For which patients with left main stem disease is percutaneous intervention rather than coronary artery bypass grafting the better option?

Malvindi, Pietro Giorgio; Dunning, Joel; Vitale, Nicola

doi:10.1510/icvts.2007.169938

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The topic addressed was to identify the patients with left main stem disease for which percutaneous intervention would be a better option than coronary artery bypass grafting. Altogether 665 papers were found using the reported search, of which 15 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. We conclude that if a bare metal stent is used for left main stenting the mortality at one year may be from 3% to over 28% in reported series. The restenosis rate of the bare metal stent in the left main position is around 20% at one year. There are some early series and randomized studies of drug eluting stents for left main stem lesions and the restenosis rate is reported to be around 10%. The European Society of Cardiology in their 2005 percutaneous intervention guidelines state that coronary bypass grafting is the procedure of choice for left main stem disease and only patients with a prohibitively high surgical risk should be considered. We consider that with such high restenosis rates, and with short-term follow-up in such low numbers and short periods compared to coronary artery bypass grafting, left main stenting should only be used as a last resort in patients turned down for coronary artery bypass grafting after full assessment by a cardiac surgeon due to prohibitive co-morbidities.

Evidence-based medicine, Left main coronary disease, Coronary artery bypass, Percutaneous coronary intervention, Coronary stent

1. Introduction

A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].

2. Clinical scenario

You are asked by the interventional cardiologist on-call to discuss a 73-year-old gentleman still on the table in the angiography lab. He was admitted with a non-ST myocardial infarction with a small troponin rise, has had clopidogrel, aspirin and reopro and is currently stable. The coronary angiogram shows a tight proximal left main stem lesion of about 70%. The patient is mildly obese and diabetic with some varicosities of the left leg and has prostate carcinoma, which is currently well controlled. The cardiologist would like to stent this lesion if you thought that he was not a good surgical candidate and asks for your opinion.

3. Three-part question

In a [patient with left main stem coronary disease] does [percutaneous stenting or CABG] result in the best [long-term survival].

4. Search strategy

Medline 1995 to Aug 2007 using Ovid Interface.

[LMS.mp or left main.mp] AND [exp Angioplasty/OR angioplasty.mp]

5. Search outcome

Using the reported search, 665 papers were identified from which 15 papers provided the best evidence to answer the question. These are summarized in Table 1 .

