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PARK AND KIM
Other, more potent, hemodynamic support devices such as the Tandem-Heart (CardiacAssist, Pittsburgh, PA) or the Impella Recover LP 2.5 System (Impella CardioSystems, Aachen,
Germany) may allow safe treatment of exceedingly high-risk patients.
Technique Execution
Guide Selection
For LMCAinterventions, a guidingcatheter with side holesis selected tomaintain blood flow to
the target lesion. Some operators use guide catheters without side holes, particularly in patients
with renal insufficiency, to reduce the amount of contrast used. Selection of the size and shape
of the guiding catheter is based on the complexity of procedure and lesion morphology. When
debulking is planned (rotational or directional atherectomy), a large caliber guiding catheter
and a strong support are required. Also, when elective double stenting is planned, an 8-Fr
guiding catheter is necessary to facilitate stent delivery and optimize visualization. In terms of
back-up force, XB (Extra-backup)or EBU (ExtraBack Up) catheterhas stronger back-up support
than JL (Judkins left)catheter. However, caution need tobe exercised while using catheters with
strong support due to the possibility of damage to the LMCA.
Thus, in the majority of LMCA
interventions using provisional stenting, we use an 8-Fr JL guiding catheter.
Lesion Preparation: Role of Debulking
In the BMS era, debulking coronary atherectomy (DCA) before stenting was often used in
an attempt to reduce restenosis by reducing plaque burden. However, the role of DCA has
diminished after the introduction of DES because of the dramatic reduction of restenosis.
Nonetheless, a study of 99 patients with LMCA lesions suggested a viable role for DCA
even in the DES era (21). Of interest, DCA in the MB and SB for the LMCA stenoses allowed
single-stenting in 60 out of 63 LMCA bifurcation stenoses. There were no serious adverse
events at one-year follow-up. This study indicates that DCA may have a role in the treatment
of LMCA bifurcation lesions to optimize the success of provisional stenting strategy. In the
patient illustrated in Figure 8, DCA was used to remove the plaque in the LMCA, hindering
advancement of the wire into the LAD. Also, rotational atherectomy remains a valuable
technique in severely calcified LMCA lesions. Therefore, although data is limited, DCA or
rotational atherectomy still plays a limited, but important, role even in the DES era primarily
to reduce plaque shift and facilitate stent expansion.
Main Branch (LMCA) Stenting
There is no evidence that one DES is better than others in terms of reducing procedural or
long-term complications. The only RCT that compared two different DES in the LMCA is the
ISAR-LEFT MAIN (A Randomized Clinical Trial on Drug-Eluting Stents for Unprotected Left
Main Lesions study) (22). In this trial, 607 patients with unprotected LMCA disease (distal
LMCA disease was present in 63% of patients) were randomized to receive either a paclitaxeleluting stent (PES) or sirolimus-eluting stent (SES). Provisional stenting was used in ∼50% of
patients. There was no difference in the primary endpoint at one year (MACEwas 13.6% in PES
vs. 15.8% in SES; RR = 0.85; 95% CI = 0.56–1.29). However, based on bench testing, tubular
type stents seemsto be better in achievingoptimal lesion coverage in the SB and stronger radial
force inthe LMCA than thecoil or hybrid typestents (23). In theprovisional approach, themain
branch (LMCA) stent should be directed towards the LAD. In cases where the ostial LCX is
heavily diseased, elective double stenting should be considered.
