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130
(A) (B) (C)
Figure 11 (A) Note the distal LM disease extending to both the ostium of the LAD and the LCx artery; (B) note
mild disease in the RCA. The patient was counseled by both the cardiac surgeon who offered the patient CABG
surgery and the interventionalist who offered the patient PCI with DES placement. (C) The patient declined CABG
and subsequently underwent ULMCAD PCI with DES. At six-month follow-up patient remains free of symptoms
and with subsequent improvement in left ventricular function.
MOUSSA ET AL.
possible. Thereare two methodsto restore blood flow to yourheart: CABG surgery, which
has been the “standard of care,” and angioplasty with stents, which is another option.
When you return to your room, both the cardiac surgeon and I will visit with you and
explain the pros and cons of both options!
It is very likely that almost all of our surgical colleagues and many interventionalists in
the United States would opt to use counseling option #1, while a minority of interventionalists
would chose counseling option #2. A variation on option #2 is when a patient is referred to a
surgeon and there is no offer to have an interventional consultant weighin with an opinion. We
argue to opt for counseling option #3.
At the crux of deciding how to counsel patients are two basic question: first, should we
as physicians execute clinical practice guidelines that were published several years prior to
patient encounter or make a contemporary judgment that reflects the current knowledge at the
time of patient encounter? And secondly are caregivers as well as patients obligated to accept
the clinical trialist “tradition” of giving equal weight to the need for repeat intervention versus
that of death, myocardial infarction, or stroke? Shouldn’t patients be consulted as to what they
would accept as potential consequences of revascularization, stroke, and prolonged recovery or
the need to undergo another PCI! As caregivers, the ethics of the practice of medicine calls on
us to investigate the reliability of current knowledge as well as “standards of care” (40).
In counseling patients with ULMCAD regarding coronary revascularization, three important facts need to be made clear: (i) the revascularization procedure, CABG, or PCI, is not a cure
and there is a chance that they may need repeat interventions in the future (more so with the
PCI compared to the CABG surgery in cases where the LM disease is associated with two or
three vessel CAD); (ii) although CABG surgery is currently considered the “standard of care,”
there is no evidence that CABG surgery is better than PCI for prevention of death and MI (up
to 3–5 years) and; (iii) CABG surgery involves higher “up-front” risk of significant adverse
events (including higher stroke rate) and a prolonged recovery. When the cardiac surgeon or
the interventionalists offers their perspectives separately, it is likely that both would be conflicted in their presentation. To present patients with a balanced view, both the interventional
cardiologist and the cardiac surgeon should provide an informed consent not solely based on
the current guidelines but also on the individual data of each patient: (i) the extent of disease
beyond the LMCA; (ii) the morphology of disease, particularly thepresence of combined severe
calcifications and torousity and CTOs; (iii) the projected number of stents that are needed;
(iv) the presence of disease in the distal coronary segments that may affect the effectiveness of
bypass grafts;(v) quality ofarterial and/or venous conduitsfor grafting; and(vi) patient and/or
referring physician preferences.
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Undoubtedly, there is pressing need for more high-quality data comparing CABG to PCI
to enrich and further inform clinical decision making. However, the primary endpoint of future
trials shouldfocus on safetyendpoints (death, MI, stroke). The needfor repeat revascularization
for PCI and the high frequency of CABG surgery–related complications should be considered
secondary endpoints, as it is in the NHLBI-sponsored FREEDOM trial (41).
SUMMARY
Although scientific and technological advances refine clinical insight and provide tools, physicians still work in an environment of uncertainty. This uncertainty leads many of us to use the
term ‘‘Medicine is both a science and an art’’ to manage the gaps in our knowledge base. This
paradoxical description of the practice of medicine is ‘‘convenient’’ because it is flexible enough
to allow us to be empiric at times yet scientific at others. We rationalize that we are empiric
when we do not have ‘‘evidence,’’ yet we are scientific when we have evidence. The problem is
that the evidence is a moving target.
Although no one knows what the “evidence” for management of patients with ULMCAD
will be 10 to 15 years from now, it is likely that both PCI and CABG will have a role in the
management of these patients. Of course, whatever the “evidence” is at the time, there will
continue to be uncertainties because both CABG and PCI would have advanced beyond the
existing evidence of the day. What will not change is our mission as physicians to always
investigate the reliability of current knowledge as well as standards of care and treat individual
patients using our best judgment.
