Percutaneous coronary intervention left main coronary artery disease

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Overview

PCI Approaches:

CAD Revascularization:

Heart Team Approach to Revascularization Decisions
Left Main Coronary Artery Disease
Intervention in left main coronary artery disease
Non-Left Main Coronary Artery Disease
Revascularization to Improve Symptoms
Dual Antiplatelet Therapy Compliance and Stent Thrombosis
Hybrid Coronary Revascularization

Pre-procedural Considerations:

Contrast-Induced Acute Kidney Injury
Anaphylactoid Reactions
Statin Treatment
Bleeding Risk
Role of Onsite Surgical Backup

Procedural Considerations:

Vascular Access
PCI in Specific Clinical Situations:
Asymptomatic Ischemia or CCS Class I or II Angina
CCS Class III Angina
Unstable Angina/Non–ST-Elevation Myocardial Infarction
ST-Elevation Myocardial Infarction:
General and Specific Considerations
Coronary Angiography Strategies in STEMI
Primary PCI of the Infarct Artery
Delayed or Elective PCI in patients with STEMI
Fibrinolytic-Ineligible Patients
Facilitated PCI
Rescue PCI
After Successful Fibrinolysis or for Patients Not Undergoing Primary Reperfusion
Cardiogenic Shock
Prior Coronary Bypass Surgery
Revascularization Before Non-cardiac Surgery
Adjunctive Diagnostic Devices:
Fractional Flow Reserve
Intravascular Ultrasound
Adjunctive Therapeutic Devices:
Coronary Atherectomy
Thrombectomy
Laser Angioplasty
Cutting Balloon Angioplasty
Embolic Protection Devices
Percutaneous Hemodynamic Support Devices
Antiplatelet therapy:
Oral Antiplatelet Therapy
Glycoprotein IIb/IIIa Receptor Antagonists
Intravenous Antiplatelet therapy:
STEMI
UA/NSTEMI
SIHD
Anticoagulant Therapy:
Parenteral Anticoagulants During PCI
Unfractionated Heparin
Enoxaparin
Bivalirudin and Argatroban
Fondaparinux
No-Reflow Pharmacological Therapies
PCI in Specific Anatomic Situations:
Chronic Total Occlusions
Saphenous Vein Grafts
Bifurcation Lesions
Aorto-Ostial Stenoses
Calcified Lesions
PCI in Specific Patient Populations:
Chronic Kidney Disease
Peri-procedural Myocardial Infarction Assessment
Vascular Closure Devices

Post-Procedural Considerations:

Post-procedural Antiplatelet Therapy
Proton Pump Inhibitors and Antiplatelet Therapy
Clopidogrel Genetic Testing
Platelet Function Testing
Restenosis
Exercise Testing
Cardiac Rehabilitation

Quality and Performance Considerations:

Quality and Performance
Certification and Maintenance of Certification
Operator and Institutional Competency and Volume

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [12]

2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[1]

Revascularization to Improve Survival in Left Main Coronary Artery Disease (DO NOT EDIT)[1]

Class I
"1. CABG to improve survival is recommended for patients with significant (≥50% diameter stenosis) left main coronary artery stenosis (Level of Evidence: B)"
Class III (Harm)

"1. PCI to improve survival should not be performed in stable patients with significant (greater than or equal to 50% diameter stenosis) unprotected left main CAD who have unfavorable anatomy for PCI and who are good candidates for CABG. [2][3][4][5][6][7][8][9][10][11] (Level of Evidence: B)"

Class IIa

"1. PCI to improve survival is reasonable as an alternative to CABG in selected stable patients with significant (greater than or equal to 50% diameter stenosis) unprotected left main CAD with:

a. Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (e.g., a low SYNTAX score [lower than or equal to 22], ostial or trunk left main CAD); and (Level of Evidence: B)
b. Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., Society of Thoracic Surgeons–predicted risk of operative mortality 5%). [2][3][4][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] (Level of Evidence: B)"

"2. PCI to improve survival is reasonable in patients with UA/NSTEMI when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG. [4][18][30][20][21][26][27][28][29][31] (Level of Evidence: B)"

