, stenting for an unprotected LMCA bifurcation lesion may be performed with a high procedural success rate and a favorable clinical outcome in selected patients with normal left ventricular function, suggesting that stenting would be an effective alternative to surgery in these patients.

Elective stenting of unprotected left main coronary artery stenosis: effect of debulking before stenting and intravascular ultrasound guidance

OBJECTIVES

We sought to evaluate: 1) the long-term outcomes of 127 selected patients receiving unprotected left main coronary artery (LMCA) stenting; and 2) the impact of the debulking procedure before stenting and intravascular ultrasound (IVUS) guidance on their clinical outcomes.

BACKGROUND

The long-term safety of stenting of unprotected LMCA stenoses has not been established yet.

METHODS

A total of 127 consecutive patients with unprotected LMCA stenosis and normal left ventricular function were treated by elective stenting. The long-term outcomes were evaluated between two groups: IVUS guidance (n = 77) vs. angiographic guidance (n = 50); and debulking plus stenting (debulking/stenting; n = 40) vs. stenting only (n = 87).

RESULTS

Angiographic restenosis was documented in 19 (19%) of 100 patients. The lumen diameter after stenting was significantly larger in IVUS-guided group (p = 0.003). The angiographic restenosis rate was significantly lower in the debulking/stenting group (8.3% vs. 25%, p = 0.034). The reference artery size was the only independent predictor of angiographic restenosis. During follow-up (25.5 +/- 16.7 months), there were four deaths, but no nonfatal myocardial infarctions occurred. The survival rate was 97.0 +/- 1.7% at two years.

CONCLUSIONS

These data suggest that stenting of unprotected LMCA stenosis might be associated with a favorable long-term outcome in selected patients. Guidance with IVUS may optimize the immediate results, and debulking before stenting seems to be effective in reducing the restenosis rate. However, we need a large-scale, randomized study.

Initial and long-term results of directional coronary atherectomy in unprotected left main coronary artery

Angioplasty in the unprotected left main coronary artery (LMCA) has been controversial. Recently, several studies have suggested that new procedures and devices such as directional coronary atherectomy (DCA) and stents may change this situation. Although there are many reports of unprotected LMCA stenting, there are few reports of DCA of this lesion. Therefore, initial and long-term results were evaluated in 101 patients who underwent DCA for unprotected LMCA in our hospital. Emergency procedures were performed in 15 patients and electively in 86 patients. Scheduled angiographic follow-up was routinely performed, and all patients were clinically followed for >4 months after DCA. Technical success was achieved in 99%, and in-hospital outcomes were cardiac death (2%), noncardiac death (4%), Q-wave myocardial infarction (1%), non-Q-wave myocardial infarction (8.9%), coronary artery bypass grafting (0%), and repeat angioplasty (4%). In-hospital results varied considerably, depending on presentation. In-hospital mortality was significantly higher in the emergency, left ventricular ejection fraction < or =35%, and high-risk surgical subgroups. The angiographic restenosis rate was 20.4% at follow-up, and its predictor was postminimal lumen diameter by multivariate analysis. Mean clinical follow-up was 2.8 years; estimated 1- and 3-year survival rates were 87% and 80.7%, respectively. The cardiac survival rate of the low-risk surgical subgroup was significantly higher than that of the high-risk surgical subgroup (p <0.05). Thus, our data show that DCA can be performed safely and effectively in unprotected LMCA with an acceptable low restenosis rate and high survival rate.

Unprotected left main coronary artery stenting: correlates of midterm survival and impact of patient selection

BACKGROUND

The study served to present the in-hospital and six-month clinical outcome and also the long-term survival data of a consecutive series of patients undergoing stenting for unprotected left main coronary artery (LMCA) disease.

METHODS

Revascularization with coronary bypass surgery has been generally recommended for treatment of left main coronary stenosis. Improvements in angioplasty and coronary stent techniques and equipment may result in the wider applicability of a percutaneous approach. A total of 92 consecutive patients underwent unprotected LMCA stenting between March 1994 and December 1998. For the initial 39 patients (group I) angioplasty was performed only when surgical revascularization was contraindicated. The remaining 53 patients (group II) also included patients in whom surgery was feasible. Patients were followed for 7.3 +/- 5.8 months (median 239 days; range 49 to 1,477 days).