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7
Provisional Stenting for Left Main Coronary
Artery Bifurcation Lesions:
Patient Selection and Technique
Seung-Jung Park and Young-Hak Kim
University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
INTRODUCTION
Coronary artery stenting has made percutaneous coronary intervention (PCI) for revascularization of patients with unprotected left main coronary artery (LMCA) disease safer (1). Moreover, drug-eluting stents (DES), together with advances in periprocedural and postprocedural
adjunctive pharmacotherapies, have improved outcomes of PCI for these patients (2–9). In fact,
compared with bare-metal stents (BMS), DES reduced the incidence of angiographic restenosis and subsequently the need of repeat revascularization (2–4). In the early series of studies
for unprotected LMCA stenosis,
implantation was 2% to 19%, as compared with 12% to 31% after BMS implantation (2–4).
However
tected LMCA remains a challenge. Besides the technical complexity of the procedure, lesions
located at bifurcations are at higher risk for restenosis and thrombosis after stenting compared
with nonbifurcation location (5,10–14). Patients with bifurcation LMCA disease who require a
two-stent strategy have higher incidence of restenosis compared to patients with bifurcation
LMCA disease who require a single stent (11,12). Whether the cause of this difference is the
more complex bifurcation anatomy in thetwo-stent strategy or thetechnique itself remains to be
revealed. Therefore, until the appropriateRCTs comparing single- versus two-stentstrategies in
bifurcation LMCA disease are available, selection of the bifurcation stenting technique should
be based on the individual lesion morphology. In patients with suitable anatomy, an initial
strategy of provisional stenting, as opposed to “routine” side branch (SB) stenting should be
attempted. With the provisional approach, stenting of the SB is reserved for suboptimal result
or significant dissection in the SB after main branch (MB) stenting.
This chapter reviews proper patient selection and preparation and technical execution of
provisional stenting in patients with unprotected LMCA bifurcation stenosis.
, despite the great benefit of DES, treatment of bifurcation lesions in an unpro-
the one-year incidence of repeat revascularization after DES
WHO QUALIFIES FOR THE PROVISIONAL STENTING APPROACH:
ANATOMIC CONSIDERATIONS
Plaque Distribution and Side Branch Lesion Severity and Length
LMCA bifurcation stenoses Medina class (1,1,0 or 1,0,0) (i.e., plaque located in the MB alone)
should betreated usingthe provisionalstenting technique. By contrast, when LMCA bifurcation
stenoses involving the MB and SB (true bifurcation lesions) are treated with the provisional
stenting approach, they are more likely to result in SB deterioration (Table 1). For example,
Figure 1 shows a patient with LMCA bifurcation stenosis not involving the SB (the LCX artery)
treated with provisional stenting, in which a single stent was placed in the LMCA crossing the
left circumflex artery (LCX). However, as shown in Figure 2, a patient with LMCA bifurcation
stenosis involving the ostia of the LCX and LAD arteries was treated with elective double
stenting technique. IVUS is very helpful in determining the extent of disease in the ostial LCX
artery where angiography can over- or underestimate the extent of disease.
Size of the SB (LCX Artery)
In making a selection between provisional and elective double stenting of LMCA bifurcation
stenoses, the size of the LCX artery and the size of the myocardial territory it supplies are
PROVISIONAL STENTING FOR LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
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Tab le 1 Favorable or Unfavorable Anatomical Features for Provisional Stenting
in the Treatment of Unprotected Left Main Coronary Artery Stenosis
Anatomical features
Favorable
r
Significant stenosis at the ostial LCX with MEDINA
classification 1,1,0 or 1,0,0
r
Large size of LCX with ≥2.5 mm in diameter
r
Right dominant coronary system
r
Narrow angle with LAD
r
No concomitant disease in LCX
r
Focal disease in LCX
135
Unfavorable
Abbreviations
: LAD, left anterior descending artery; LCX, left circumflex artery.
r
Insignificant stenosis at the ostial LCX with MEDINA
classification 1,1,1; 1,0,1; or 0,1,1
r
Diminutive LCX with <2.5 mm in diameter
r
Left dominant coronary system
r
Wide angle with LAD
r
Concomitant disease in LCX
r
Diffuse disease in LCX
of prime importance. The size of the LCX artery does not only refer to the diameter of the
vessel (which may appear smaller due to diffuse disease) but also to its length and number
of branches (which indicate the amount of myocardium at jeopardy). Elective double stenting
should be strongly considered if the LCX artery supplies large myocardial territory and has
severe ostial/proximal disease (Fig. 2).
On the other hand, provisional stenting should be the
strategy of choiceif theLCX artery is small (<2.5mm andit supplies small myocardial territory),
irrespective of the extent of disease in the ostium (Figs. 3 and 4).