"3. PCI to improve survival is reasonable in patients with acute STEMI when an unprotected left main coronary artery is the culprit lesion, distal coronary flow is less than TIMI (Thrombolysis In Myocardial Infarction) grade 3, and PCI can be performed more rapidly and safely than CABG. [15][32][33] (Level of Evidence: C)"

Class IIb

"1. PCI to improve survival may be reasonable as an alternative to CABG in selected stablepatients with significant (greater than or equal to 50% diameter stenosis) unprotected left main CAD with:

a. Anatomic conditions associated with a low to intermediate risk of PCI procedural complicationsand an intermediate to high likelihood of good long-term outcome (e.g., low-intermediateSYNTAX score of lower than 33, bifurcation left main CAD); and (Level of Evidence: B)
b. Clinical characteristics that predict an increased risk of adverse surgical outcomes (e.g., moderate-severe chronic obstructive pulmonary disease, disability from previous stroke, or previous cardiac surgery; Society of Thoracic Surgeons–predicted risk of operative mortality greater than 2%). [2][3][4][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][34] (Level of Evidence: B)"

References

  1. ↑ 1.0 1.1 Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions" (PDF). Journal of the American College of Cardiology. 58 (24): 2550–83. doi:10.1016/j.jacc.2011.08.006. PMID 22070837. Retrieved 2011-12-08. Text "PDF" ignored (help); Unknown parameter |month= ignored (help)
  2. ↑ 2.0 2.1 2.2 Chakravarty T, Buch MH, Naik H, White AJ, Doctor N, Schapira J et al. (2011)Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization. Am J Cardiol 107 (3):360-6. DOI:10.1016/j.amjcard.2010.09.029 PMID:21256999
  3. ↑ 3.0 3.1 3.2 Kim YH, Park DW, Kim WJ, Lee JY, Yun SC, Kang SJ et al. (2010) Validation of SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score for prediction of outcomes after unprotected left main coronary revascularization. JACC Cardiovasc Interv 3 (6):612-23.DOI:10.1016/j.jcin.2010.04.004 PMID:20630454
  4. ↑ 4.0 4.1 4.2 4.3 Morice MC, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A et al. (2010)Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation 121 (24):2645-53.DOI:10.1161/CIRCULATIONAHA.109.899211 PMID:20530001
  5. ↑ Caracciolo EA, Davis KB, Sopko G, Kaiser GC, Corley SD, Schaff H et al. (1995) Comparison of surgical and medical group survival in patients with left main coronary artery disease. Long-term CASS experience. Circulation 91 (9):2325-34. PMID: 7729018
  6. ↑ Chaitman BR, Fisher LD, Bourassa MG, Davis K, Rogers WJ, Maynard C et al. (1981)Effect of coronary bypass surgery on survival patterns in subsets of patients with left main coronary artery disease. Report of the Collaborative Study in Coronary Artery Surgery (CASS). Am J Cardiol 48 (4):765-77. PMID:7025604
  7. ↑ Dzavik V, Ghali WA, Norris C, Mitchell LB, Koshal A, Saunders LD et al. (2001)Long-term survival in 11,661 patients with multivessel coronary artery disease in the era of stenting: a report from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators. Am Heart J142 (1):119-26. DOI:10.1067/mhj.2001.116072 PMID:11431667
  8. ↑ Takaro T, Hultgren HN, Lipton MJ, Detre KM (1976) The VA cooperative randomized study of surgery for coronary arterial occlusive disease II. Subgroup with significant left main lesions.Circulation 54 (6 Suppl):III107-17. PMID: 791537