Table 1

Open in new tab

Best evidence papers

Author, date,	Patient group	Outcomes	Key results	Comments
and country
Study type
(level of evidence)
ACC/AHA/SC	Report of the	CABG using IMA grafting is the ‘gold standard’ for treatment of ULM disease and has
AI guidelines,	American	proven benefit on long-term outcomes. The use of DES has shown encouraging short-term
(2005), J Am	College of	outcomes, but long-term follow-up is needed. Nevertheless, the use of PCI for
Coll Cardiol,	Cardiology/	patients with significant ULM stenosis who are candidates for revascularization
USA, [2]	American Heart	but not suitable for CABG can improve cardiovascular outcomes and is a reasonable
	Association	revascularization strategy in carefully selected patients
Guideline	Task Force on
(level 2a)	Practice	PCI is not recommended in patients with asymptomatic ischemia or CCS class I or II
	Guidelines	angina, left main disease and eligibility for CABG
	Practice	Use of PCI is reasonable in patients with CCS class III angina with significant
	guideline group	left main CAD (>50% diameter stenosis) who are candidates for revascularization
	consisted entirely	but are not eligible for CABG. (Level of Evidence: B)
	of cardiologists
	from the 3	PCI is not recommended for patients with CCS class III angina and significant left
	organisations	main CAD and candidacy for CABG. (Level of Evidence: C)
	involved
		Use of PCI is reasonable in patients with UA/NSTEMI with significant left main
		CAD (>50% diameter stenosis) who are candidates for revascularization but are not
		eligible for CABG. (Level of Evidence: B)
		In patients with cardiogenic shock and significant left main disease or severe 3-vessel
		disease and without right ventricular infarction or major comorbidities such as
		renal insufficiency or severe pulmonary disease, CABG can be considered as the
		revascularization strategy
European	Report of the	The presence of a left main (LM) coronary artery stenosis identifies an anatomic subset
Society for	European Society	still requiring bypass surgery for revascularization. PCI of protected LMS (i.e. by a distal graft)
Cardiology	of Cardiology	can be performed although a 1-year MACE of 25% is still rather high, which may
guidelines,		reflect an increased mortality in patients with severe CAD with previous CABG.
(2005),
Eur Heart J, [3]		Stenting for unprotected LM disease should only be considered in the absence of other
		revascularization options. Therefore, PCI can be recommended in these subsets
Guidelines		when bypass surgery has a very high perioperative risk (e.g. EuroSCORE >10%)
(level 2a)
		Until proved otherwise, PCI should be used only with reservation in diabetics with multi-vessel
		disease and in patients with unprotected left main stenosis
Erglis et al., (2007),	103 patients	Myocardial infarction	BMS 7/50 (14%)	Patient population
J Am Coll	with unprotected	by 6 months	PES 5/53 (10%)	is those also ideal
Cardiol,	LMS disease,			for surgery
Australia and	2004–2006	Restenosis	BMS 11/50 patients	Mean age 62
Latvia, [4]			(22%)	Only 6 had previous
	All patients		PES 3/53 patients (6%)	CABG, mean
PRCT	were good		P=0.021	LVEF 54%
(level 1b)	candidates for
	CABG	6 months adverse	BMS 15/50 (30%)
		cardiac-event free	PES 7/53 (13%)
	Randomized to	survival	P=0.036
	express or
	liberte BMS	Mortality at	BMS and PES 1
	or Paclitaxel	6 months	patient each (2%)
	eluting stent
	(PES) with