Figure 1 Provisional stenting in a 69-year-old man with unprotected LMCA bifurcation lesion and normal left
ventricular ejection fraction. (A and B) Baseline coronary angiography showing distal LMCA stenosis involving the
ostium of the LAD. (C)Preintervention IVUSimage ofthe ostialLCX (
after stenting of the LMCA-LADwith a 3.5 ×28 mm Xience everolimus-eluting stent (Abbott Vascular, Santa Clara,
CA). Note the angiographic compromise of the LCX ostium. (E) FKI after high-pressure balloon dilation of the
LMCA stent with a 4.5 × 8 mm noncompliant balloon. (F and G) Final coronary angiography after FKI with two
3.5 × 15 mm noncompliant balloons. Note the improvement in the LCX ostium.
(A)
(E) (F) (G)
(B) (C) (D)
dotted white circle
). (D) Coronary angiography
(A)
(B) (C)
(E) (F)(D) (G)
Figure 2 Elective double stenting in a 38-year-old man with unprotected LMCA bifurcation lesion and normal
left ventricular ejection fraction. (A–C) Baseline coronary angiography shows distal LMCA bifurcation stenosis involving both the LAD and LCX. (D) Preintervention IVUS image of the ostial LCX (
(E) Simulatneous kissing stents with two 3.5 × 33 mm (LAD) and 3.0 × 23 mm (LCX) Cypher sirolimus-eluting
stents (Cordis Corp, Johnson & Johnson, Warren, NJ). (F and G) Final coronary angiography.
Magnification
dotted white circle
).
(A) (B) (C)
(D)
Figure 3 Provisional stenting in a 63-year-old man with unprotected LMCA bifurcation lesion and normal left
ventricular ejection fraction (A–C) Baseline coronary angiography. Note that although the LCX ostium is involved,
the LCX artery is small. (D) Stenting of the LMCA into the LAD with a 3.5 ×33 mm Cypher sirolimus-eluting stent
(Cordis Corp, Johnson & Johnson, Warren, NJ); (E and F) Final coronary angiography (no final kissing balloon
inflation).
(E)
(F)
PROVISIONAL STENTING FOR LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
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(A) (B) (C)
(D) (E)
137
Figure 4 Provisional stenting in an 82-year-old woman with unprotected LMCA bifurcation lesion and normal left
ventricular ejectionfraction. (A and B) Baseline coronary angiography.Note the smallmyocardial territory supplied
by the LCX artery. (C) Stenting of the LMCA towards the LAD with a 4.0 × 28 mm Xience everolimus-eluting
stent (Abbott Vascular, Santa Clara, CA); (D and E) Final coronary angiography. Note that despite the apparent
angiographic compromise of the ostial LCX, final kissing balloon inflation was not performed because the patient
was asymptomatic and the LCX artery supplies a small territory.
Angulation in the Distal LMCA Bifurcation
By angiography, bifurcations are classified according to the internal angle between the main
vessel and the side branch, with a Y-shaped lesion having an angle <70 degrees and a T-shaped
lesion ≥70 degrees. A Y-angle allows easier wire access to the SB than a T-angle. On the other
hand, precise stent placement at the ostial SB is more difficult in a Y-angle lesion compared
to a T-angle lesion. The LMCA bifurcations (LAD/LCX) are often T-shaped with an average
angulation of 80 degrees. Therefore, the potential difficulty in rewiring the SB after MB stenting
is an important consideration in selecting the stenting strategy for LMCA bifurcation stenosis.
Figure 5 shows an example of LMCA bifurcation stenosis with a wide angle between the LAD
and LCX arteries, which has a moderate stenosis at the ostium. To avoid the potential failure
of wire recrossing to the LCX (large vessel supplying large myocardial territory), an elective
double-stenting technique (crush technique) was used.
Concomitant Disease in the Distal Circumflex Artery
Although DES has impr
of higher risk of unfavorable outcomes (15).
oved patient outcomes after PCI,
IVUS
studies have demonstrated that incomplete
diffuse disease remains an indicator
lesion coverage leaving significant plaque proximal or distal to DES is associated with worse
outcomes (16,17); therefore, complete lesion coverage is an important factor for good long-term
outcomes.
Patients withbifurcationLMCA diseaseand diffuse coronarydisease elsewhere inthe
coronary tree are a particularly high-risk group. We typically avoid performing elective double
stenting on the LMCA bifurcation in combination with multiple stents to treat distal diffuse
disease because of the additive procedural and long-term risk. Figure 6 shows a patient with
LMCA disease and small LCX artery with diffuse disease. In this patient, provisional LMCA
stenting was used and a decision was made not to implant multiple stents in the diffusely
diseased LCX artery.
