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Updated guidelines recommended regarding percutaneous treatment of unprotected left main coronary disease
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Surgical revascularization has been the recommended appropriate therapy for the treatment of unprotected left main coronary disease, but evidence from more recent trials has suggested that a percutaneous approach may also be effective.
A collection of clinical evidence cited in a white paper suggested that percutaneous coronary intervention using drug-eluting stents may be an equally effective, less invasive alternative to surgical revascularization in certain patient populations. Guidelines and recommendations, the investigators said, currently have not been updated to reflect the emerging evidence.
“The issue is not whether unprotected left main PCI can be technically performed, but rather what treatment should be performed, and how the relative merits and risks of revascularization strategies can be responsibly translated to patients as part of informed consent,” the researchers wrote.
The investigators cited several randomized and nonrandomized trials to support their contention. Results from the MAIN-COMPARE trial, which evaluated outcomes of PCI in unprotected left main coronary disease with a surgical revascularization approach, suggested lower rate of freedom from repeat revascularization and no significant differences in safety endpoints between treatment groups.
The researchers from the randomized SYNTAX trial comparing CABG with PCI for the treatment of left main/multivessel disease reported no significant differences between PCI and CABG for the outcomes of death and MI, despite a reported association between CABG and lower rates of revascularization.
The researchers for the ISAR-LEFT MAIN trial, which compared the outcomes of treating unprotected left main coronary disease with two different drug-eluting stents, reported no significant differences between the two stent types for the primary one-year endpoint of death, MI or target lesion revascularization, as well as no difference in angiographic restenosis or in two-year left main-specific target lesion revascularization. Rates of late and very late stent thrombosis reported in the DELFT, ISAR-LEFT MAIN and SYNTAX registries were low when compared with those seen after CABG.
Some of the limitations for the percutaneous treatment of unprotected left main coronary disease included anatomical and procedural considerations. Lesion location, features of the coronary anatomy and lesion morphology and the presence of bifurcated lesions were cited as important considerations. The addition of intravascular ultrasound for the evaluation of lesion complexity (where appropriate) was also recommended as an effective method of assessing plaque distribution and the severity of disease.
Ultimately, the researchers said the existing data cited in the paper were substantial enough to recommend changes in the American College of Cardiology/American Heart Association/Society for Coronary Angiography and Interventions PCI guidelines. They recommended advancing unprotected left main coronary disease PCI to Class IIa status, and the indication for more complex unprotected left main coronary disease PCI beyond the Class III recommendation to Class IIb in the absence of complex coexisting multivessel disease. They also recommended that such procedures be performed at centers and by operators skilled with left main intervention, and only after full consultation between the patient, a cardiac surgeon and an interventionalist. Further definition of optimal adjunctive pharmacologic therapy, examination of cost-effectiveness and improved standardization of post-procedural surveillance were also among the investigators’ recommendations.
Kandzari D. J Am Coll Cardiol. 2009;doi:10.1016/j.jacc.2009.07.021.