EXCEL Sub-Study: The Site of the Left Main Coronary Artery Lesion Does Not Alter History

The EXCEL study, originally presented at TCT 2016 and published simultaneously in the New England Journal of Medicine (NEJM), showed that angioplasty and surgery in patients with left main coronary artery disease have similar rates of mortality, infarction, and stroke at 3 years.

This sub-study, recently published in J Am Coll Cardiol Intv, adds that the site of the left main coronary artery lesion (ostial, shaft, or bifurcation lesion) does not alter the outcomes of the overall study. An important detail: the EXCEL trial (unlike almost all studies carried out in these last years) did not include revascularization in its primary endpoint; only death, infarction, and stroke.

Revascularization was analyzed as a secondary endpoint and offered no surprises: clinically-driven revascularization was more frequent in patients with distal lesions, but it was similar to surgery in patients with ostial or shaft lesions.

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About 84.2% (n = 1559) of patients experienced distal bifurcation lesions vs. 15.8% (n = 293) who presented isolated ostial or shaft lesions.

At 3 years, there were no significant differences between angioplasty and surgery in the composite primary endpoint of death, infarction, and stroke regarding both the distal segment (15.6% vs. 14.9%; odds ratio [OR]: 1.08; 95% confidence interval [CI]: 0.81 to 1.42; p = 0.61) and isolated ostial or shaft lesions (12.4% vs. 13.5 %; OR: 0.90; 95% CI: 0.45 to 1.81; p = 0.77) (p for interaction = 0.65).

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Ischemia-driven revascularization was more frequent in patients who underwent angioplasty when the lesion was located in the distal segment of the left main coronary artery (13.0% vs. 7.2%; OR: 2.00; p = 0.0001), but there was no difference between both revascularization strategies in patients with ostial or shaft lesions (9.7% vs. 8.4%; OR: 1.18; p = 0.68).

Conclusion

In the EXCEL study, angioplasty and surgery were comparable in terms of death, infarction, or stroke at three years in patients with left main coronary artery lesions, including those with distal bifurcation lesions. Repeat revascularization during follow-up was more frequent after angioplasty in patients with distal lesions, but not in patients with shaft or ostial lesions.

Original title: Outcomes After Left Main Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting According to Lesion Site. Results from the EXCEL Trial.

Reference: Anthony H. Gershlick et al. J Am Coll Cardiol Intv 2018;11:1224-33.

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