  9. ↑ Takaro T, Peduzzi P, Detre KM, Hultgren HN, Murphy ML, van der Bel-Kahn J et al. (1982) Survival in subgroups of patients with left main coronary artery disease. Veterans Administration Cooperative Study of Surgery for Coronary Arterial Occlusive Disease. Circulation 66 (1):14-22. PMID: [1]
  10. ↑ Taylor HA, Deumite NJ, Chaitman BR, Davis KB, Killip T, Rogers WJ (1989) Asymptomatic left main coronary artery disease in the Coronary Artery Surgery Study (CASS) registry. Circulation 79 (6):1171-9. PMID:2785870
  11. ↑ Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW et al. (1994) Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 344 (8922):563-70. PMID: [2]
  12. ↑ 12.0 12.1 Kappetein AP, Feldman TE, Mack MJ, Morice MC, Holmes DR, Ståhle E et al. (2011)Comparison of coronary bypass surgery with drug-eluting stenting for the treatment of left main and/or three-vessel disease: 3-year follow-up of the SYNTAX trial. Eur Heart J 32 (17):2125-34. [3] PMID: 21697170
  13. ↑ 13.0 13.1 Capodanno D, Caggegi A, Miano M, Cincotta G, Dipasqua F, Giacchi G et al. (2011)Global risk classification and clinical SYNTAX (synergy between percutaneous coronary intervention with TAXUS and cardiac surgery) score in patients undergoing percutaneous or surgical left main revascularization. JACC Cardiovasc Interv 4 (3):287-97. DOI:10.1016/j.jcin.2010.10.013PMID: 21435606
  14. ↑ 14.0 14.1 Hannan EL, Wu C, Walford G, Culliford AT, Gold JP, Smith CR et al. (2008)Drug-eluting stents vs. coronary-artery bypass grafting in multivessel coronary disease. N Engl J Med 358 (4):331-41.DOI:10.1056/NEJMoa071804 PMID: [4]
  15. ↑ 15.0 15.1 15.2 Ellis SG, Tamai H, Nobuyoshi M, Kosuga K, Colombo A, Holmes DR et al. (1997) Contemporary percutaneous treatment of unprotected left main coronary stenoses: initial results from a multicenter registry analysis 1994-1996.Circulation 96 (11):3867-72. PMID: 9403609
  16. ↑ 16.0 16.1 Biondi-Zoccai GG, Lotrionte M, Moretti C, Meliga E, Agostoni P, Valgimigli M et al. (2008) A collaborative systematic review and meta-analysis on 1278 patients undergoing percutaneous drug-eluting stenting for unprotected left main coronary artery disease. Am Heart J 155 (2):274-83.DOI:10.1016/j.ahj.2007.10.009 PMID:18215597
  17. ↑ 17.0 17.1 Boudriot E, Thiele H, Walther T, Liebetrau C, Boeckstegers P, Pohl T et al. (2011)Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis. J Am Coll Cardiol 57 (5):538-45.DOI:10.1016/j.jacc.2010.09.038 PMID:21272743
  18. ↑ 18.0 18.1 18.2 Brener SJ, Galla JM, Bryant R, Sabik JF, Ellis SG (2008) Comparison of percutaneous versus surgical revascularization of severe unprotected left main coronary stenosis in matched patients. Am J Cardiol 101 (2):169-72. [5] PMID: 18178401
  19. ↑ 19.0 19.1 Buszman PE, Kiesz SR, Bochenek A, Peszek-Przybyla E, Szkrobka I, Debinski M et al. (2008) Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization. J Am Coll Cardiol 51 (5):538-45.DOI:10.1016/j.jacc.2007.09.054 PMID:18237682
  20. ↑ 20.0 20.1 20.2 Chieffo A, Morici N, Maisano F, Bonizzoni E, Cosgrave J, Montorfano M et al. (2006)Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience.Circulation 113 (21):2542-7. [6] PMID: 16717151
  21. ↑ 21.0 21.1 21.2 Lee MS, Kapoor N, Jamal F, Czer L, Aragon J, Forrester J et al. (2006)Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease. J Am Coll Cardiol 47 (4):864-70. [7] PMID: 16487857
  22. ↑ 22.0 22.1 Mäkikallio TH, Niemelä M, Kervinen K, Jokinen V, Laukkanen J, Ylitalo I et al. (2008) Coronary angioplasty in drug eluting stent era for the treatment of unprotected left main stenosis compared to coronary artery bypass grafting. Ann Med 40 (6):437-43. DOI:10.1080/07853890701879790PMID: 18608116
