Elective stenting of unprotected left main coronary disease

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.

Treatment of unprotected left main coronary artery stenosis with a drug eluting stent in a heart transplant patient with allograft vasculopathy

High risk angioplasty with drug eluting stent placement into an unprotected left main coronary artery in a heart transplant recipient with allograft vasculopathy is reported. Ten month angiographic follow up is reported. The literature is reviewed and current methods of revascularisation are described in detail. This is the first report of drug eluting stent use in this clinical situation.

Should we still perform angioplasty and stenting of an unprotected left main coronary artery stenosis in heart transplant patients? Two new cases and a review of the literature

Coronary balloon angioplasty with stent implantation has emerged as a possible alternative to bypass grafting or repeat transplantation in left main coronary stenosis in heart transplant patients. We report 2 new cases of stent implantation for unprotected and isolated left main stenosis in heart transplant patients. Despite an initially successful procedure, restenosis prompted the performance of bypass surgery in both patients. The relative advantages and disadvantages of available techniques of revascularization are discussed in the context of the literature.

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.

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.