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Vol 80, No 4 (2022)
Review paper
Published online: 2022-03-24
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Percutaneous coronary intervention to treat unprotected left main: Common (un-answered) challenges

Mila Kovacevic12, Francesco Burzotta34, Ilija Srdanovic12, Milovan Petrovic12, Carlo Trani34
DOI: 10.33963/KP.a2022.0078
·
Pubmed: 35545858
·
Kardiol Pol 2022;80(4):417-428.
Affiliations
  1. Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
  2. Institute of Cardiovascular Diseases of Vojvodina, Cardiology Clinic, Sremska Kamenica, Serbia
  3. Dipartimento di Scienze Cardiovascolari, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
  4. Università Cattolica del Sacro Cuore, Rome, Italy

open access

Vol 80, No 4 (2022)
Review
Published online: 2022-03-24

Abstract

Percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation is a widely adopted strategy to obtain myocardial revascularization in patients with unprotected left main (LM) disease. Although thoroughly investigated across scientific literature, LM PCI offers patient-specific technical options and poses many operative challenges that cannot be fully addressed by the pub-lished studies. Therefore, we have summarized and discussed in this review possible options related to PCI in LM patients. First, functional and imaging assessment for LM is still evolving and requires increased dedication to identify patients requiring revascularization and to enhance the results in the case of PCI performance. Second, specific coronary atherosclerosis patterns of LM involvement (like an isolated ostial disease of one of its bifurcation branches, extensive disease jeopardizing both branches, etc.) pose specific challenges for DES implantation so that careful selection of technical options (stepwise provisional single stent, upfront 2-stent strategy, when and how apply “kissing ballooning”) is required. Third, despite improvement of techniques, PCI-related ischemia might not be tolerated by some patients with LM disease so mechanical circulatory support devices may come into play.

Abstract

Percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation is a widely adopted strategy to obtain myocardial revascularization in patients with unprotected left main (LM) disease. Although thoroughly investigated across scientific literature, LM PCI offers patient-specific technical options and poses many operative challenges that cannot be fully addressed by the pub-lished studies. Therefore, we have summarized and discussed in this review possible options related to PCI in LM patients. First, functional and imaging assessment for LM is still evolving and requires increased dedication to identify patients requiring revascularization and to enhance the results in the case of PCI performance. Second, specific coronary atherosclerosis patterns of LM involvement (like an isolated ostial disease of one of its bifurcation branches, extensive disease jeopardizing both branches, etc.) pose specific challenges for DES implantation so that careful selection of technical options (stepwise provisional single stent, upfront 2-stent strategy, when and how apply “kissing ballooning”) is required. Third, despite improvement of techniques, PCI-related ischemia might not be tolerated by some patients with LM disease so mechanical circulatory support devices may come into play.

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Keywords

left main bifurcation, PCI, ostial disease, and stenting techniques

About this article
Title

Percutaneous coronary intervention to treat unprotected left main: Common (un-answered) challenges

Journal

Kardiologia Polska (Polish Heart Journal)

Issue

Vol 80, No 4 (2022)

Article type

Review paper

Pages

417-428

Published online

2022-03-24

Page views

333

Article views/downloads

218

DOI

10.33963/KP.a2022.0078

Pubmed

35545858

Bibliographic record

Kardiol Pol 2022;80(4):417-428.

