Change We Can Believe In: The Hyper-Evolution of Percutaneous Coronary Intervention for Unprotected Left Main Disease With Drug-Eluting Stents

Abstract

T he initial adoption of percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) obstruction was tempered by poor acute outcomes after balloon angioplasty and the potential lethality of restenosis in the left main trunk suggested by bare-metal stent registries. 1 The marked antirestenotic efficacy of drug-eluting stents (DES) ushered in a new wave of enthusiasm for unprotected LMCA intervention. However, the accumulation of robust data to guide and support clinical practice has been challenged by the relatively low prevalence of this lesion subset combined with its historical characterization as a "forbidden zone" for PCI. The DES left main database has grown from initial, small, single-center experiences 2-4 to larger multicenter registries, 5 prospective, risk-adjusted comparisons with coronary artery bypass grafting, 6 and most recently to small randomized clinical trials and prespecified subgroups of larger clinical trials. 7,8 Catalyzed by an ethos in interventional cardiology that embraces (1) investigation, (2) dissemination of new information through journals, conferences, and a tradition of live-case demonstration; and (3) rapid adaptation of new techniques, there has been a marked evolution and improvement of the technical approach to unprotected LMCA intervention in a remarkably short period of time. The study reported by Palmerini et al 9 in this issue of the Circulation Cardiovascular Intervention provides further pressure on interventional cardiologists to follow a straightforward maxim: simpler is usually better. Article see p 185The interpretation of the studies of left main PCI with DES has been complicated by heterogeneity within study populations related to both the disease location (ostial, shaft, or distal bifurcation) and the technical approach used (single stent, dedicated 2-stent technique, or provisional stenting of the left main with "bail-out" stenting of the branch vessel). The early, single-center observational studies of DES for the unprotected LMCA demonstrated the dependence of clinical outcome on the anatomic location of the obstruction within the left main: higher major adverse cardiac event (MACE) rates were observed in cohorts with a heavy burden of distal disease 10 and subsequent meta-regression confirmed that distal disease predicted MACE and target vessel revascularization. 11 Centers that frequently used dedicated 2-stent techniques (ie, "crush" or simultaneous kissing stents) 3,4,12 also reported higher target lesion revascularization (TLR) and MACE rates compared with those using a single stent or provisional approach. 13,14 Determining the optimal approach is difficult because stent technique is driven by a combination of clinical and angiographic characteristics and a strong dose of operator preference for which an analysis cannot be easily adjusted. Indeed, the relative predilection to use a single versus 2-stent technique was initially geographic in nature, with a 2-stent approach favored in the United States and parts of Europe, wh...

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