	cutting balloon
	pre-treatment
	under IVUS
	control
	Clopidogrel,
	Heparin,
	GpIIb/IIIa
	given
	BMS n=50
	PES n=53
Palmerini et al.,	154 patients	30 days		– Short-term
(2006),	underwent			follow-up
Am J Cardiol,	CABG and	Overall mortality	CABG 4.5%
Italy, [6]	157 patients		PCI 3.2%	– Early and
	underwent PCI		P=NS	long-term
Prospective	for left main			mortality were not
cohort study	stenosis (94 DES)	Cardiac related	CABG 3.9%	significantly
(level 2b)		mortality	PCI 2.5%	different between
	From		P=NS	CABG and PCI
	2002–2005
		Myocardial	CABG 1.9%	– Target lesion
	Mean age±S.D.:	infarction at	PCI 4.5%	revascularization
	CABG	30 days	P=NS	was significantly
	69.3±9.5			higher in PCI-treated
	PCI 73.0±10.9	Target lesion	CABG 0.6%	patients
		revascularization	PCI 0.6%
	Left main		P=NS	– Although patients
	disease alone:	Follow-up		treated with drug-eluting
	CABG 5.2%			stents had a
	PCI 12.7%	Overall mortality	CABG 12.3%	25% relative risk
	P<0.001		PCI 13.4%	reduction in the
			P=0.861	rate of major adverse
	Left main lesions			cardiac events
	locations:		CABG 12.3%	compared with
	P=0.742		PCI-DES 11.7%	patients treated
			P=0.968	with bare metal
	Follow-up:			stents, event survival
	430 days	Cardiac related	CABG 9.7%	was still higher in
	(105–730)	mortality	PCI 9.5%	the CABG group
			P=0.994	than in the drug
				eluting stent group
			CABG 9.7%
			PCI-DES 7.4%
			P=0.667
		Myocardial	CABG 4.5%
		infarction	PCI 8.3%
			P=0.170
			CABG 4.5%
			PCI-DES 5.3%
			P=0.690
		Target lesion	CABG 2.6%
		revascularization	PCI 25.5%
			P=0.0001
Chieffo et al.,	142 patients	30 days		The patients
(2006),	underwent			receiving DES
Circulation,	CABG (86	Mortality	CABG 2.1%	were significantly
Italy, [7]	patients had		PCI 0	younger than
	on-pump			CABG patients
Prospective	CABG, 56	Myocardial	CABG 26.5%	(64 vs. 68 years),
Cohort study	patients	infarction	PCI 9.3%	had lower incidence
(level 2b)	underwent off-pump		P=0.0009	of smoking,
	CABG)			significantly less
		Q-wave MI	CABG 3.5%	hypertension, less
	107 patients		PCI 0	diabetes, and
	underwent		P=0.07	significantly less
	PCI-DES for			renal failure
	left main	Target lesion	CABG 2.1%
	stenosis	revascularization	PCI 0	The PCI patients
	(2002–2004)			were therefore
	81.3% of	TVR	CABG 2.1%	fitter than the
	patients		PCI 0	CABG patients
	treated with
	PCI had distal	Follow-up		26% perioperative
	LMCA			MI rate after CABG is
		Mortality	CABG 6.4%	incredibly high, due to
	Mean age±S.D.:		PCI 2.8%	their definition of MI
	CABG		P=0.07
	67.5±9.7
	PCI 63.6±10.3	Myocardial	CABG 1.4%
		infarction	PCI 0.9%
	Renal failure:
	CABG 8.4%	Target lesion	CABG 3.6%
	PCI 1.9%	revascularization	PCI 15.8%
	P=0.02		P=0.001
	Follow-up:	TVR	CABG 3.6%
	1-year		PCI 19.6%
			P=0.0001
Lee et al.,	123 patients	30 days		– PCI with DES is a
(2006), J Am	underwent			viable alternative
Coll Cardiol,	CABG and 50	Mortality	CABG 5%	to CABG for
USA, [8]	patients PCI		PCI 2%	treatment of left
	with DES for		P=0.34	main coronary
Prospective	left main stenosis			artery when
cohort study	(2003–2006)	Myocardial	CABG 2%	clinical judgment
(level 2b)		infarction	PCI 0	was used for
	Mean age±S.D.:		P>0.9	patients allocation
	CABG 70±10
	PCI 72±15	Target vessel	CABG 1%	– There may be an
		revascularization	PCI 0	incidence of late
	Parsonnet score:		P>0.9	complications
	CABG 13.7±9.7			associated with
	PCI 18.3±10.9	In-hospital length	CABG 7.6±4.9	DES that will be