Keywords

left main bifurcation
PCI
ostial disease
and stenting techniques

Authors

Mila Kovacevic
Francesco Burzotta
Ilija Srdanovic
Milovan Petrovic
Carlo Trani

References (81)
  1. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019; 40(2): 87–165.
  2. Isner JM, Kishel J, Kent KM, et al. Accuracy of angiographic determination of left main coronary arterial narrowing. Angiographic-histologic correlative analysis in 28 patients. Circulation. 1981; 63(5): 1056–1064.
  3. Toth G, Hamilos M, Pyxaras S, et al. Evolving concepts of angiogram: fractional flow reserve discordances in 4000 coronary stenoses. Eur Heart J. 2014; 35(40): 2831–2838.
  4. Patel P, Rao R, Sethi P, et al. Functional assessment of coronary artery lesions-old and new kids on the block. Int J Angiol. 2021; 30(1): 40–47.
  5. Modi BN, van de Hoef TP, Piek JJ, et al. Physiological assessment of left main coronary artery disease. EuroIntervention. 2017; 13(7): 820–827.
  6. Milasinovic D, Stankovic G. Towards a common pathway for the treatment of left main disease: contemporary evidence and future directions: Left main disease treatment. AsiaIntervention. 2021; 7(2): 85–95.
  7. Warisawa T, Cook CM, Rajkumar C, et al. Safety of revascularization deferral of left main stenosis based on instantaneous wave-free ratio evaluation. JACC Cardiovasc Interv. 2020; 13(14): 1655–1664.
  8. Layland J, Oldroyd KG, Curzen N, et al. FAMOUS–NSTEMI investigators. Fractional flow reserve vs. angiography in guiding management to optimize outcomes in non-ST-segment elevation myocardial infarction: the British Heart Foundation FAMOUS-NSTEMI randomized trial. Eur Heart J. 2015; 36(2): 100–111.
  9. Nam CW, Hur SH, Koo BK, et al. Fractional flow reserve versus angiography in left circumflex ostial intervention after left main crossover stenting. Korean Circ J. 2011; 41(6): 304–307.
  10. de la Torre Hernandez JM, Hernández Hernandez F, Alfonso F, et al. LITRO Study Group (Spanish Working Group on Interventional Cardiology). Prospective application of pre-defined intravascular ultrasound criteria for assessment of intermediate left main coronary artery lesions results from the multicenter LITRO study. J Am Coll Cardiol. 2011; 58(4): 351–358.
  11. Mintz GS, Lefèvre T, Lassen JF, et al. Intravascular ultrasound in the evaluation and treatment of left main coronary artery disease: a consensus statement from the European Bifurcation Club. EuroIntervention. 2018; 14(4): e467–e474.
  12. de la Torre Hernandez JM, Garcia Camarero T, Baz Alonso JA, et al. Outcomes of predefined optimisation criteria for intravascular ultrasound guidance of left main stenting. EuroIntervention. 2020; 16(3): 210–217.
  13. Prati F, Guagliumi G, Mintz GS, et al. Expert's OCT Review Document. Expert review document part 2: methodology, terminology and clinical applications of optical coherence tomography for the assessment of interventional procedures. Eur Heart J. 2012; 33(20): 2513–2520.
  14. Radu MD, Räber L, Heo J, et al. Natural history of optical coherence tomography-detected non-flow-limiting edge dissections following drug-eluting stent implantation. EuroIntervention. 2014; 9(9): 1085–1094.
  15. Burzotta F, Dato I, Trani C, et al. Frequency domain optical coherence tomography to assess non-ostial left main coronary artery. EuroIntervention. 2015; 10(9): e1–e8.
  16. Dato I, Burzotta F, Trani C, et al. Optical coherence tomography guidance for the management of angiographically intermediate left main bifurcation lesions: Early clinical experience. Int J Cardiol. 2017; 248: 108–113.
  17. Cortese B, Burzotta F, Alfonso F, et al. Role of optical coherence tomography for distal left main stem angioplasty. Catheter Cardiovasc Interv. 2020; 96(4): 755–761.