RESULTS

Compared to group I, group II patients had higher left ventricular ejection fraction (60 +/- 12% vs. 51 +/- 16%, p < 0.01), less severe LMCA stenosis (68 +/- 12% vs. 80 +/- 10%, p < 0.001), lower surgical risk score (13 +/- 7 vs. 20 +/- 7, p < 0.001), and had angioplasty more often performed via the radial approach (88% vs. 23%, p < 0.001) with smaller guiding catheters (6F: 49% vs. 15%; 8F: 2% vs. 77%, p < 0.001). The procedural success rate was 100%. In-hospital mortality was 4% (4 deaths, 3 cardiac). During follow-up there were six deaths, 13 patients required repeat percutaneous transluminal coronary angioplasty (4 LMCA), and two required coronary artery bypass graft surgery. Estimated survival (+/- SEE) was 89 +/- 6.3% at 500 days and 85 +/- 12% at 1,000 days post-stenting. Overall mortality was 3.8% in group II and 20.5% in group I (p < 0.02).

CONCLUSIONS

Coronary stenting can be performed safely in high-risk individuals with acceptable intermediate-term outcome. It may be feasible to broaden the application of this technique in selected patients needing revascularization for left main coronary disease.

Stent development and local drug delivery

Stent implantation has become the new standard angioplasty procedure. In-stent re-stenosis remains the major limitation of coronary stenting. Re-stenosis is related to patient-, lesion- and procedure-specific factors. Patient-specific factors can not be influenced to any extent. Procedure-specific factors are affected by implantation technique and stent characteristics. Design and material influence vascular injury and humoral and cellular response. Radiation has been shown to have inhibitory effects on smooth muscle cell growth and neo-intima formation, but in clinical trials the outcome has been hampered by re-stenosis at the edges of the radioactive stent ('candy wrapper'). New approaches target pharmacological modulation of local vascular biology by local administration of drugs. This allows for drug application at the precise site and time of vessel injury. Systemic release is minimal and this may reduce the risk of toxicity. The drug and the delivery vehicle must fulfil pharmacological, pharmacokinetic and mechanical requirements and the application of eluting degradable matrices seems to be a possible solution. Numerous pharmacological agents with antiproliferative properties are currently under clinical investigation, e.g. actinomycin D, rapamycin or paclitaxel. Another approach is for stents to be made of biodegradable materials as an alternative to metallic stents. Their potential long-term complications, such as in-stent re-stenosis and the inaccessibility of the lesion site for surgical revascularization, needs to be assessed. Current investigational devices and the line of (pre)clinical investigation are discussed in detail. Currently, there is little experimental, and only preliminary clinical, understanding of the acute and long-term effects of drug-eluting or biodegradable stents in coronary arteries. The clinical benefit of these approaches still has to be proven.

Factors predicting mortality in patients after myocardial infarction caused by left main coronary artery occlusion: significance of ST segment elevation in both aVR and aVL leads

Acute left main coronary artery obstruction is rare and most patients in this clinical setting die of sudden death or cardiogenic shock. During the past 8 years, we encountered 13 patients with acute myocardial infarction caused by total occlusion of the left main coronary artery (LMCA-AMI). Thus, we surveyed these patients, and attempted to elucidate helpful predictors related to the prognosis. Six of 13 patients with LMCA-AMI survived. Successful left coronary artery dilatation was achieved in all survivors (group S), and in 5 (71%) non-survivors (group non-S). The age was not different between the two groups. A past history of angina was confirmed in 83% of group S. while only in 29% of group non-S. Clinical findings such as time of onset of AMI, interval from the AMI onset to admission, elapsed period from the AMI onset to recanalization of LMCA and the value of CK on admission were not different between the two groups. However, cardiogenic shock occurred in only 1 patient (17%) in group S compared with 5 patients (71%) in group non-S. As emphasized in the literature, good collateral circulation to the left anterior descending artery was observed in 5 patients (83%) in group S, while not observed in group non-S. Electro cardiographically, ST elevation in the aVR lead was very characteristic. This finding was confirmed in 69% of the total patients. Noticeably, 5 out of 6 non-survivors (83%) showed ST elevation not only in leads aVR but also in the aVL lead. In addition to the absence of collateral circulation, this electrocardiographic finding, which obviously indicates the presence of extensive myocardial ischemia in the diseased heart, is a simple and important predictor suggesting a poor prognosis in LMCA-AMI patients.