  23. ↑ 23.0 23.1 Naik H, White AJ, Chakravarty T, Forrester J, Fontana G, Kar S et al. (2009)A meta-analysis of 3,773 patients treated with percutaneous coronary intervention or surgery for unprotected left main coronary artery stenosis.JACC Cardiovasc Interv 2 (8):739-47. [8] PMID: 19695542
  24. ↑ 24.0 24.1 Palmerini T, Marzocchi A, Marrozzini C, Ortolani P, Saia F, Savini C et al. (2006) Comparison between coronary angioplasty and coronary artery bypass surgery for the treatment of unprotected left main coronary artery stenosis (the Bologna Registry). Am J Cardiol 98 (1):54-9.DOI:10.1016/j.amjcard.2006.01.070 PMID:16784920
  25. ↑ 25.0 25.1 Park DW, Seung KB, Kim YH, Lee JY, Kim WJ, Kang SJ et al. (2010) Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry. J Am Coll Cardiol 56 (2):117-24. [9] PMID: 20451344
  26. ↑ 26.0 26.1 26.2 Rodés-Cabau J, Deblois J, Bertrand OF, Mohammadi S, Courtis J, Larose E et al. (2008) Nonrandomized comparison of coronary artery bypass surgery and percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease in octogenarians. Circulation 118 (23):2374-81.DOI:10.1161/CIRCULATIONAHA.107.727099 PMID:19029471
  27. ↑ 27.0 27.1 27.2 Sanmartín M, Baz JA, Claro R, Asorey V, Durán D, Pradas G et al. (2007) Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease. Am J Cardiol 100 (6):970-3.DOI:10.1016/j.amjcard.2007.04.037 PMID:17826380
  28. ↑ 28.0 28.1 28.2 Seung KB, Park DW, Kim YH, Lee SW, Lee CW, Hong MK et al. (2008) Stents versus coronary-artery bypass grafting for left main coronary artery disease. N Engl J Med 358 (17):1781-92.DOI:10.1056/NEJMoa0801441 PMID:18378517
  29. ↑ 29.0 29.1 29.2 White AJ, Kedia G, Mirocha JM, Lee MS, Forrester JS, Morales WC et al. (2008)Comparison of coronary artery bypass surgery and percutaneous drug-eluting stent implantation for treatment of left main coronary artery stenosis.JACC Cardiovasc Interv 1 (3):236-45. [10] PMID: 19463306
  30. ↑ Chieffo A, Magni V, Latib A, Maisano F, Ielasi A, Montorfano M et al. (2010)5-year outcomes following percutaneous coronary intervention with drug-eluting stent implantation versus coronary artery bypass graft for unprotected left main coronary artery lesions the Milan experience. JACC Cardiovasc Interv 3 (6):595-601. DOI:10.1016/j.jcin.2010.03.014 PMID:20630452
  31. ↑ Montalescot G, Brieger D, Eagle KA, Anderson FA, FitzGerald G, Lee MS et al. (2009) Unprotected left main revascularization in patients with acute coronary syndromes. Eur Heart J 30 (19):2308-17.DOI:10.1093/eurheartj/ehp353 PMID:19720640
  32. ↑ Lee MS, Tseng CH, Barker CM, Menon V, Steckman D, Shemin R et al. (2008)Outcome after surgery and percutaneous intervention for cardiogenic shock and left main disease. Ann Thorac Surg 86 (1):29-34.DOI:10.1016/j.athoracsur.2008.03.019 PMID:18573394
  33. ↑ Lee MS, Bokhoor P, Park SJ, Kim YH, Stone GW, Sheiban I et al. (2010) Unprotected left main coronary disease and ST-segment elevation myocardial infarction: a contemporary review and argument for percutaneous coronary intervention. JACC Cardiovasc Interv 3 (8):791-5.DOI:10.1016/j.jcin.2010.06.005 PMID:20723848
  34. ↑ Park SJ, Kim YH, Park DW, Yun SC, Ahn JM, Song HG et al. (2011)Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med 364 (18):1718-27.DOI:10.1056/NEJMoa1100452 PMID:[11]

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