	P<0.01	of stay (days	PCI 3.9±4.5	defined with a
		mean±S.D.)		longer-term
	Follow-up:			follow-up
	CABG 6.7±6.2 months	Follow-up
	PCI 5.6±3.9	(Kaplan–Meier)
		Freedom from	6 months
		mortality	CABG 87%
			PCI 96%
			P=0.861
			1-year
			CABG 85%
			PCI 96%
			P=0.18
		Freedom from TVR	6 months
			CABG 99%
			PCI 93%
			1-year
			CABG 93%
			PCI 87%
			P=0.22
		Target lesion	CABG 3.6%
		revascularization	PCI 15.8%
			P=0.001
		TVR	CABG 3.6%
			PCI 19.6%
			P=0.0001
Tan et al.,	279 patients who	30 days		Complete data
(2001),	had ULMS			regarding RCA are
Circulation,	PCI from 1 of	Mortality	13.7%	unavailable
USA, Europe,	25 sites of	Follow-up
Japan, Korea, [9]	multicenter study			CABG is the first
	(1993–1998)	Mortality	12.2%	choice for ULMS
Prospective
multicenter	46% of patients	Cardiac related	9.1%	PCI is a viable
cohort study	were deemed	mortality		option in AMI,
(level 2b)	inoperable or at			inoperable patients
	high surgical risk	AMI	8.7%	or low-risk patients
	50% had a post	CABG	8.7%
	procedure IABP
	Follow-up:
	1-year (97.1%
	complete)
Kelley et al.,	142 patients	30 days		– Stenting for
(2003), Eur	treated with			unprotected
Heart J, USA,	BMS for LMS	Mortality	LMS 2.1%	LMCA disease in
France, [10]	(1997–2003)		ULMS 9.3%	a high risk
	99 patients with	Follow-up		population is
Retrospective	protected LMS			associated with a
cohort study	43 patients with	Mortality	LMS 5%	poor one-year
(level 2b)	ULMS		ULMS 28%	survival and should
			P<0.0001	only be considered
	ULMS cohort			in the absence
	had significant			of other
	higher age and			revascularization
	percentage of	MI	LMS 3%	options
	AMI and 20%		ULMS 7%
	were in cardiogenic			– BMS procedure
	shock	Target lesion	LMS 18%	for protected
		revascularization	ULMS 23%	LMCA disease is
	MACE:			still associated
	death+non-fatal	MACE	LMS 25%	with increased
	MI+TLR		ULMS 49%	mortality and
			P=0.005	MACE rates
	Follow-up:			compared to PCI
	1-year (96% complete)			of other coronary
				lesions
Valgimigli et al.,	181 patients	30 days		– The use of DES as
(2005),	underwent PCI for			a default strategy
Circulation,	LMS (2002–2003)	Mortality	BMS 7%	to treat LM
Italy, The	95 patients were		DES 11%	disease was
Netherlands,	treated with DES			associated with a
[12]	(52 SES, 43 PES)	MI	BMS 9%	significant
			DES 4%	reduction in
Retrospective	2 cohorts BMS			adverse events
cohort study	(86 patients) and	Target vessel	BMS 2%
(level 2b)	DES (95 patients)	revascularization	DES 0	– CABG should
	with no differences			remain the
	in clinical features	Follow-up		preferred
				revascularization
	Higher prevalence	Mortality	BMS 16%	treatment in good
	of 3-vessel disease		DES 14%	surgical candidates
	and bifurcation			presenting with
	stenting in the DES	AMI	BMS 12%	LM coronary
	group		DES 4%	artery disease
			P=0.006
	Follow-up: mean
	503 days (range	Target vessel	BMS 23%
	331–873)	revascularization	DES 6%
			P=0.004
Agostoni et al.,	58 patients	30 days		– When ostial or
(2005), Am J	electively treated			mid-LM disease is
Cardiol, The	for ULMS	Mortality	3%	treated with DESs,
Netherlands, [13]	(2002–2003)			the rate of cardiac
				events is
	24 procedures with			particularly low
Retrospective	IVUS aid
cohort study		Follow-up		– In patients with
(level 2b)	FU: mean 433 days	(Kaplan–Meier)		distal LM involvement,
	(range 178–780)			the rate of events
		Mortality	5%	was significantly
				higher, but also in
		AMI	3%	this instance, no
				significant clinical