Stenting with a true bifurcated stent: acute and mid-term follow-up results

Percutaneous therapy of coronary bifurcated lesions is associated with greater risk of acute complications and late restenosis. Numerous innovative techniques using various stent types have been proposed. We report the first clinical use of a truly bifurcated stent (Bard XT Carina). The implantation procedure, favorable medium-term angiographic and 1-year clinical follow-up of the first human use in a 43-year-old female are illustrated with angiography and intravascular ultrasound. As a single prosthesis that effectively covers the bifurcation, this stent presents appealing alternative for the treatment of coronary bifurcation lesions when compared to methods that involve multiple-stent implantation. Cathet. Cardiovasc. Intervent. 47:361-369, 1999.

A prospective study of elective stenting in unprotected left main coronary disease

The standard treatment of left main coronary artery (LMCA) disease has been bypass surgery (CABG). Recent reports suggested that stenting of LMCA disease might be feasible. From January 1995 to April 1998, we carried out a prospective study of elective stenting of unprotected LMCA disease to evaluate its immediate and long-term results. Of 61 consecutive patients with unprotected LMCA disease, 6 were excluded. Acute procedural success was 100% for the remaining 55 patients, without any complications such as stent thrombosis, myocardial infarction, CABG, or death. During a mean follow-up of 16.1+/-9.6 months, 11 patients (20%) had symptomatic recurrence, between 2 to 6 months after their procedure. Seven patients underwent CABG, two had repeat intervention, one continued with medical therapy, and one died before planned angiography. There was no late sudden death. Forty-four patients (80%) remained asymptomatic. We conclude that elective stenting may be a safe alternative to CABG in unprotected LMCA disease.

Intravascular ultrasound predictors of target lesion revascularization after stenting of protected left main coronary artery stenoses

We evaluated the predictors of late clinical outcomes after stenting of protected left main coronary artery (LMCA) stenoses. Intravascular ultrasound (IVUS) guided stenting of protected LMCA stenoses was performed in 87 consecutive patients between January 1994 and December 1996. Results were evaluated using conventional (clinical, angiographic, and IVUS) methodology. Late (12 month) clinical follow-up information was obtained in all patients. Initial procedural success was achieved in 86 patients (99%). There was 1 in-hospital death (in the 1 patient with a procedural failure). There were no other in-hospital complications, including Q-wave myocardial infarction, emergency bypass surgery, or repeat coronary angioplasty. The overall target lesion revascularization (TLR) rate was 13%. Using multivariate logistic regression analysis, the only independent predictor of TLR was the postintervention lumen area by IVUS. A final lumen area > or =7.0 mm2 was obtained in 74 patients (86%); the TLR rate for these patients was 7%. This was compared with patients with a final lumen area <7.0 mm2 in whom the TLR rate was 50% (p = 0.0011). Stenting of protected LMCA stenoses is safe and effective with acceptable long-term clinical outcomes. The most important factor determining long-term success was the postintervention lumen area by IVUS.