  18. Amabile N, Rangé G, Souteyrand G, et al. Optical coherence tomography to guide percutaneous coronary intervention of the left main coronary artery: the LEMON study. EuroIntervention. 2021; 17(2): e124–e131.
  19. Cortese B, de la Torre Hernandez JM, Lanocha M, et al. Optical coherence tomography, intravascular ultrasound or angiography guidance for distal left main coronary stenting. The ROCK cohort II study. Catheter Cardiovasc Interv. 2022; 99(3): 664–673.
  20. Oviedo C, Maehara A, Mintz GS, et al. Intravascular ultrasound classification of plaque distribution in left main coronary artery bifurcations: where is the plaque really located? Circ Cardiovasc Interv. 2010; 3(2): 105–112.
  21. Medina A, Martín P, Suárez de Lezo J, et al. Vulnerable carina anatomy and ostial lesions in the left anterior descending coronary artery after floating-stent treatment. Rev Esp Cardiol. 2009; 62(11): 1240–1249.
  22. Suárez de Lezo J, Medina A, Martín P, et al. Predictors of ostial side branch damage during provisional stenting of coronary bifurcation lesions not involving the side branch origin: an ultrasonographic study. EuroIntervention. 2012; 7(10): 1147–1154.
  23. Szabo S, Abramowitz B, Vaitkus P. New technique for aorto-ostial stent placement. Am J Cardiol. 2005; 96: 212H.
  24. Chen GC, Lu XM, Song YM, et al. A 3-year experience of a simple, novel technique for accurate ostial/non-ostial coronary stenting: The buddy balloon anchor stent technique. Catheter Cardiovasc Interv. 2018; 92(6): 1147–1152.
  25. Mallek K, Dalton RT, Pareek N, et al. Rapid transcoronary pacing to facilitate ostial stent placement. JACC Cardiovasc Interv. 2021; 14(10): e111–e112.
  26. Rigatelli G, Zuin M, Baracca E, et al. Long-term clinical outcomes of isolated ostial left anterior descending disease treatment: ostial stenting versus left main cross-over stenting. Cardiovasc Revasc Med. 2019; 20(12): 1058–1062.
  27. Yang ZK, Hu J, Ding FH, et al. One-year outcome of single-stent crossover versus accurate ostial stenting for isolated left anterior descending ostial stenosis. Coron Artery Dis. 2022; 31(1): e67–e72.
  28. Burzotta F, Lassen JF, Louvard Y, et al. European Bifurcation Club white paper on stenting techniques for patients with bifurcated coronary artery lesions. Catheter Cardiovasc Interv. 2020; 96(5): 1067–1079.
  29. Dérimay F, Rioufol G, Nishi T, et al. Optimal balloon positioning for the proximal optimization technique? An experimental bench study. Int J Cardiol. 2019; 292: 95–97.
  30. Zhong M, Tang B, Zhao Q, et al. Should kissing balloon inflation after main vessel stenting be routine in the one-stent approach? A systematic review and meta-analysis of randomized trials. PLoS One. 2018; 13(6): e0197580.
  31. Liu G, Ke X, Huang ZB, et al. Final kissing balloon inflation for coronary bifurcation lesions treated with single-stent technique: A meta-analysis. Herz. 2019; 44(4): 354–362.
  32. Kini AS, Dangas GD, Baber U, et al. Influence of final kissing balloon inflation on long-term outcomes after PCI of distal left main bifurcation lesions in the EXCEL trial. EuroIntervention. 2020; 16(3): 218–224.
  33. Lee C, Nam CW, Cho YK, et al. 5-year outcome of simple crossover stenting in coronary bifurcation lesions compared with side branch opening. JACC: Asia. 2021; 1(1): 53–64.
  34. Chevalier B, Mamas MA, Hovasse T, et al. Clinical outcomes of the proximal optimisation technique (POT) in bifurcation stenting. EuroIntervention. 2021; 17(11): e910–e918.
  35. Burzotta F, Trani C. In bifurcation PCI, as in everyday life, the consequences of kissing may not always be the same. EuroIntervention. 2016; 11(11): e1209–e1213.