Provisional Approaches for the Management of the SB
Final kissing balloon inflation (FKI)
Provisional treatment of the SB (usually the LCX artery) with either balloon angioplasty or
stenting is reserved for patients with suboptimal results. Despite the controversy, we do not
r
outinely perform balloon angioplasty or FKI after MB stenting. As shown in Figure 9, angio-
graphic
narrowing at the ostial LCX is often caused by the MB stent strut, not by plaque
shift. Therefore, to avoid unnecessary barotrauma to the ostial LCX artery, FKI is selectively
(A) (B) (C)
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(D) (E) (F)
Figure 8 Provisional stenting after debulking coronary atherectomy (DCA) in a 71-year-old man. (A and B)
Baseline coronary angiography. Note the distal LMCA lesion extending to the ostial LAD. (C) DCA to the distal
LMCA toward the LCX artery due to inability to wire the LAD. (D) Successful wiring of the LAD. (E and F) Final
coronary angiography after three Cypher sirolimus-eluting stents (Cordis Corp, Johnson & Johnson, Warren, NJ),
3.5 × 18 mm, 3.0 ×23 mm, and 2.5 × 33 mm, in the LMCA toward the LAD without FKI (provisional approach).
LCX
(B)(A)
(C)
LCX
LAD
(G)(F)(E) (H)
Figure 9 Provisional stenting in a 54-year-old woman with normal ejection fraction. (A and B) Baseline coronary
angiography. (C) Baseline IVUS image showing normal ostial LCX (
showing diseased ostial LAD and normal ostial LCX; (E and F) Final coronary angiography after stenting the ostial
LAD toward the LMCA with a 3.5 × 33 mm Cypher sirolimus-eluting stent (Cordis Corp, Johnson & Johnson,
Warren, NJ) using a provisional approach. (G) Final IVUS image of the LAD ostium showing normal ostial LCX
(
arrow
). (H) Fractional flow reserve (FFR) after hyperemia in the LCX (FFR = 0.97).
dotted white circle
LAD
(D)
); (D) Baseline IVUS image
142
(A) (B) (D)(C)
PARK AND KIM
Jailed SB after
MB stenting
Figure 10 A diagram illustrating provisional T-stenting with minimal protrusion. (A) After main branch (MB)
stenting; (B) stenting in the side branch (SB) with T-shape through the MB stent; (C) final kissing balloon inflation;
(D) final result.
SB stenting with
minimal protrusion
Final kissing is
necessary
Slightly protruded
stent to MB
performed inlesions that developtrue narrowingafter MB stenting,as shown inFigure 1. When
a decision is made to perform FKI, we use a
However,
when a standard guidewire fails to recross due to a wide bifurcation angleor a severe
standard
guidewire to recross into the LCX artery.
stenosis, hydrophilic-coatedor stiffer guidewires may beuseful with the caveatthat these wires
can easily induce dissections if not used carefully. If all these techniques fail, recrossing with a
small
fixed-wire balloon should be attempted.
Stenting of the SB
Stenting of the LCX artery is only required provisionally in the case of suboptimal result or
significant
dissection after FKI. When SB stenting is required as a bailout procedure, we use
provisional T-stenting or the reverse crush technique (24–28). The “provisional T-stenting”
technique (Fig. 10) is a strategy of T-stenting in the LCX artery after MB stenting with minimal
protrusion into the LMCA. FKI after T-stenting is a mandatory step for optimal final result. In
the “reverse crush technique,” a LCX stent is implanted with also minimal protrusion into the
LMCA, but the protruding LCX stent is crushed to the vessel wall by the MB balloon, after
the removal of the LCX wire and balloon. Then the LCX artery is rewired and stent struts
dilated with high-pressure noncompliant balloon. FKI of both branches should be performed
with noncompliant balloons (Fig.
11).
Stent Deployment Optimization
Role of IVUS
IVUS is a useful modality to help in selecting treatment strategies as well as optimize stent
deployment and outcomes even in the DES era (29–31). Although one study reported that
the clinical impact of IVUS-guided stenting for LMCA with DES did not show significant
clinical long-term benefit compared with angiography-guided procedure (32), this study was
retrospective and underpowered. Recent registry data provide support for the concept that
IVUS-guidance may reduce the long-term risk of restenosis and late mortality (33,34). IVUS
interrogation in patients with unprotected LMCA bifurcation disease can provide unique and
useful information that cannot be derived from angiography:
1. IVUS provide more accurate assessment of the LMCA stenosis severity and true vessel
size—both are important elements to optimize stent deployment in the LMCA.
