Clinical and Procedural Predictors of Suboptimal Outcome After the Treatment of Drug-Eluting Stent Restenosis in the Unprotected Distal Left Main Stem

Abstract

Background— Few data are available regarding the optimal revascularization strategy for unprotected distal left main coronary artery (UDLM) in-stent restenosis (ISR). Methods and Results— Between April 2002 and December 2008, UDLM-ISR following drug-eluting stent (DES) implantation occurred in 92 of 474 patients (19.4%). Of these, 8 (8.7%) who underwent a coronary artery bypass graft (CABG) were excluded, and the remaining 84 (91.3%) who underwent percutaneous coronary intervention (PCI) (43 plain old balloon angioplasty [POBA] and 41 DES) were analyzed to assess the feasibility of PCI for UDLM-ISR. The overall cardiac death, myocardial infarction (MI), and major adverse cardiac events during the follow-up period (median, 24 months) occurred in 4, 2, and 31 patients, respectively. Repeat target lesion revascularization (TLR) occurred in 28 patients. The incidence of repeat TLR was higher following PCI with POBA than with DES (hazard ratio [HR], 2.79; 95% CI, 1.23–6.34; P =0.014). On Cox regression analysis, the independent predictors of repeat TLR were treatment with POBA (HR, 3.29; 95% CI, 1.41–7.69; P =0.006) and EuroSCORE (European System for Cardiac Operative Risk Evaluation) >6 (HR, 2.53; 95% CI, 1.02–6.28; P =0.045). More complex lesions requiring a 2-stent strategy were associated with a higher occurrence of TLR for restenosis of the left circumflex coronary artery ostium (LCX-ISR) (HR, 2.51; 95% CI, 1.59–3.97; P =0.001) as well as repeat TLR for recurrent LCX-ISR (HR, 4.32; 95% CI, 0.97–19.20; P =0.05) compared to a 1-stent strategy. No cardiac death at 2 years occurred in patients with LCX-ISR. Conclusions— UDLM restenosis is better treated with DES than with POBA. The rate of recurrent ISR following repeat PCI was high, whereas the rates of MI and death were relatively low. Complex lesions requiring a 2-stent strategy had a higher recurrence rate at the ostial LCX but without an associated increased risk of MI and death.

The impact of main branch restenosis on long term mortality following drug‐eluting stent implantation in patients with de novo unprotected distal left main bifurcation coronary lesions: The Milan and New‐Tokyo (MITO) registry

“…This is the first study to demonstrate such association between MB‐ISR in UDLM and cardiac mortality. Previous studies have demonstrated that SB‐ISR is more common than MB‐ISR and often patients are asymptomatic . Consistent with the previous reports, which have demonstrated the nonmalignant nature of SB‐ISR, the incidence of cardiac death in SB‐ISR alone was also low in our series (0% at 3‐years).…”

Long‐term outcomes following mini‐crush versus culotte stenting for the treatment of unprotected left main disease: Insights from the milan and New‐Tokyo (MITO) registry

“…The occurrence of TLR in our study is higher to that reported in other studies, most probably triggered by high angiographic follow‐up. On the basis of previous reports, TLR is associated with lesion complexity (especially true bifurcation) and the rate of angiographic follow‐up . In our study, the greater lesion complexity of ULMCA when compared to previous studies possibly accounted for the higher observed rate of TLR.…”

Comparison Between 1- and 2-Stent Strategies in Unprotected Distal Left Main Disease

“…Furthermore, our group previously reported that SB-ISR had a lesser impact on long-term mortality compared with MB-ISR and that it was a largely asymptomatic and relatively benign phenomenon, especially when the LCx was small. 9 Thus, the higher occurrence of TLR in the 2-SS cases seemed to have a smaller clinical impact than expected.…”

“…The characteristics of the ULM lesions, along with details of the PCI procedure, have been described previously. 9,10 A true bifurcation lesion was defined as Medina class 1-1-1, 1-0-1, and 0-1-1. For the original procedure, a 1-SS was defined by the use of a single stent, regardless of lesion type, whereas a 2-SS procedure was defined by the use of 2 stents, regardless of the technique used.…”