1
|
Das P, Meredith I. Role of intravascular ultrasound in unprotected left main percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2014; 5:81-9. [PMID: 17187459 DOI: 10.1586/14779072.5.1.81] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Percutaneous coronary intervention (PCI) to the unprotected left main stem offers an attractive alternative to bypass grafting, but is associated with a significant clinical risk and therefore demands special consideration. Successful left main PCI is dependent upon the morphology of the lesion and the technical quality of the procedure. For these reasons, intravascular ultrasound (IVUS) has been the most popular adjunct to coronary angiography during left main PCI. However, trials of IVUS in left main PCI have produced inconclusive results, and most data predate the use of drug-eluting stents. Despite this, IVUS offers practical benefits in both case selection, and in guiding angioplasty and stenting. Here, we review the arguments for the present and future role of IVUS in left main PCI.
Collapse
Affiliation(s)
- Paul Das
- Monash Medical Center, Clayton, Melbourne 3168, Victoria, Australia.
| | | |
Collapse
|
2
|
Hsueh SK, Wu CJ, Fang HY, Hsieh YK, Fang CY, Chen CJ, Chen SM, Yang CH, Yip HK, Chen MC, Fu M, Cheng CI. Comparison of Drug-Eluting Stent With Bare Metal Stent for Distal De Novo Unprotected Left Main Coronary Artery Stenosis - A Propensity Score-Matched Cohort Study -. Circ J 2011; 75:290-8. [DOI: 10.1253/circj.cj-10-0468] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shu-Kai Hsueh
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Chiung-Jen Wu
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Hsiu-Yu Fang
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Yuan-Kai Hsieh
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Chih-Yuan Fang
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Chien-Jen Chen
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Shyh-Ming Chen
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Cheng-Hsu Yang
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Hon-Kan Yip
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Mien-Cheng Chen
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Morgan Fu
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| | - Cheng-I Cheng
- Chang Gung University College of Medicine
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung Medical Center
| |
Collapse
|
3
|
Use of intravascular ultrasound in procedures involving the left main coronary artery. COR ET VASA 2010. [DOI: 10.33678/cor.2010.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
4
|
|
5
|
Puymirat E, Labèque JN, Coste P. [Unprotected left main coronary artery stenting: immediate and medium-term outcomes of 24 procedures]. Ann Cardiol Angeiol (Paris) 2008; 57:195-200. [PMID: 18550024 DOI: 10.1016/j.ancard.2008.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Accepted: 05/05/2008] [Indexed: 10/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- E Puymirat
- Unité de soins intensifs de cardiologie, hôpital Haut-Lévêque, 1, avenue Magellan, 33604 Pessac, France.
| | | | | |
Collapse
|
6
|
Abstract
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.
Collapse
|
7
|
Lee BK, Hong MK, Lee CW, Choi BR, Kim MJ, Park KH, Kim YH, Han KH, Kim JJ, Park SW, Park SJ. Five-year outcomes after stenting of unprotected left main coronary artery stenosis in patients with normal left ventricular function. Int J Cardiol 2007; 115:208-13. [PMID: 16904209 DOI: 10.1016/j.ijcard.2006.02.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2005] [Revised: 01/05/2006] [Accepted: 02/24/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND We analyzed the long-term (5-year) outcome of patients treated with stenting for unprotected left main coronary artery (LMCA) stenosis. METHODS Between January 1995 and September 2001, 187 consecutive patients with unprotected LMCA stenosis and normal left ventricular function underwent elective stenting. Patients were examined or interviewed after 1, 3 and 6 months, and every 4 months thereafter for the occurrence of major adverse cardiac events (MACE), including death, myocardial infarction (MI) and target lesion revascularization (TLR). RESULTS The procedural success rate was 99.5%. During hospitalization, there were no deaths and only one stent thrombosis. Six-month angiography in 162 patients (follow-up rate, 86.6%) showed a restenosis rate of 33.3%. During 5-year follow-up, there were 13 deaths (6 cardiac, 7 noncardiac) and 2 nonfatal MI. TLRs were required in 36 (20.9%) patients and new lesion revascularizations were required in 13 (5.0%) patients. At 1, 3 and 5 years, the cumulative probabilities for freedom from MACE were 79.9+/-1.8%, 77.5+/-2.5% and 77.5+/-2.5%, respectively. CONCLUSION The initial favorable outcomes of patients with normal left ventricular function after stenting of unprotected LMCA stenosis were sustained for up to 5 years.