2. Coronary angiography is not accurate in discriminating between true and pseudostenosis
in the ostial LCX artery. The degree of ostial LCX stenosis and plaque burden impacts
the probability of LCX compromise after LMCA stenting. An IVUS confirmation of small
PROVISIONAL STENTING FOR LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
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(A) (C)(B) (D)
Crushed
SB stent
143
Jailed SB after
MB stenting
Recross of wire
into SB
Figure 11 A diagram illustrating reverse crush stenting. (A) After main branch (MB) stenting; (B) stenting in the
side branch (SB) keeping the balloon in the MB; (C) crushing the SB stent with a MB balloon; (D) crushed SB
stent; (E) wire recrossing into the SB; (F) balloon dilation of the SB stent; (G) kissing balloon inflation; (H) final
result.
Keeping balloon
in MB
(F)(E)
Opening of SB
(G)
Final kissing balloon
inflation
(H)
plaque burden at the LCX ostium makes provisional stenting success more likely, while a
large plaque burden makes provisional stenting success less likely.
3. IVUS interrogation of the LCX ostium after LMCA stent placement is more accurate than
angiography to make a determination as to the need for further intervention on the LCX.
Figure 9 is an example of usefulness of IVUS examination after stenting.
Angiographic
haziness at the ostial LCX after MB stenting turned out to bethe MB stent strutwithout flow
limitation.
Role of fractional flow reserve
Fractional
flow reserve is a reliable physiological measurement to assess the significance of
lumen compromise in the SB after MB stenting. In a study comparing the discrepancy between
angiographic severity and fractional flow reserve (FFR) of the SB for 94 coronary bifurcations,
there was weak correlation between the twomeasurements (
35). Of interest, only 27% of lesions
with ≥75% angiographic stensosis had significant flow impairment as determined by FFR
144
PARK AND KIM
<0.75. Based on this finding, we occasionally measure FFR when the functional severity of the
SB stenosis after LMCA stenting in not certain by visual evaluation. Figure 9 is an example
showing the advantage of FFR measurement, in that no angioplasty or stenting was performed
in the LCX because FFR was >0.75 despite the presence of moderate LCX stenosis. A detailed
discussion on therole of FFR in guiding provisional stenting of bifurcation lesions can be found
in chapter 4.
TIPS AND TRICKS IN PROVISIONAL STENTING OF LMCA BIFURCATION LESIONS
Although provisionalstenting isthe easiest techniqueto treatLMCA bifurcationslesions, several
considerations are worth noting:
r
Predilation of the LCX artery ostium before MB stenting is generally not recommended if
the stenosis of the LCX is not significant because it may cause a flow limiting dissection that
requires the operator to perform an unplanned stenting of the SB.
r
The “jailed wiretechnique” is avery important element ofthe provisionalstenting technique.
It helps maintain SB patency during MB stenting, provides a marker of the SB origin in case
of occlusion, and may change the angle from T- to Y-shape that may facilitate SB recrossing
(Fig.
r
6).
Careful preprocedural evaluation of ostial LCX lesion severity and angulation by angiography and IVUS are important to choose the appropriate technique as well as to anticipate
potential problems. If the angle between a severely diseased ostial LCX and the LMCA is
wide, it may be very difficult to recross into the LCX after MB stenting. As an example, the
patient in Figure 12 underwent an elective two-stent strategy (kissing stenting) due to the
concern about LCX compromise/occlusion after MB stenting.
(A)
(D)
Figure 12 Simultaneous kissing stenting for a 69-year-old man with normal ejection fraction. (A and B) Baseline
coronary angiography. Note the severe stenosis involving the distal LMCA, ostial LAD, and ostial and distal LCX;
(C) deployment of a 2.75 ×18 mm Cypher sirolimus-eluting stent (Cordis Corp, Johnson & Johnson, Warren, NJ)
in the distal LCX; (D) kissing stents (Cypher sirolimus-eluting stents) deployed in the ostial LAD (3.5 × 33 mm)
and ostial LCX (3.0 × 23 mm) into the distal LMCA; (E and F) final coronary angiography.