  36. Gaido L, D'Ascenzo F, Imori Y, et al. Impact of kissing balloon in patients treated with ultrathin stents for left main lesions and bifurcations: an analysis from the RAIN-CARDIOGROUP VII study. Circ Cardiovasc Interv. 2020; 13(3): e008325.
  37. Burzotta F, Lassen JF, Lefèvre T, et al. Percutaneous coronary intervention for bifurcation coronary lesions: the 15 consensus document from the European Bifurcation Club. EuroIntervention. 2021; 16(16): 1307–1317.
  38. Finet G, Derimay F, Motreff P, et al. Comparative analysis of sequential proximal optimizing technique versus kissing balloon inflation technique in provisional bifurcation stenting: fractal coronary bifurcation bench test. JACC Cardiovasc Interv. 2015; 8(10): 1308–1317.
  39. Derimay F, Finet G, Souteyrand G, et al. Benefit of a new provisional stenting strategy, the re-proximal optimisation technique: the rePOT clinical study. EuroIntervention. 2018; 14(3): e325–e332.
  40. Murasato Y, Finet G, Foin N. Final kissing balloon inflation: the whole story. EuroIntervention. 2015; 11 Suppl V: V81–V85.
  41. Kovacevic M, Burzotta F, Elharty S, et al. Left main trifurcation and its percutaneous treatment: what is known so far? Circ Cardiovasc Interv. 2021; 14(3): e009872.
  42. Ford TJ, McCartney P, Corcoran D, et al. Single- versus 2-stent strategies for coronary bifurcation lesions: a systematic review and meta-analysis of randomized trials with long-term follow-up. J Am Heart Assoc. 2018; 7(11): e008730.
  43. Chen SL, Zhang JJ, Han Y, et al. Double kissing crush versus provisional stenting for left main distal bifurcation lesions: DKCRUSH-V randomized trial. J Am Coll Cardiol. 2017; 70(21): 2605–2617.
  44. Hildick-Smith D, Egred M, Banning A, et al. The European Bifurcation Club Left Main Coronary Stent study: a randomized comparison of stepwise provisional vs. systematic dual stenting strategies (EBC MAIN). Eur Heart J. 2021; 42(37): 3829–3839.
  45. Medina A, Lezo JS, Pan M. A new classification of coronary bifurcation lesions. Rev Esp Cardiol. 2006; 59(2): 183.
  46. Burzotta F, Lassen JF, Banning AP, et al. Percutaneous coronary intervention in left main coronary artery disease: the 13th consensus document from the European Bifurcation Club. EuroIntervention. 2018; 14(1): 112–120.
  47. Chen SL, Sheiban I, Xu Bo, et al. Impact of the complexity of bifurcation lesions treated with drug-eluting stents: the DEFINITION study (Definitions and impact of complEx biFurcation lesIons on clinical outcomes after percutaNeous coronary IntervenTIOn using drug-eluting steNts). JACC Cardiovasc Interv. 2014; 7(11): 1266–1276.
  48. Chen SL, Santoso T, Zhang JJ, et al. Clinical outcome of double kissing crush versus provisional stenting of coronary artery bifurcation lesions: the 5-year follow-up results from a randomized and multicenter DKCRUSH-II study (randomized study on double kissing crush technique versus provisional stenting technique for coronary artery bifurcation lesions). Circ Cardiovasc Interv. 2017; 10(2): e004497.
  49. Christofferson RD, Lehmann KG, Martin GV, et al. Effect of chronic total coronary occlusion on treatment strategy. Am J Cardiol. 2005; 95(9): 1088–1091.
  50. Capodanno D, Di Salvo ME, Tamburino C. Impact of right coronary artery disease on mortality in patients undergoing percutaneous coronary intervention of unprotected left main coronary artery disease. EuroIntervention. 2010; 6(4): 454–460.
  51. Migliorini A, Valenti R, Parodi G, et al. The impact of right coronary artery chronic total occlusion on clinical outcome of patients undergoing percutaneous coronary intervention for unprotected left main disease. J Am Coll Cardiol. 2011; 58(2): 125–130.