Collapse
Affiliation(s)
- Bong-Ki Lee
- Department of Internal Medicine, Kangwon National University Hospital, Kangwon National University College of Medicine, Chunchon, Kangwon-do, Korea
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
|
9
|
Belghiti H, Kettani M, Mouline N, Guedira S, Ghannam R, El Haitem N, Srairi JE, Benomar M. [Left main coronary artery angioplasty: report of five cases illustrating the current indications]. Ann Cardiol Angeiol (Paris) 2006; 55:216-21. [PMID: 16922172 DOI: 10.1016/j.ancard.2005.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVES The purpose of our study is to illustrate by five original observations the various situations where the stenting of the left main coronary artery can be proposed in alternative to aortocoronary bridging with encouraging results in short- and long-term. MATERIALS AND METHODS We report a retrospective study relating to five cases with left main disease treated by stenting between 1996 and 2002 at our institution. In two cases the left main stem was unprotected. In two other cases, the left main trunk was protected. And the last case was an emergency stenting for an iatrogenic dissection of the left main coronary artery. RESULTS The stenting was carried out successfully among the five patients without major in-hospital complication. During the follow-up of 29 months at mean, no death was deplored, and no target lesion revascularization was required on the left main coronary artery (with a left main trunk permeable on three coronarographic controls). CONCLUSIONS In the light of these results, and basing on the published data, we conclude that stenting for the left main coronary disease may be a safe and effective alternative to coronary artery bypass surgery in particular cases among "selected" patients (refusal or surgical contraindication, protected left main coronary artery, spontaneous or iatrogenic acute occlusion of the left main coronary artery).
Collapse
Affiliation(s)
- H Belghiti
- Service de cardiologie A, hôpital Ibn-Sina, CHU de Rabat-Salé, 10100 Rabat, Maroc.
| | | | | | | | | | | | | | | |
Collapse
|
10
|
Tanigawa J, Sutaria N, Goktekin O, Di Mario C. Treatment of Unprotected Left Main Coronary Artery Stenosis in the Drug-Eluting Stent Era. J Interv Cardiol 2005; 18:455-65. [PMID: 16336426 DOI: 10.1111/j.1540-8183.2005.00086.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Coronary angiography is often inadequate for estimating the severity of ambiguous left main coronary artery (LMCA) stenoses. Our assessment of these lesions can be improved by the techniques of intravascular ultrasound and fractional flow reserve which provide indices of stenosis severity to enable the prediction of future events and planning of treatment. For patients requiring LMCA revascularization, coronary artery bypass graft (CABG) surgery has been gold standard for decades. However, this technique continues to be limited by factors such as periprocedural mortality, prolonged hospital stay and rehabilitation, and long-term graft patency. LMCA stenosis remains one of the few serious challenges for the interventional cardiologists and, in the bare metal stent era, the long-term results were not sufficient to replace CABG surgery, mainly because of the high restenosis rate. Drug-eluting stents (DES) have dramatically reduced the restenosis rate and early results in small series (approximately 300 patients in total) treated with DES in LMCA have been encouraging, especially for lesions at the ostium and in the left main shaft. Before changes are made in the guidelines for treatment, we must wait for a refinement in the technique and stent design used for bifurcational left main lesion and the results of randomized, specific multicenter studies (SYNTAX trial). It is likely that, for selected patients, LMCA stenosis will be regarded as an indication for PCI.
