Left Main PCI: Despite Auspicious Long-Term Outcomes, Optimal Strategy Still under Discussion

Left main coronary artery bifurcation interventions have shown very good results at long term, especially with new generation DES. The one-stent strategy has seen better results than the two-stent strategy, according to this registry recently published in J Am Coll Cardiol Intv. However, how does this registry of the daily practice between the years 2002 and 2013 impact the daily practice in 2018?

Multiple studies have compared different two-stent techniques to treat bifurcations, but the first to consider the provisional stent technique for all patients was the SMART-STRATEGY trial (randomization was after stent implantation in the main branch), published in 2012, in J Am Coll Cardiol Intv.

This study at 3 years provided us with more aggressive criteria, or more conservative, to salvage the side branch, but always with an initial provisional stent strategy. The SMART-STRATEGY of course included patients with left main lesions. For about 5 years, the left main coronary artery seemed simply the largest bifurcation, but at TCT 2017 the DKCRUSH-V was presented and simultaneously published in J Am Coll Cardiol, showing the two-stent technique was superior to provisional stenting, and we had to reconsider. Literature, technique and devices are constantly being advanced, and we need to keep up.

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

The present registry (with all of registries’ virtues and limitations) assessed the long-term outcomes of left main PCI, focusing on the kind of stent and, of course, the optimal technique to treat bifurcations.

The registry included 1353 ‘real life’ patients treated with different techniques and with different generation stents. Primary endpoint was a composite of cardiac death, infarction, stent thrombosis and target vessel revascularization at 3 years. Patient characteristics were adjusted using propensity score.

The one-stent strategy had better clinical results than the two-stent strategy (4.7% vs. 18.6%, HR: 3.71; CI 95%: 2.55 to 5.39; p < 0.001) and new generation DES had better results than old DES (4.6% vs. 10.9%, HR: 0.55; CI 95%: 0.34 to 0.89; p=0.014). The difference between DES generations was more obvious when using the 2 stent technique. For patients with contemporary DES, the presence of kidney failure and preintervention side branch ≥50% diameter stenosis were independent predictors of major events.

Read also: Post-Dilation in Valve-in-Valve Implantation Offers Hemodynamic Improvement.

Meanwhile, the DKCRUSH-V sub-studies are coming out and of course we look forward to seeing their long terms outcomes (so far, we only have data at one year).

Original title: Long-Term Clinical Outcomes and Optimal Stent Strategy in Left Main Coronary Bifurcation Stenting.

Reference: Sungsoo Cho et al. J Am Coll Cardiol Intv 2018;11:1247–58.

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