Original Title: Angiographic and Clinical Outcomes After Everolimus-Eluting Stenting for Unprotected Left Main Disease and High Anatomic Coronary Complexity.
Reference: JACC Cardiovascular Interventions. Doi: 10.1016/j.jcin.2016.02.016.
Courtesy of Dr. Agustín Vecchia.
In patients with unprotected left main disease (ULMD) associated to complex coronary anatomy, choosing a revascularization strategy can be challenging.
Current guidelines recommend surgery for these patients based mainly on the Syntax trial. It has been hypothesized that using the latest generation stents in the Syntax would have significantly reduced the number of events.
The aim of this study was to compare outcomes after PCI for ULMD in patients with SYNTAX score (SS) ≥ 33 vs. patients with SS < 33. It included patients from the city of Florence, from May 2008 to July 2014.
393 patients received everolimus eluting stents (EES):
- 181 had ≥ 33 SS.
- 212 had < 33 SS.
Overall, restenosis rate was 4.9%:
p=0.399
- 6% in patients with ≥ 33 SS.
- 4.1% in those with < a 33 SS.
In multivariable analysis, the only variable associated to restenosis was stent length (odds ratio [OR]: 1.06; 95% confidence interval [CI]: 1.02 to 1.09; p=0.002).
Survival at 3 years in patients with EuroSCORE < 6 was:
- 99 +- 1% in subgroups with < 33 SS.
- 98 +- 2% in subgroups with ≥ 33 SS.
In the group with EuroSCORE > 6 survival was:
- 90 +- 3% in subgroups with < 33 SS
- 87+- 3% in subgroups with ≥ 33 SS.
Conclusion
The authors conclude that complex coronary anatomy defined by SS does not predict clinical outcomes in patients with unprotected left main disease.
Editorial Comment
One of the reasons behind current class III recommendations for PCI in ULMD with complex coronary anatomy (SS ≥ 33) was the high rate of new revascularizations per year (17%) observed in the original Syntax study.
When comparing the present outcomes against those of the original Syntax trial, we see:
- Higher rate of complete revascularization (only 52% in the original study).
- Higher success rate of chronic total occlusion (technical retrograde and subintimal) and complex lesions.
- Better performance of drug eluting stents as regards restenosis.
On the downside, this is an observational study and, despite adjustments, there may be confounders unaccounted for.
This is a study from a monocentric registry of an experienced group with very good outcomes in CTO and high percentage of patients with complete revascularization.
The fact that these advances have rendered the Syntax obsolete, is yet to be determined by a randomized study on these kind of patients.
To conclude, complex coronary anatomy (SS > 33) in patients with ULND may not play against PCI, especially if we can achieve complete revascularization, as long as we use the newest generation stents.
Courstesy of Dr Agustín Vecchia. German Hospital, Buenos Aires, Argentina.