Collapse
Affiliation(s)
- Jun Tanigawa
- Cardiology, 1st Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | | | | | | |
Collapse
|
11
|
Curzen N. Percutaneous coronary intervention in unprotected left main stem disease: the state of play. Heart 2005; 91 Suppl 3:iii39-41. [PMID: 15919652 PMCID: PMC1876361 DOI: 10.1136/hrt.2004.058461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- N Curzen
- Wessex Cardiothoracic Unit, Southampton General Hospital, Tremona Road, Southampton S016 6YD, UK.
| |
Collapse
|
12
|
Lozano Í, Herrera C, Morís C, Gómez-Hospital JA, Rondán J, Iráculis E, Martín M, Cequier Á, Suáreza E, Esplugas E. Stent liberador de fármacos en lesiones de tronco coronario izquierdo en pacientes no candidatos a revascularización quirúrgica. Rev Esp Cardiol 2005. [DOI: 10.1157/13071888] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
13
|
Intervencionismo percutáneo en la enfermedad del tronco común izquierdo: ¿es hora de cambiar las guías de actuación? Rev Esp Cardiol (Engl Ed) 2004. [DOI: 10.1016/s0300-8932(04)77235-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
14
|
Hu FB, Tamai H, Kosuga K, Kyo E, Hata T, Okada M, Nakamura T, Fujita S, Tsuji T, Takeda S, Motohara S, Uehata H. Intravascular ultrasound-guided directional coronary atherectomy for unprotected left main coronary stenoses with distal bifurcation involvement. Am J Cardiol 2003; 92:936-40. [PMID: 14556869 DOI: 10.1016/s0002-9149(03)00973-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Stent implantation in unprotected left main coronary artery (LMCA) bifurcation lesions may improve procedural and late clinical outcomes. However, concerns regarding stent-related complications, such as stent jail, subacute thrombosis, and in-stent restenosis remain. Optimal debulking by directional coronary atherectomy (DCA) with intravascular ultrasound (IVUS) guidance may be effective in this complex lesion subset, but this strategy has not yet been established. Our objective was to evaluate the safety and efficacy of IVUS-guided DCA for unprotected LMCA stenoses with distal bifurcation involvement. A total of 67 consecutive patients were included in this study and procedural success was achieved in all cases. Two cardiac deaths (2.9%) were noted and 3 patients (4.5%) underwent repeat angioplasty during hospitalization. There was no Q-wave myocardial infarction or emergency bypass surgery. Non-Q-wave myocardial infarction (creatine kinase-MB >3 times normal) occurred in 13.4% of patients. Stent implantation was necessary in 17 cases (25.4%) to achieve an optimal result. IVUS showed an improved lumen cross-sectional area and a low plaque burden in the LMCA after intervention. All-cause mortality, angiographic restenosis, and the target lesion revascularization rates at 6 months were 7.4%, 23.8%, and 20.0%, respectively. With IVUS guidance, aggressive DCA can be performed safely in unprotected LMCA bifurcation lesions, and optimal angiographic and IVUS results can be achieved with low residual plaque burden, which leads to a low restenosis rate. Optimal lesion debulking by DCA does not necessarily need adjunctive stenting in this specific anatomic subset.
Collapse
Affiliation(s)
- Fang-Bin Hu
- Department of Cardiology, Shiga Medical Center for Adults, Moriyama, Japan
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Sadeghi HM, O'Neill WW, Grines CL. Percutaneous intervention of unprotected left main coronary artery. J Interv Cardiol 2003; 16:281-8. [PMID: 12800408 DOI: 10.1034/j.1600-0854.2003.8051.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Successful percutaneous intervention of unprotected left main coronary artery (LMCA) in lieu of surgical revascularization represents the next wave of challenges that the field of interventional cardiology will try to overcome. Significant LMCA stenosis, commonly secondary to atherosclerosis, is seen in about 4-10% of cases presenting to the cardiac catheterization laboratory. Currently, the vast majority of these patients undergo surgical revascularization unless there are prohibitive reasons for surgical revascularization. Several challenges of percutaneous revascularization have been overcome with stents, intravascular brachytherapy, and other technical improvements. Yet, several remaining limitations of percutaneous intervention, such as in-stent restenosis, have to be improved further before randomized clinical trials of surgical and percutaneous revascularization of unprotected LMCA disease can be contemplated to establish a new standard of care.
