Percutaneous Coronary Intervention vs. Coronary Artery Bypass Grafting for Treating In-Stent Restenosis in Unprotected-Left Main: LM-DRAGON-Registry

Background

Data regarding management of patients with unprotected left main coronary artery in-stent restenosis (LM-ISR) are scarce.

Objectives

This study investigated the safety and effectiveness of percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG) for the treatment of unprotected LM-ISR.

Methods

Consecutive patients who underwent PCI or CABG for unprotected LM-ISR were enrolled. The primary endpoint was a composite of major adverse cardiac and cerebrovascular events (MACCE), defined as cardiac death, myocardial infarction (MI), target vessel revascularization (TVR), and stroke.

Results

A total of 305 patients were enrolled, of which 203(66.6%) underwent PCI and 102(33.4%) underwent CABG. At 30-day follow-up, a lower risk of cardiac death was observed in the PCI group, compared with the CABG-treated group (2.1% vs. 7.1%, HR 3.48, 95%CI 1.01–11.8, p = 0.04). At a median of 3.5 years [interquartile range (IQR) 1.3–5.5] follow-up, MACCE occurred in 27.7% vs. 29.6% (HR 0.82, 95%CI 0.52–1.32, p = 0.43) in PCI- and CABG-treated patients, respectively. There were no significant differences between PCI and CABG in cardiac death (9.9% vs. 18.4%; HR 1.56, 95%CI 0.81–3.00, p = 0.18), MI (7.9% vs. 5.1%, HR 0.44, 95%CI 0.15–1.27, p = 0.13), or stroke (2.1% vs. 4.1%, HR 1.79, 95%CI 0.45–7.16, p = 0.41). TVR was more frequently needed in the PCI group (15.2% vs. 6.1%, HR 0.35, 95%CI 0.15–0.85, p = 0.02).

Conclusions

This analysis of patients with LM-ISR revealed a lower incidence of cardiac death in PCI compared with CABG in short-term follow-up. During the long-term follow-up, no differences in MACCE were observed, but patients treated with CABG less often required TVR.

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Registration

https://www.clinicaltrials.gov; Unique identifier: NCT04968977.

Clinical significance of mirror lesions in lower extremity arterial disease

OBJECTIVE

The aim of this study was to investigate the clinical relevance of bilateral peripheral arterial disease (PAD) patterns.

BACKGROUND

No prior study has evaluated the clinical significance of symmetrical lesion patterns, particularly the coexistence of same-level significant plaques in both lower extremities ("mirror lesions").

METHODS

We conducted a single-facility, primary data analysis involving 225 patients with symptomatic PAD.

RESULTS

Eighty-two percent of the patients had bilateral lesions: 14.2% had femoropopliteal, 38.7% had infrapopliteal, and 27.1% had both femoropopliteal and infrapopliteal lesions. The lesions were found in the exact same arteries bilaterally in 24.9% of the patients, while 26.7% had a local mirror pattern limited to the femoropopliteal (13.7%) or infrapopliteal (12.9%) arteries. Having a lesion in an artery was a risk factor for occlusive disease of the corresponding artery on the other side. Patients presenting with critical limb ischemia (CLI) had a history of resting pain (17%), ulceration/gangrene (13%), or prior amputation (26%) of the contralateral limb. Patients with significant bilateral disease had unilateral false-negative ABI results in 11.6% of the cases. The arterial Doppler study results were unilaterally false-negative in 19.6% and bilaterally false-negative in 2.8% of the patients.

CONCLUSIONS

Patients with known peripheral arterial disease need to have both limbs fully evaluated and monitored, even in cases with negative screening results. Mirror angiographic imaging is common and often accompanied by symptoms of claudication. Unilateral ischemia is a strong risk factor for contralateral disease. Patients with CLI are at high risk for occlusive lesions of the nonindex limb.