  52. Takagi K, Ielasi A, Chieffo A, et al. Impact of residual chronic total occlusion of right coronary artery on the long-term outcome in patients treated for unprotected left main disease: the Milan and New-Tokyo registry. Circ Cardiovasc Interv. 2013; 6(2): 154–160.
  53. Skorupski WJ, Grygier M, Araszkiewicz A, et al. The impact of right coronary artery support on outcomes of patients with unprotected left main disease undergoing percutaneous coronary intervention. Kardiol Pol. 2021; 79(6): 631–637.
  54. Lee CH, Chong SZ, Hsueh SK, et al. Residual right coronary artery stenosis after left main coronary artery intervention increased the 30-day cardiovascular death and 3-year right coronary artery revascularization rate. J Interv Cardiol. 2020; 2020: 4587414.
  55. Burzotta F, Crea F. "Protected" PCI: time to act. Minerva Cardioangiol. 2018; 66(5): 547–550.
  56. Burzotta F, Kovacevic M, Trani C. Right coronary artery patency as a modulator for unprotected left main PCI risk: myth or reality? Kardiol Pol. 2021; 79(6): 609–611.
  57. Aurigemma C, Burzotta F, Chieffo A, et al. IMP-IT Investigators. Clinical impact of revascularization extent in patients undergoing impella-protected PCI enrolled in a nationwide registry. JACC Cardiovasc Interv. 2021; 14(6): 717–719.
  58. Chieffo A, Dudek D, Hassager C, et al. Joint EAPCI/ACVC expert consensus document on percutaneous ventricular assist devices. EuroIntervention. 2021; 17(4): e274–e286.
  59. Gaba P, Gersh BJ, Ali ZA, et al. Complete versus incomplete coronary revascularization: definitions, assessment and outcomes. Nat Rev Cardiol. 2021; 18(3): 155–168.
  60. Xu Bo, Redfors B, Yang Y, et al. Impact of operator experience and Volume on outcomes after left main coronary artery percutaneous coronary intervention. JACC Cardiovasc Interv. 2016; 9(20): 2086–2093.
  61. Song YB, Hahn JY, Yang JH, et al. Differential prognostic impact of treatment strategy among patients with left main versus non-left main bifurcation lesions undergoing percutaneous coronary intervention: results from the COBIS (Coronary Bifurcation Stenting) Registry II. JACC Cardiovasc Interv. 2014; 7(3): 255–263.
  62. Niemelä M, Kervinen K, Erglis A, et al. Nordic-Baltic PCI Study Group. Randomized comparison of final kissing balloon dilatation versus no final kissing balloon dilatation in patients with coronary bifurcation lesions treated with main vessel stenting: the Nordic-Baltic Bifurcation Study III. Circulation. 2011; 123(1): 79–86.
  63. Nishida K, Toyofuku M, Morimoto T, et al. AOI LMCA Stenting Registry Investigators. Prognostic impact of final kissing balloon technique after crossover stenting for the left main coronary artery: from the AOI-LMCA registry. Cardiovasc Interv Ther. 2019; 34(3): 197–206.
  64. Song YB, Hahn JY, Song PS, et al. Randomized comparison of conservative versus aggressive strategy for provisional side branch intervention in coronary bifurcation lesions: results from the SMART-STRATEGY (Smart Angioplasty Research Team-Optimal Strategy for Side Branch Intervention in Coronary Bifurcation Lesions) randomized trial. JACC Cardiovasc Interv. 2012; 5(11): 1133–1140.
  65. Pan M, Medina A, Suárez de Lezo J, et al. Coronary bifurcation lesions treated with simple approach (from the Cordoba & Las Palmas [CORPAL] Kiss Trial). Am J Cardiol. 2011; 107(10): 1460–1465.
  66. Ahn JM, Lee PH, Park DW, et al. Benefit of final kissing balloon inflation mandatory after simple crossover stenting for left main bifurcation narrowing. Am J Cardiol. 2017; 119(4): 528–534.
  67. Gao Z, Xu Bo, Yang YJ, et al. Effect of final kissing balloon dilatation after one-stent technique at left-main bifurcation: a single center data. Chin Med J (Engl). 2015; 128(6): 733–739.