(A) (B)
(C)
(D)
Figure 5 Elective double stenting in a 66-year-old man with unprotected LMCA bifurcation lesion and normal left
ventricular ejection fraction. (A and B) Baseline coronary angiography. Note the distal LMCA lesion involving the
ostial LAD and LCX (
significant plaque burden. (D) Based on these findings, the decision was to proceed with elective double stenting
using the minicrush technique. Two sirolimus-eluting stents (Cordis Corp, Johnson & Johnson, Warren, NJ) were
positioned and sequentially deployed in the LM/LAD (3.5 × 23 mm) and the LCX (3.0 × 18 mm). (E and F) Final
coronary angiography after sequential high-pressure balloon dilation with a noncompliant balloon of 4.0 ×18 mm
in LAD and a noncompliant balloon of 3.0 × 18 mm in LCX followed by kissing balloon inflation.
(A) (D)(B) (C)
wide angle
). (C) Preintervention IVUS image of the ostial LCX (
(F)(E)
dotted white circle
)showed
(E)
Figure 6 Provisional stenting in a 72-year-old woman with unprotected LMCA bifurcation lesion and normal left
ventricular ejection fraction. (A and B) Baseline coronary angiography. Note the distal LMCA lesion involving the
ostial LAD and LCX (
stents (Cordis Corp, Johnson & Johnson, Warren, NJ) with a jailed wire in the LCX (
stenting. Note the compromise of the LCX ostium. (E) Due to the large size of the compromised LCX artery, a
decision was made to implant a stent using a provisional T-stenting approach with a 2.75 ×33 mmsirolimus-eluting
stent; (F and G) Final coronary angiography after kissing balloon inflation.
wide angle
). (C) Stenting of the LMCA towards the LAD with two 3.5 ×23 mm sirolimus-eluting
(F)
(G)
arrow
). (D) Angiography after
PROVISIONAL STENTING FOR LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
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139
PROVISINAL STENTING OF LMCA BIFURCATION LESIONS
Patient Preparation
In general, the elements of patient preparation before the procedure are dependent on the
clinical riskprofile of thepatient and theanatomic complexity ofthe lesion. Optimalantiplatelet
and antithrombotic therapy is, of course, required in all patients, but we do
not use IIb/IIIa
receptorantagonists routinely.Although the femoralapproach isthe mostwidely usedin LMCA
bifurcation interventions, few studies have reportedthe feasibility of the radial approach (18,19).
When the radial approach is used, a 6-Fr guiding catheter is often used,although a 7-Fr guiding
catheter can be used in male patients. We think that the femoral approach is preferable when a
complex LMCA bifurcation intervention is required.
In addition,elective useof hemodynamic support isoccasionally necessary. The frequency
of elective use of intra-aortic balloon pump (IABP) with LM PCI varies widely. Recently, a
study in 219 elective LMCA interventions evaluated the role of IABP (20). An elective IABP
was used in a broad range of patients undergoing LMCA bifurcation interventions including
patients with unstable angina, patients with left ventricular ejection fraction <40%, patients
with critical RCA disease, and when debulking devices are used. In this study, although the
patients receiving elective IABP had more complex clinical risk profile, the rate of procedural
complications was lower than those not receiving an IABP (1.4% vs. 9.3%; p = 0.032). Old age,
myocardial infarction, cardiogenic shock,severely reducedleft ventricular ejectionfraction, and
occlusion of the right coronary artery are common conditions requiring elective or provisional
hemodynamic support. Patients in Figures 1 to 6 underwent LMCA PCI using the femoral
approach without IABP support and without IIb/IIIa receptor antagonists. On the other hand,
the patient in Figure 7 who was presented with cardiogenic shock underwent LM PCI with
elective use of IABP.
(D)
Figure 7 Provisional stenting in a 60-year-old woman presenting with cardiogenic shock due to acute anterior
wall ST-elevation myocardial infarction. (A and B) baseline coronary angiography. Note the severe stenosis in
the body of the LMCA with the small caliber and diffusely diseased LCX artery. (C) an intra-aortic balloon pump
was placed prior to intervention. (D)A3.5× 23 mm Cypher sirolimus-eluting stent (Cordis Corp, Johnson &
Johnson, Warren, NJ) was deployed in the LMCA toward the LAD (provisional approach). (E and F) final coronary
angiography without kissing balloon inflation.
(E)
(C)(B)(A)
(F)
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