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Percutaneous Coronary Intervention for Unprotected Left Main Coronary Disease
follow-up in PCI for LMCA bifurcation stenosis. However, the study was populations, the outcomes of PCI with DES showed comparable incidences
limited by the exclusive use of complex stenting strategy (two stents in both of death or MI but a higher risk of repeat revascularisation compared with
branches) in 84% of patients, which may increase the need for repeat CABGs. A recent large registry study supported the early studies with a
revascularisation. Although there has been debate about it,
20
a recent novel statistical adjustment using propensity-score matching.
26
In the
report proposed a probability that the complex stenting technique might be MAIN-COMPARE (revascularization for unprotected left MAIN coronary
associated with high occurrence of restenosis compared with the simple artery stenosis: COMparison of Percutaneous coronary Angioplasty versus
stenting technique.
21
Taken together, before the novel treatment strategy surgical REvascularization) study, overall 2,240 patients who underwent PCI
is settled, the simple stenting approach (LMCA to left anterior descending or CABG in Korea were recruited. In 542 pairs of patients matched with
artery with optional treatment in the circumflex artery) is primarily propensity score, the risk of death (hazard ratio 1.18, 95% CI 0.77–1.80)
recommended in patients with relatively patent or diminutive circumflex and the risk of the composite outcome (hazard ratio 1.10, 95% CI
arteries. In addition, we hope that future stent platforms specifically 0.75–1.62) were not significantly different for patients undergoing PCI
designed for bifurcation lesions will provide better scaffolding and more versus CABG. The rates of target-vessel revascularisation were significantly
uniform drug delivery to the bifurcation LMCA stenosis. higher in the PCI group (hazard ratio 4.76, 95% CI 2.80–8.11). Similar
results were obtained in comparisons of BMS with concurrent CABGs and
Comparison with Bypass Surgery of DES with concurrent CABGs.
It is surprising to note that current guidelines for unprotected LMCA
treatment, in which elective PCI for patients who are treatable with bypass Conclusion
surgery is a contraindication,
22
are based mostly on the 20-year-old clinical The current registry studies, although limited by the non-randomised study
trials.
23,24
These studies demonstrated a definite benefit of survival of design, have demonstrated promisingly the procedural and mid-term safety
coronary artery bypass grafts (CABGs) in LMCA stenosis compared with and effectiveness of DES compared with BMS or CABG. With these
medical treatment. However, application of these results to the current attempts, in our opinion, the use of PCI with DES will progressively increase
practice may not be appropriate because the surgical technique, as well as and can be recommended as a reliable alternative to bypass surgery for
medical treatment, in these studies was outdated by today’s standards, and patients with unprotected LMCA stenosis, especially as the first-line therapy
no randomisation studies between PCI and CABGs have been conducted. for ostial or shaft stenosis. Although bifurcation stenosis remains
The lack of data on the current CABG procedure used in unprotected challenging for the percutaneous approach, we are still optimistic because
LMCA stenosis further precludes a theoretical comparison of the two further research on the novel procedural technique, a new dedicated stent
revascularisation strategies. platform and optimal pharmacotherapies may improve the outcomes. In
addition, we hope that with the upcoming randomised clinical trials
Currently, several non-randomised studies comparing the safety and comparing PCI with CABGs for unprotected LMCA stenosis, more
efficacy of DES treatment for unprotected LMCA stenosis with CABGs have confidence in the long-term safety, durability and efficacy of PCI will be
been published.
6,7,25
In the early series of studies comprising small study achieved in the near future. ■
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