  68. Biondi-Zoccai G, Sheiban I, De Servi S, et al. To kiss or not to kiss? Impact of final kissing-balloon inflation on early and long-term results of percutaneous coronary intervention for bifurcation lesions. Heart Vessels. 2014; 29(6): 732–742.
  69. Hariki H, Shinke T, Otake H, et al. Potential benefit of final kissing balloon inflation after single stenting for the treatment of bifurcation lesions-insights from optical coherence tomography observations. Circ J. 2013; 77(5): 1193–1201.
  70. Maeng M, Holm NR, Erglis A, et al. Nordic-Baltic Percutaneous Coronary Intervention Study Group. Long-term results after simple versus complex stenting of coronary artery bifurcation lesions: Nordic Bifurcation Study 5-year follow-up results. J Am Coll Cardiol. 2013; 62(1): 30–34.
  71. Ferenc M, Gick M, Kienzle RP, et al. Randomized trial on routine vs. provisional T-stenting in the treatment of de novo coronary bifurcation lesions. Eur Heart J. 2008; 29(23): 2859–2867.
  72. Ferenc M, Ayoub M, Büttner HJ, et al. Long-term outcomes of routine versus provisional T-stenting for de novo coronary bifurcation lesions: five-year results of the Bifurcations Bad Krozingen I study. EuroIntervention. 2015; 11(8): 856–859.
  73. Kim YH, Lee JH, Roh JH, et al. Randomized comparisons between different stenting approaches for bifurcation coronary lesions with or without side branch stenosis. JACC Cardiovasc Interv. 2015; 8(4): 550–560.
  74. Kumsars I, Holm NR, Niemelä M, et al. Nordic Baltic bifurcation study group. Randomised comparison of provisional side branch stenting versus a two-stent strategy for treatment of true coronary bifurcation lesions involving a large side branch: the Nordic-Baltic Bifurcation Study IV. Open Heart. 2020; 7(1): e000947.
  75. Behan MW, Holm NR, de Belder AJ, et al. Coronary bifurcation lesions treated with simple or complex stenting: 5-year survival from patient-level pooled analysis of the Nordic Bifurcation Study and the British Bifurcation Coronary Study. Eur Heart J. 2016; 37(24): 1923–1928.
  76. Hildick-Smith D, de Belder AJ, Cooter N, et al. Randomized trial of simple versus complex drug-eluting stenting for bifurcation lesions: the British Bifurcation Coronary Study: old, new, and evolving strategies. Circulation. 2010; 121(10): 1235–1243.
  77. Hildick-Smith D, Behan MW, Lassen JF, et al. The EBC TWO study (European Bifurcation Coronary TWO): a randomized comparison of provisional t-stenting versus a systematic 2 stent culotte strategy in large caliber true bifurcations. Circ Cardiovasc Interv. 2016; 9(9): e003643.
  78. Song YB, Park TK, Hahn JY, et al. Optimal strategy for provisional side branch intervention in coronary bifurcation lesions: 3-year outcomes of the SMART-STRATEGY randomized trial. JACC Cardiovasc Interv. 2016; 9(6): 517–526.
  79. Chen SL, Santoso T, Zhang JJ, et al. Clinical outcome of double kissing crush versus provisional stenting of coronary artery bifurcation lesions: the 5-year follow-up results from a randomized and multicenter DKCRUSH-II study (randomized study on double kissing crush technique versus provisional stenting technique for coronary artery bifurcation lesions). Circ Cardiovasc Interv. 2017; 10(2): e004497.
  80. Ge L, Airoldi F, Iakovou I, et al. Clinical and angiographic outcome after implantation of drug-eluting stents in bifurcation lesions with the crush stent technique: importance of final kissing balloon post-dilation. J Am Coll Cardiol. 2005; 46(4): 613–620.
  81. Grundeken MJ, Lesiak M, Asgedom S, et al. Clinical outcomes after final kissing balloon inflation compared with no final kissing balloon inflation in bifurcation lesions treated with a dedicated coronary bifurcation stent. Heart. 2014; 100(6): 479–486.

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