		Target vessel	7%	benefit occurred
		revascularization		in the IVUS subgroup
Jonsson et al.,	1888 patients who	30 days		During the period
(2006), Eur J	had CABG for LM			1970–1999 there
Cardiothorac	stenosis from	Mortality	Overall	was a decrease of
Surg, Sweden,	(1970–1999)	(1970–1999)	LM 2.7%	early and five-year
[19]			No LM 2%	mortality in
	8759 patients		Males	patients with LM
Retrospective	undergone CABG		LM 2.2%	after CABG despite
cohort study	for coronary		No LM 1.9%	increases of patient
(level 2b)	disease with no		Females	age and risk factors
	LM		LM 4.7%
			No LM 2.6%	An increased risk of
	Follow-up: 5 years			early and late
		Follow-up		deaths after CABG
				in patients with
		5-year mortality	Overall	LM stenosis
			LM 10%	compared with
			No LM 8.1%	patients without
			Males	LM stenosis in the
			LM 10.1%	1970s and 1980s
			No LM 8.2%	was neutralised
			Females	during the 1990s.
			LM 9.6%	There has been an
			No LM 7.8%	improvement of
				peri- and
				postoperative
				management of
				patients undergoing
				CABG during this
				time period
Ellis et al.,	107 patients	In-hospital results	4 deaths in Cath lab	Very small numbers
(1997),	treated for LMS		20% in-hospital death	from each centres
Circulation,	disease from 16		10% Q wave MI
USA, [5]	centres		5% CABG
Cohort study	These patients	Event-free survival	88.8±3.5% at 1 month
(level 2b)	represented 0.2%		72.6±5% at 6 months
	of all procedures		71±5% at 12 months
	performed in these
	hospitals	>4 month	22% had restenosis
		angioplasty
	27% were
	inoperable
	30% high risk for
	surgery
	15% prev CABG
	15% acute MI
	Age mean 66
	50% BMS
	24% atherectomy
	20% balloon
	angioplasty
	All had aspirin, 26
	Ticlopidine, 2
	abciximab
	Follow-up
	15±8 months
Park et al.,	1995–2000, 270	Hospital	3 stent thromboses,	Pre-DES era
(2003), Am J	consecutive	complications	3 Q-Wave MIs
Cardiol, South	patients with		No deaths
Korea, [14]	unprotected LMS		3 emergency CABG
	and normal LV
Cohort study	at 4 centres	Angiographic	Restenosis rate
(level 2b)		follow-up	21.1%
	Mean follow-up
	32±18 months	Deaths over mean	20 deaths
		3 years	8 cardiac deaths
	Mean age
	61 years	Target vessel	45 patients (17%)
		revascularization
		3-year freedom	77.7%±2.7%
		from major
		cardiac events
Price et al.,	50 patients with	In-lesion restenosis	21/50 (42%)	84% bifurcational
(2006), J Am	unprotected left			LMS stenting
Coll Cardiol,	main stenosis who	Target lesion	19 (38%)
USA, [17]	had a Sirolimus	revascularization
	eluting stent
Cohort study		Death	5 (10%)
(level 2b)	Patients too high
	risk for CABG or	MACE, death, MI,	22/50 (44%)
	refused CABG	TLR, Thormbosis
	58% had
	EuroSCORE
	predicted mortality
	>5%
	Repeat
	angiography at 3
	and 9 months
Lee et al.,	187 patients	6 months	Restenosis rate 33%	After 2 years there
(2007), Int	undergoing elective	angiography	at 6 months on	were no further
J Cardiol	BMS unprotected		angiography	MIs, deaths or
South Korea,	LMCA stenting			revascularization
[16]	with normal LV	5-year mortality	Mortality 7.6%	procedures
	function from 1995	and MI rate	6/13 cardiac deaths
Cohort study	to 2001
(level 2b)			2 non-fatal MIs
	Follow-up: 5 years
	(71 months	Repeat	Target lesion
	45–117 months)	revascularization	36 patients (21%)
	angiography at		New lesion
	6 months		13 patients (7.6%)
	Mean age 56		20 had PCI, 16 had
	Prev MI 6%		CABG
	EF mean 62%
		Freedom from	1 year – 80%
		MACE	3 years – 78%
			5 years – 78%