(B)
(E)
(C)
(F)
PROVISIONAL STENTING FOR LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
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145
(A)
(D)
Figure 13 Simultaneous kissing stenting in a 46-year-old-man with severe in-stent restenosis of a bare metal
stent placed in the LMCA across the LCX. (A–C) Baseline coronary angiography. Note the proliferative pattern of
restenosis within a bare metal stent extending from the distal LMCA to the ostial LAD. (D) Simultaneous kissing
stenting with two 3.5 × 24 mm (LAD) and 3.5 × 8 mm (LCX) Taxus paclitaxel-eluting stents (Boston Scientific,
Natick, MA); (E and F) Final coronary angiography.
r
Although restenosis remains an important limitation of the long-term efficacy of PCI for
LMCA bifurcation
lesions, itis relativelyan uncommon event(<
(E)
10%), particularlyin patients
(C)(B)
(F)
with less-complex lesion morphology who are suitable for provisional stenting (12). Even
in patients with restenosis,
the majority have focal restenosis that can be easily treated with
repeat PCI. As shown in Figure 13, repeat PCI with DES is a useful strategy for restenosis of
BMS or DES.
ANTIPLATELET THERAPY IN PATIENTS UNDERGOING PROVISIONAL STENTING
OF LMCA BIFURCATION LESIONS
Although the reported incidence of stent thrombosis after DES implantation in LMCA lesions
is very low (36), fear of stent thrombosis remains a major concern. Premature discontinuation
of clopidogrel is strongly associated with stent thrombosis (13,37). Therefore, as generally recommended, dual antiplatelet therapy including aspirin and clopidogrel (or ticlopidine) should
be maintained for at least one year. Furthermore, during the procedure, elective or provisional
use of glycoprotein IIb/IIIa inhibitor may play a role in reducing procedure-related thrombotic
complications. In a patient illustrated in Figure 12, prophylactic abciximab was administered
before the procedure due to the complex lesion morphology. In some institutions in Asian
countries, adjunctive administration of cilostazol has been used for the purpose of reducing
thrombotic complications (38). However, the additive role of glycoprotein IIb/IIIa inhibitor,
cilostazol, low-molecular-weight heparin, direct thrombin inhibitor, or other new drugs in DES
treatment for LMCA lesions need to be investigated in future studies. Some operators recommend to continuedual antiplatelettherapy for morethan one year in high-risk patients (diabetes
mellitus, multiple stents, chronic renal failure, or presentation with myocardial infarction) (39).
146
PARK AND KIM
TAKE HOME MESSAGE
1. In percutaneous interventional treatment of patients with unprotected LMCA bifurcation
lesions, provisional stenting should be the preferred technique in the following anatomic
subsets:
(a) Patients
without ostial LCX involvement as assessed by angiography and IVUS.
(b) Patients with diminutive LCX artery irrespective of the extent of disease in the ostium.
2. In patientswith unprotectedLMCA bifurcation lesionsand severe involvementof theostium
of a large LCX artery, elective double stenting strategy should be considered.
3. In patients with complex unprotected LMCA bifurcation lesions, a large guiding catheter
(
8-Fr guiding) provides more options for optimal treatment.
4. ProphylacticIABP (or
who are
hemodynamically unstable or who have very complex coronary lesions.
other hemodynamic supportdevices) shouldbe consideredin patients
5. Aggressive lesion preparation with debulking (excisional or rotational atherectomy) should
be considered in very bulky or severely calcified LMCA bifurcation lesions.
6. Final kissing balloon inflation (FKI) should be selectively performed only when the ostium
of the LCX artery is significantly compromised.
7. Provisional stenting of the LCX artery (using T-stenting, inverse crush technique, or culotte
stenting) should be only performed after failure of FKI in obtaining an acceptable result in
a large LCX artery.