Collapse
Affiliation(s)
- H Mehrdad Sadeghi
- Department of Medicine, Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | | | | |
Collapse
|
16
|
Schwartz L, Bui S. The role of intravascular ultrasound in the diagnosis and treatment of patients with coronary artery disease. COMPREHENSIVE THERAPY 2003; 29:54-65. [PMID: 12701344 DOI: 10.1007/s12019-003-0008-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
Approximately 95% of the coronary vasculature is atherosclerotic before lesions are visible by coronary angiography. Intravascular ultrasound assesses the burden of coronary atherosclerosis, as well as clarifying the anatomical and physiological characteristics of ambiguous lesions.
Collapse
Affiliation(s)
- Leonard Schwartz
- Division of Cardiology, Department of Medicine, Toronto General Hospital, 200 Elizabeth St, Toronto, M5G 2C4, Canada
| | | |
Collapse
|
17
|
De Franco AC, Nissen SE. Coronary intravascular ultrasound: implications for understanding the development and potential regression of atherosclerosis. Am J Cardiol 2001; 88:7M-20M. [PMID: 11705417 DOI: 10.1016/s0002-9149(01)02109-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The incremental value of intravascular ultrasound (IVUS), compared with angiographic analysis of coronary atherosclerosis, originates principally from 2 key features-its tomographic perspective and the ability to image coronary atheroma directly. Whereas angiography depicts the cross-sectional coronary anatomy as a planar silhouette of the lumen, ultrasound directly images the atheroma within the vessel wall, allowing measurement of atheroma size, distribution, and to some extent, composition. Although angiography remains the principal method to assess the extent of coronary atherosclerosis and to guide percutaneous coronary interventions, IVUS is rapidly altering conventional paradigms in the diagnosis and therapy of coronary artery disease. Thus, IVUS has become a vital adjunctive imaging modality for the aggressive coronary interventional cardiologist. As such, ultrasound has earned a role as a viable complementary technique relative to angiography, rather than an alternative to conventional angiographic methods. This article reviews the rationale, technical advantages and limitations, and interpretation of intravascular ultrasonography from the perspective of the general and invasive cardiologist. We emphasize the impact that IVUS studies have had on our understanding of the atherosclerotic coronary artery disease process, because these findings have important implications for all cardiologists. We then review several trials that are currently using intravascular ultrasonography for the study of coronary artery disease regression.
Collapse
Affiliation(s)
- A C De Franco
- McLaren Heart and Vascular Center and Cardiac Catheterization Laboratory, McLaren Regional Medical Center, Michigan State University, Flint, Michigan, USA
| | | |
Collapse
|
18
|
Park SJ, Hong MK, Lee CW, Kim JJ, Song JK, Kang DH, Park SW, Mintz GS. Elective stenting of unprotected left main coronary artery stenosis: effect of debulking before stenting and intravascular ultrasound guidance. J Am Coll Cardiol 2001; 38:1054-60. [PMID: 11583882 DOI: 10.1016/s0735-1097(01)01491-7] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- S J Park
- Department of Medicine, College of Medicine, University of Ulsan, Cardiac Center, Asan Medical Center, Seoul, South Korea.
