Dedicated stents for distal left main stenting

Safety and efficacy of self-apposing Stentys drug-eluting stent in left main coronary artery PCI: Multicentre LM-STENTYS registry

BACKGROUND

There is a paucity of data on left main (LM) percutaneous coronary intervention (PCI) therapy with dedicated DES platforms. The LM-STENTYS is a multicenter registry aimed at evaluating clinical outcome after PCI of LM performed with a self-apposing Stentys DES implantation.

METHODS

The registry consists of 175 consecutive patients treated with Stentys DES implanted to LM. The primary endpoint was the composite of major adverse cardiac and cerebral events (MACCE) defined as cardiac death, myocardial infarction (MI), target lesion revascularization (TLR), and stroke assessed after 1 year. The secondary endpoint was stent thrombosis (ST) at 1 year.

RESULTS

The median age was 69 years (IQR, 62-78 years). Acute coronary syndrome (ACS) was the presenting diagnosis in 117 (66.9%) patients [74 (63.2%) unstable angina, 31 (26.5%) NSTEMI, 12 (10.3%) STEMI] and stable angina (SA) was present in 58 (33.1%) patients. The median SYNTAX score was 23.0 (IQR, 18.7-32.2) in the SA group and 25.0 (IQR, 20.0-30.7) in the ACS group. During 1-year follow-up in the SA group two (3.4%) MACCE occurred, both of them were cardiac deaths. In ACS patients there were 19 (16.2%) MACCE [9 (7.7%) cardiac deaths, 11 (9.4%) MIs, 11(9.4%) TLR, 1(0.9%) stroke]. Altogether, three (1.7%) cases of acute ST were noted, all of them in ACS subset.

CONCLUSION

LM PCI using self-apposing Stentys DES showed favorable clinical outcomes at 1-year in patients with SA. Events of ST in the ACS group warrant further research.

Patient selection and percutaneous technique of unprotected left main revascularization

Increasing evidence suggests that percutaneous coronary intervention with newer generation drug-eluting stents may be an acceptable alternative, or even preferred in selected cases to the surgical approach, in patients with left main disease. This review will discuss the anatomic factors, the clinical variables, and the procedural strategies to consider, including physiology assessment and imaging guidance, in order to optimize outcomes.

Coronary bifurcations in clinical practice: Tell me what we can do better

In bifurcation lesion, a precise evaluation of lesion severity and disease extension requires the use of bifurcation (three branches) quantitative coronary angiography. The use of Intravascular imaging to guide PCI in bifurcation has shown to reduce clinical events. Selection and duration of the dual antiplatelet therapy after bifurcation lesion PCI require further investigation.

Practical based approach to left main bifurcation stenting

Despite the recent developments that have been made in the field of percutaneous left main (LM) intervention, the treatment of distal LM bifurcation remains challenging. The provisional one-stent approach for LM bifurcation has shown more favorable outcomes than the two-stent technique, making the former the preferred strategy in most types of LM bifurcation stenosis. However, elective two-stent techniques, none of which has been proven superior to the others, are still used in patients with severely diseased large side branches to avoid acute hemodynamic compromise. Selecting the proper bifurcation treatment strategy using meticulous intravascular ultrasound evaluation for side branch ostium is crucial for reducing the risk of side branch occlusion and for improving patient outcomes. In addition, unnecessary complex intervention can be avoided by measuring fractional flow reserve in angiographically isolated side branches. Most importantly, good long-term clinical outcomes are more related to the successful procedure itself than to the type of stenting technique, emphasizing the greater importance of optimizing the chosen technique than the choice of method.

Is there a need for dedicated devices?

Although the provisional approach is recommended over a systematic two-stent approach in bifurcation lesions, an a priori two-stent approach may be considered in certain specific anatomies in a minority of cases. Virtual bench test and intravascular imaging studies have provided essential insights into the technical aspects of bifurcation stenting and led to recommendations on how to optimise both the provisional and the two-stent strategies. Dedicated bifurcation stents may further optimise the procedural and clinical outcomes of both strategies. However, randomised data are sparse and more randomised trials are needed to provide evidence as to whether these dedicated devices will indeed improve procedural and clinical outcomes.