Author, date,	Patient group	Outcomes	Key results	Comments
and country
Study type
(level of evidence)
ACC/AHA/SC	Report of the	CABG using IMA grafting is the ‘gold standard’ for treatment of ULM disease and has
AI guidelines,	American	proven benefit on long-term outcomes. The use of DES has shown encouraging short-term
(2005), J Am	College of	outcomes, but long-term follow-up is needed. Nevertheless, the use of PCI for
Coll Cardiol,	Cardiology/	patients with significant ULM stenosis who are candidates for revascularization
USA, [2]	American Heart	but not suitable for CABG can improve cardiovascular outcomes and is a reasonable
	Association	revascularization strategy in carefully selected patients
Guideline	Task Force on
(level 2a)	Practice	PCI is not recommended in patients with asymptomatic ischemia or CCS class I or II
	Guidelines	angina, left main disease and eligibility for CABG
	Practice	Use of PCI is reasonable in patients with CCS class III angina with significant
	guideline group	left main CAD (>50% diameter stenosis) who are candidates for revascularization
	consisted entirely	but are not eligible for CABG. (Level of Evidence: B)
	of cardiologists
	from the 3	PCI is not recommended for patients with CCS class III angina and significant left
	organisations	main CAD and candidacy for CABG. (Level of Evidence: C)
	involved
		Use of PCI is reasonable in patients with UA/NSTEMI with significant left main
		CAD (>50% diameter stenosis) who are candidates for revascularization but are not
		eligible for CABG. (Level of Evidence: B)
		In patients with cardiogenic shock and significant left main disease or severe 3-vessel
		disease and without right ventricular infarction or major comorbidities such as
		renal insufficiency or severe pulmonary disease, CABG can be considered as the
		revascularization strategy
European	Report of the	The presence of a left main (LM) coronary artery stenosis identifies an anatomic subset
Society for	European Society	still requiring bypass surgery for revascularization. PCI of protected LMS (i.e. by a distal graft)
Cardiology	of Cardiology	can be performed although a 1-year MACE of 25% is still rather high, which may
guidelines,		reflect an increased mortality in patients with severe CAD with previous CABG.
(2005),
Eur Heart J, [3]		Stenting for unprotected LM disease should only be considered in the absence of other
		revascularization options. Therefore, PCI can be recommended in these subsets
Guidelines		when bypass surgery has a very high perioperative risk (e.g. EuroSCORE >10%)
(level 2a)
		Until proved otherwise, PCI should be used only with reservation in diabetics with multi-vessel
		disease and in patients with unprotected left main stenosis
Erglis et al., (2007),	103 patients	Myocardial infarction	BMS 7/50 (14%)	Patient population
J Am Coll	with unprotected	by 6 months	PES 5/53 (10%)	is those also ideal
Cardiol,	LMS disease,			for surgery
Australia and	2004–2006	Restenosis	BMS 11/50 patients	Mean age 62
Latvia, [4]			(22%)	Only 6 had previous
	All patients		PES 3/53 patients (6%)	CABG, mean
PRCT	were good		P=0.021	LVEF 54%
(level 1b)	candidates for
	CABG	6 months adverse	BMS 15/50 (30%)
		cardiac-event free	PES 7/53 (13%)
	Randomized to	survival	P=0.036
	express or
	liberte BMS	Mortality at	BMS and PES 1
	or Paclitaxel	6 months	patient each (2%)
	eluting stent
	(PES) with
	cutting balloon
	pre-treatment
	under IVUS
	control
	Clopidogrel,
	Heparin,
	GpIIb/IIIa
	given
	BMS n=50
	PES n=53
Palmerini et al.,	154 patients	30 days		– Short-term
(2006),	underwent			follow-up
Am J Cardiol,	CABG and	Overall mortality	CABG 4.5%
Italy, [6]	157 patients		PCI 3.2%	– Early and
	underwent PCI		P=NS	long-term
Prospective	for left main			mortality were not
cohort study	stenosis (94 DES)	Cardiac related	CABG 3.9%	significantly
(level 2b)		mortality	PCI 2.5%	different between
	From		P=NS	CABG and PCI
	2002–2005
		Myocardial	CABG 1.9%	– Target lesion
	Mean age±S.D.:	infarction at	PCI 4.5%	revascularization
	CABG	30 days	P=NS	was significantly
	69.3±9.5			higher in PCI-treated
	PCI 73.0±10.9	Target lesion	CABG 0.6%	patients
		revascularization	PCI 0.6%
	Left main		P=NS	– Although patients
	disease alone:	Follow-up		treated with drug-eluting
	CABG 5.2%			stents had a
	PCI 12.7%	Overall mortality	CABG 12.3%	25% relative risk
	P<0.001		PCI 13.4%	reduction in the
			P=0.861	rate of major adverse
	Left main lesions			cardiac events
	locations:		CABG 12.3%	compared with
	P=0.742		PCI-DES 11.7%	patients treated
			P=0.968	with bare metal
	Follow-up:			stents, event survival