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Nageh T, De Belder AJ, Thomas MR, Wainwright RJ. Intravascular ultrasound-guided stenting in long lesions: an insight into possible mechanisms of restenosis and comparison of angiographic and intravascular ultrasound data from the MUSIC and RENEWAL trials. J Interv Cardiol 2001; 14:397-405. [PMID: 12053493 DOI: 10.1111/j.1540-8183.2001.tb00349.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The high restenosis rates in long stents may be related to suboptimal stent deployment. In an attempt to understand the potential components associated with restenosis in long stents, this study compares angiographic and intravascular ultrasound (IVUS) data from the MUSIC and RENEWAL studies where IVUS was used to optimize stent deployment in short (< 15 mm) and long (> 20 mm) coronary lesions, respectively. The RENEWAL study, a randomized trial, compared the NIR stent and Wallstent in long (> 20 mm) coronary lesions and used on-line visual IVUS criteria to optimize stent expansion. Detailed analysis of IVUS data was performed off line. Angiographic and IVUS data from this study was compared to that from the MUSIC study. Initial stent deployment was deemed optimal by the operator after visual angiographic and IVUS assessment in 50 of 70 lesions. In the remaining 20 lesions further balloon inflations were required to optimize stent apposition that led to an average gain in minimal in-stent luminal area (MISA) of 15.9% (P < 0.01). Off-line IVUS data analysis showed that the number reaching "MUSIC criteria" for optimal stent deployment preredilatation was 8 (11.4%) of 70 and 14 (20%) of 70 postredilatation. The ratio of MISA/MRAprox (mean proximal reference area) was 0.69 in RENEWAL. At 6-month follow-up, the angiographic restenosis rate in RENEWAL was 36% and target lesion revascularization (TLR) rate was 7.8%, compared with MUSIC's 9.7% and 4.5%, respectively. In conclusion, angiographic assessment of stent deployment in long lesions is limited. On-line visual IVUS with further balloon inflations to improve stent apposition led to a significant gain in MISA, but the MISA/MRAprox ratio remained suboptimal. Therefore, suboptimal stent deployment due to constraint by lesion resistance may be an important mechanism underlying the high restenosis rates in long stents.
Collapse
Affiliation(s)
- T Nageh
- King's College Hospital, Denmark Hill, London, England SE5 9RS.
| | | | | | | |
Collapse
|
20
|
Maehara A, Mintz GS, Castagna MT, Pichard AD, Satler LF, Waksman R, Laird JR, Suddath WO, Kent KM, Weissman NJ. Intravascular ultrasound assessment of the stenoses location and morphology in the left main coronary artery in relation to anatomic left main length. Am J Cardiol 2001; 88:1-4. [PMID: 11423049 DOI: 10.1016/s0002-9149(01)01575-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Eighty-seven left main stenoses were evaluated by angiography and intravascular ultrasound. Intravascular ultrasound analysis included left main length (bifurcation to ostium), stenosis location, stenosis length, stenosis external elastic membrane, lumen, plaque & media cross-sectional area (CSA), plaque burden (plaque & media/external elastic membrane CSA), calcium arc, calcium length, eccentricity, and remodeling index (stenosis/reference external elastic membrane CSA). Long anatomic left main arteries (length > or =10 mm, n = 43) were compared with short anatomic left main arteries (length <10 mm, n = 44) regarding stenosis location. Ostial (proximal third of left main artery) (n = 32) and nonostial (midthird and distal third) stenoses (n = 55) were compared regarding stenosis morphology. Short anatomic left main arteries developed stenoses more frequently near the ostium (ostium 55%, bifurcation 38%). Conversely, long anatomic left main arteries developed stenoses more frequently near the bifurcation (ostium 18%, bifurcation 77%, p = 0.001). Ostial left main stenoses were more common in women (44% vs 20%, p = 0.02), had larger lumen area (6.2 +/- 2.2 vs 4.6 +/- 2.3 mm(2), p = 0.002), less plaque burden (62 +/- 15% vs 80 +/- 9%, p <0.0001), less calcification (arc = 78 +/- 65 degrees vs 195 +/- 101 degrees, p <0.0001), and more negative remodeling (remodeling index = 0.87 +/- 0.19 vs 1.01 +/- 0.21, p = 0.005) than nonostial left main stenoses. Most ostial left main stenoses were categorized as eccentric (97% vs 76%, p = 0.01). Short and long left main arteries develop stenoses at different locations. Stenosis morphology was significantly different in these 2 locations.