Initial and long-term results of angioplasty in unprotected left main coronary artery

Angioplasty of the unprotected left main coronary artery (LMCA) has been controversial. Although recent single-center studies suggest that new devices may change the situation, many questions and problems remain. Therefore, the results of unprotected left main coronary angioplasty of 175 procedures in 107 patients were analyzed to evaluate its feasibility and effectiveness. The treatment of the initial 107 cases included balloon angioplasty (39 cases, 36%), directional coronary atherectomy (53 cases, 50%), and stents (15 cases, 14%). They were divided into 3 major subgroups: (1) acute group (n = 14), in which LMCA angioplasty was performed in patients with acute myocardial infarction; (2) emergency group (n = 10); and (3) elective group (n = 83). In-hospital mortality was higher in the acute (35.7%) and emergency (40.0%) groups than in the elective group (3.6%; p <0.0001). Angiographic follow-up was routinely performed and the restenosis rate including in-hospital restenosis was 70% in the acute group, 37.5% in the emergency group, and 40% in the elective group (p = NS). The mean clinical follow-up period was 2.9 years, and the estimated 5-year survival rates of the acute and emergency groups were 50% and 48.2%, respectively. However the 5-year survival rate of the elective group was higher than that seen in the acute or emergency group (77.5%; p <0.05). Repeat LMCA angioplasty was performed in 37 of 68 patients with 8.8% mortality (38.5% of acute and emergency cases and 1.8% of elective cases). The results indicated that elective unprotected LMCA angioplasty is relatively feasible and effective under scheduled angiographic follow-up.

Endovascular stenting of an unprotected left main coronary artery stenosis in a heart transplant patient

Endoluminal revascularizaion of left main coronary artery vessels is considered to be relatively contraindicated because of a high procedural mortality and restenosis rate. This report describes the first successful case of endovascular stenting in an unprotected left main coronary artery stenosis in a heart transplant patient.

Rotational atherectomy for bifurcation lesions of the coronary circulation: technique and initial experience

Bifurcation lesions of the coronary circulation are difficult to treat with standard balloon technology and are associated with relatively low procedural success rates and high complication rates. We hypothesized that effective debulking of bifurcation lesions with rotational atherectomy would improve observed results. Fifteen patients underwent rotational atherectomy of such lesions. Both limbs of the bifurcation were rotablated in seven patients and one limb in eight; seven patients also underwent stent deployment. Successful angiographic results were obtained in all limbs (<30% residual stenoses). One patient had a non-Q-wave myocardial infarction. No other significant complications occurred. We conclude that rotablation of bifurcation coronary stenoses is feasible, safe, and associated with a high likelihood of angiographic success.

Stenting of unprotected left main coronary artery stenoses: immediate and late outcomes

OBJECTIVES

We examined the immediate and long-term outcomes after stenting of unprotected left main coronary artery (LMCA) stenoses in patients with normal left ventricular (LV) function.

BACKGROUND

Left main coronary artery disease is regarded as an absolute contraindication for coronary angioplasty. Recently, several reports on protected or unprotected LMCA stenting, or both, suggested the possibility of percutaneous intervention for this prohibited area.

METHODS

Forty-two consecutive patients with unprotected LMCA stenoses and normal LV function were treated with stents. The post-stent antithrombotic regimens were aspirin and ticlopidine; 14 patients also received warfarin. Patients were followed very closely with monthly telephone interviews and follow-up angiography at 6 months.

RESULTS

The procedural success rate was 100%, with no episodes of subacute thrombosis regardless of anticoagulation regimen. Six-month follow-up angiography was performed in 32 of 34 eligible patients. Angiographic restenosis occurred in seven patients (22%, 95% confidence interval 7% to 37%); five patients subsequently underwent elective coronary artery bypass graft surgery (CABG), and two patients were treated with rotational atherectomy plus adjunct balloon angioplasty. The only death occurred 2 days after elective CABG for treatment of in-stent restenosis. The other patients (without angiographic follow-up) remain asymptomatic.

CONCLUSIONS

Stenting of unprotected LMCA stenoses may be a safe and effective alternative to CABG in carefully selected patients with normal LV function. Further studies in larger patient populations are needed to assess late outcome.