8. Patients undergoing provisional stenting (DES) of unprotected LMCA bifurcation lesions
should receive dual antiplatelet therapy (aspirin and clopidogrel) for at least one year or
more.
9. Routine angiographic surveillance between 6 and 9 months
is generally r
ecommended after
stenting of unprotected LMCA stenosis.
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Elective Double Stenting for Left Main Coronary
Artery Bifurcation Lesions: Patient Selection
and Technique
Azeem Latib, Alaide Chieffo, and Antonio Colombo
Interventional Cardiology Unit, San Raffaele Scientific Institute, and Interventional Cardiology Unit, EMO-GVM
Centro Cuore Columbus, Milan, Italy
INTRODUCTION
Percutaneous coronary intervention (PCI) on the left main coronary artery (LMCA) has been a
challenge since the inceptionof coronary angioplasty. In fact, in 1979,Andreas Gruentzig wrote,
“We have not been too successful in dilating stenotic main stems of left coronary arteries” (1).
Indeed the poor immediate and short-term outcome of the first attempts of PCI with balloon
angioplasty led Gruentzig to list LMCA as an exclusion criterion forelective PCI. However, PCI
for the LMCA has come a long way from those days and is currently associated with shortand medium-term survival rates similar to coronary artery bypass surgery (CABG) (2–6). This
dramatic change and improved results are consequences of the evolution and development of
PCI techniques, especially in regards to bifurcations, improvements in hemodynamic support
during PCI, and the introduction of drug-eluting stents (DES). LMCA PCI has also become the
object of randomized trials such as the Synergy between Percutaneous Coronary Intervention
with TAXUS andCardiacSurgery (SYNTAX) Study, whichshowed similarmajor adversecardiac
and cerebrovascular events at 12 months in the LMCA subgroup between PCI with DES and
CABG (4). As a result these new data, the update current guidelines no longer consider PCI for
unprotected LMCA as a Class III recommendation (contraindication) if the patient is eligible
for CABG (7,8). The ACC/AHA/SCAI 2009 updated guidelines (9) have modified the class of
recommendationfor PCIto unprotectedLMCA toClass IIb(Level ofEvidence: B), explaining the
recommendation as follows: “PCI of the left main coronary artery with stents as an alternative
to CABG may be considered in patients with anatomic conditions that are associated with a
low risk of PCI procedural complications and clinical conditions that predict an increased risk
of adverse surgical outcomes.”
A distinction needs to be made between lesions involving the
those involving the bifurcation.
to those seen with CABG (10). An important limitation to PCI is that the majority of LMCA
lesions treatedare locatedin thedistal LMCA bifurcation,which hasbeen shownto beassociated
with worse clinical outcomes (11) and for whichwe still do nothave an ideal stentingapproach.
However, in LMCA bifurcation disease, results are very much dependent on patient selection
and optimal technique. The next important distinction that needs to be made is that LMCA
bifurcation intervention differs significantly from non-LMCA bifurcations in that there is a
larger area of myocardium at jeopardy; there is less room for error during the procedure; the
vessels are larger; the side branch (SB) is as important as the main branch (MB) regarding both
the size and territory of distribution; and the operator is less likely to accept a suboptimal
result in the SB.
bifurcations unless located on the LMCA where this percentage may go up to 50% (12). For
purposes of nomenclature and clarity, we generally consider the left anterior descending artery
(LAD) the MB, and the left circumflex artery (LCX) or ramus intermediate (RI) branch as the SB
even though both branches may be of the same size and importance.
At the outset, we should state that there are no randomized trials of bifurcation strategies
specifically performed in LMCA disease. As with all bifurcation PCI, there is no single strategy
that can be applied to every bifurcation. Bifurcations vary not only in anatomy (plaque burden,
Current approaches may require two stents in about 30% of true non–left main
1
ostium or midshaft and
In nonbifurcation lesions, results are excellent and comparable
1
There are no potential conflicts of interest or funding sources to disclose.
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