Collapse
Affiliation(s)
- A Maehara
- Intravascular Ultrasound Imaging and Cardiac Catheterization Laboratories, Cardiovascular Research Institute, Washington Hospital Center, Washington, DC 20010, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Skyrme-Jones RA, Farouque HM, Ang CH, Meredith IT. Does unprotected left main-stem stenting have a role in current interventional practice? Heart Lung Circ 2001; 10:79-82. [PMID: 16352043 DOI: 10.1046/j.1444-2892.2001.00088.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Left main-stem disease is found in up to 5% of patients undergoing coronary angiography. Until recently, it has been regarded as an absolute indication for coronary bypass surgery, given the poor results of the early trials of balloon angioplasty for this condition. However, with rapidly advancing technology, including new generation stents and increasingly effective post-stenting anti-thrombotic regimens, there is now an increasing body of evidence to support the consideration of a percutaneous approach to left main-stem disease. Discerning patient selection, meticulous stent sizing and deployment, the routine use of intravascular ultrasound, aggressive anti-platelet regimes, and careful patient follow up are a few of the technical considerations required for a successful long-term outcome in this group.
Collapse
Affiliation(s)
- R A Skyrme-Jones
- Cardiovascular Research Centre, Centre for Heart and Chest Research, Monash Medical Centre, Victoria, Australia
| | | | | | | |
Collapse
|
22
|
|
23
|
Carlier SG, Coen VLMA, Sabaté M, Kay IP, Ligthart JMR, Van Der Giessen WJ, Levendag PC, Bom K, Serruys PW. The role of intravascular ultrasound imaging in vascular brachytherapy. INTERNATIONAL JOURNAL OF CARDIOVASCULAR INTERVENTIONS 2000; 3:3-12. [PMID: 12470381 DOI: 10.1080/14628840050516253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Intracoronary brachytherapy has recently emerged as a new therapy to prevent restenosis. Initial experimental work was achieved in animal models and the results were assessed by histomorphometry. Initial clinical trials used angiography to guide dosimetry and to assess efficacy. Intravascular ultrasound (IVUS) permits tomographic examination of the vessel wall, elucidating the true morphology of the lumen and transmural components, which cannot be investigated on the lumenogram obtained by angiography. This paper reviews the use of IVUS in the clinical studies of brachytherapy conducted to date. IVUS allows clinicians to make a thorough assessment of the remodeling of the vessel and appears to have a major role to play in facilitating understanding of the underlying mechanisms of action in this emerging field. The authors propose that state-of-the-art IVUS techniques should be employed to further knowledge of the mechanisms of action of brachytherapy in atherosclerotic human coronary arteries.
Collapse
Affiliation(s)
- Stéphane G Carlier
- The Thoraxcenter, Heart Center, Department of Interventional Cardiology, Academisch Ziekenhuis Rotterdam-Dijkzigt and the Experimental Echocardiography Laboratory, Erasmus University, Rotterdam, The Netherlands
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
CARLIER STÉPHANEG, LANGENHOVE GLEN, LUPOTTI FERMIN, ALBERTAL MARIANO, MASTIK FRITS, BOM KLAAS, SERRUYS PATRICKW. Coronary Flow Reserve Versus Geometric Measurements of Coronary Dimensions: Advantages and Limitations of the Functional Stenosis Assessment. J Interv Cardiol 1999. [DOI: 10.1111/j.1540-8183.1999.tb00669.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|