Left main intervention revisited: early and late outcome of PTCA and stenting

We reviewed our experience with 28 unselected, consecutive patients undergoing left main coronary artery (LMCA) angioplasty who had been considered unsuitable for coronary artery bypass graft surgery (CABG). Fourteen patients (50%) had a protected LMCA circulation. Balloon angioplasty was performed in 11 patients (39.3%), and stents were implanted in 17 patients (60.7%). The procedure was elective in 22 patients (78.6%) and acute in the setting of myocardial infarction/cardiogenic shock in 6 (21.4%). The mean follow-up duration was 15.9 +/- 12 months. There were 5 early (before hospital discharge) and 4 late deaths (total 32.1%), 1 myocardial infarction (3.6%), 6 repeat angioplasties (21.4%), and 3 subsequent CABG (10.7%). All 5 early deaths occurred in patients with cardiogenic shock and unprotected circulation. The results of our study suggest that when patients have prohibitive surgical risks, elective LMCA angioplasty and/or stenting may be undertaken with a high procedural success rate. However, our data do not support intervention in the presence of acute myocardial infarction/cardiogenic shock.

Percutaneous treatment of protected and unprotected left main coronary stenoses with new devices: immediate angiographic results and intermediate-term follow-up

OBJECTIVES

We sought to evaluate the immediate angiographic results and intermediate-term follow-up after percutaneous treatment of left main coronary stenoses in the new device era.

BACKGROUND

Historically, balloon angioplasty of left main coronary stenoses has been associated with high procedural morbidity and poor long-term results. It is not clear whether new devices are more effective in this anatomic setting.

METHODS

Between July 1993 and July 1995, we performed initial left main coronary interventions on 46 patients (mean age 67 +/- 12 years, 26% women). Quantitative angiography was available for 42 of 46 interventions, and clinical follow-up was obtained for all patients at 1 month, 6 months and 1 year after initial revascularization.

RESULTS

Most interventions (42 of 46) were performed in patients with "protected" coronary stenoses to the left coronary system owing to the presence of one or more patent left main coronary grafts. Seventy-seven percent of screened patients were deemed unsuitable for repeat coronary artery bypass surgery. Procedures performed included stenting in 73% of patients (alone in 30% and after rotational atherectomy in 43%), rotational atherectomy in 58% (alone in 15% and before stenting in 43%), directional atherectomy in 4% and angioplasty alone in 7%. Initial procedural success was achieved in all interventions, with no deaths, myocardial infarctions (creatine kinase, MB fraction > 50 IU/liter) or emergent bypass surgery. Follow-up data to date (median duration 9 months, range 6 to 19) demonstrate a 98% overall survival rate and a 6-month event-free survival rate of 78% (six target vessel revascularizations [TVRs], four non-TVRs).

CONCLUSIONS

Treatment of protected left main coronary artery stenoses can be accomplished safely and effectively with new device technology. Intermediate-term follow-up demonstrates an acceptably low rate of death, myocardial infarction or repeat revascularization at 6 months and 1 year.

Elective stenting of unprotected left main coronary disease

For the 12-mo period of 1995, we encountered seven consecutive patients with symptomatic unprotected left main coronary stenosis requiring revascularization. There were five males and two females, age ranging 48-76 years. One patient was referred to coronary bypass surgery. Of the remaining six patients, three refused surgery and the other three, including one with previous bypass surgery and two with previous interventional procedures, preferred percutaneous revascularization. All six had successful elective stenting of their left main coronary stenoses with the new short Palmaz-Schatz stents, P084 and PS104. There were no complications and all remained totally asymptomatic at 3-14 months followup. We conclude that with proper patient selection and the availability of appropriate stents, elective stenting of unprotected left main coronary stenosis is safe with good immediate and medium term results.

The V-stent: a novel technique for coronary bifurcation stenting

Intracoronary stenting as a transcatheter treatment for bifurcation stenoses remains controversial. A novel technique of coronary bifurcation stenting is reported. A 15 mm Palmaz-Schatz stent is bent 180 degrees at its bridge articulation into a V- configuration and mounted on two balloon-catheters linked together by adhesive tape. This unified stent delivery system was used successfully in five cases of porcine coronary bifurcation stenting.