	430 days	Cardiac related	CABG 9.7%	was still higher in
	(105–730)	mortality	PCI 9.5%	the CABG group
			P=0.994	than in the drug
				eluting stent group
			CABG 9.7%
			PCI-DES 7.4%
			P=0.667
		Myocardial	CABG 4.5%
		infarction	PCI 8.3%
			P=0.170
			CABG 4.5%
			PCI-DES 5.3%
			P=0.690
		Target lesion	CABG 2.6%
		revascularization	PCI 25.5%
			P=0.0001
Chieffo et al.,	142 patients	30 days		The patients
(2006),	underwent			receiving DES
Circulation,	CABG (86	Mortality	CABG 2.1%	were significantly
Italy, [7]	patients had		PCI 0	younger than
	on-pump			CABG patients
Prospective	CABG, 56	Myocardial	CABG 26.5%	(64 vs. 68 years),
Cohort study	patients	infarction	PCI 9.3%	had lower incidence
(level 2b)	underwent off-pump		P=0.0009	of smoking,
	CABG)			significantly less
		Q-wave MI	CABG 3.5%	hypertension, less
	107 patients		PCI 0	diabetes, and
	underwent		P=0.07	significantly less
	PCI-DES for			renal failure
	left main	Target lesion	CABG 2.1%
	stenosis	revascularization	PCI 0	The PCI patients
	(2002–2004)			were therefore
	81.3% of	TVR	CABG 2.1%	fitter than the
	patients		PCI 0	CABG patients
	treated with
	PCI had distal	Follow-up		26% perioperative
	LMCA			MI rate after CABG is
		Mortality	CABG 6.4%	incredibly high, due to
	Mean age±S.D.:		PCI 2.8%	their definition of MI
	CABG		P=0.07
	67.5±9.7
	PCI 63.6±10.3	Myocardial	CABG 1.4%
		infarction	PCI 0.9%
	Renal failure:
	CABG 8.4%	Target lesion	CABG 3.6%
	PCI 1.9%	revascularization	PCI 15.8%
	P=0.02		P=0.001
	Follow-up:	TVR	CABG 3.6%
	1-year		PCI 19.6%
			P=0.0001
Lee et al.,	123 patients	30 days		– PCI with DES is a
(2006), J Am	underwent			viable alternative
Coll Cardiol,	CABG and 50	Mortality	CABG 5%	to CABG for
USA, [8]	patients PCI		PCI 2%	treatment of left
	with DES for		P=0.34	main coronary
Prospective	left main stenosis			artery when
cohort study	(2003–2006)	Myocardial	CABG 2%	clinical judgment
(level 2b)		infarction	PCI 0	was used for
	Mean age±S.D.:		P>0.9	patients allocation
	CABG 70±10
	PCI 72±15	Target vessel	CABG 1%	– There may be an
		revascularization	PCI 0	incidence of late
	Parsonnet score:		P>0.9	complications
	CABG 13.7±9.7			associated with
	PCI 18.3±10.9	In-hospital length	CABG 7.6±4.9	DES that will be
	P<0.01	of stay (days	PCI 3.9±4.5	defined with a
		mean±S.D.)		longer-term
	Follow-up:			follow-up
	CABG 6.7±6.2 months	Follow-up
	PCI 5.6±3.9	(Kaplan–Meier)
		Freedom from	6 months
		mortality	CABG 87%
			PCI 96%
			P=0.861
			1-year
			CABG 85%
			PCI 96%
			P=0.18
		Freedom from TVR	6 months
			CABG 99%
			PCI 93%
			1-year
			CABG 93%
			PCI 87%
			P=0.22
		Target lesion	CABG 3.6%
		revascularization	PCI 15.8%
			P=0.001
		TVR	CABG 3.6%
			PCI 19.6%
			P=0.0001
Tan et al.,	279 patients who	30 days		Complete data
(2001),	had ULMS			regarding RCA are
Circulation,	PCI from 1 of	Mortality	13.7%	unavailable
USA, Europe,	25 sites of	Follow-up
Japan, Korea, [9]	multicenter study			CABG is the first
	(1993–1998)	Mortality	12.2%	choice for ULMS
Prospective
multicenter	46% of patients	Cardiac related	9.1%	PCI is a viable
cohort study	were deemed	mortality		option in AMI,
(level 2b)	inoperable or at			inoperable patients
	high surgical risk	AMI	8.7%	or low-risk patients
	50% had a post	CABG	8.7%
	procedure IABP
	Follow-up:
	1-year (97.1%
	complete)
Kelley et al.,	142 patients	30 days		– Stenting for
(2003), Eur	treated with			unprotected
Heart J, USA,	BMS for LMS	Mortality	LMS 2.1%	LMCA disease in
France, [10]	(1997–2003)		ULMS 9.3%	a high risk
	99 patients with	Follow-up		population is
Retrospective	protected LMS			associated with a
cohort study	43 patients with	Mortality	LMS 5%	poor one-year
(level 2b)	ULMS		ULMS 28%	survival and should
			P<0.0001	only be considered
	ULMS cohort			in the absence
	had significant			of other
	higher age and			revascularization
	percentage of	MI	LMS 3%	options
	AMI and 20%		ULMS 7%
	were in cardiogenic			– BMS procedure
	shock	Target lesion	LMS 18%	for protected
		revascularization	ULMS 23%	LMCA disease is
	MACE:			still associated
	death+non-fatal	MACE	LMS 25%	with increased
	MI+TLR		ULMS 49%	mortality and
			P=0.005	MACE rates
	Follow-up:			compared to PCI
	1-year (96% complete)			of other coronary
				lesions
Valgimigli et al.,	181 patients	30 days		– The use of DES as
(2005),	underwent PCI for			a default strategy
Circulation,	LMS (2002–2003)	Mortality	BMS 7%	to treat LM
Italy, The	95 patients were		DES 11%	disease was
Netherlands,	treated with DES			associated with a
[12]	(52 SES, 43 PES)	MI	BMS 9%	significant
			DES 4%	reduction in
Retrospective	2 cohorts BMS			adverse events
cohort study	(86 patients) and	Target vessel	BMS 2%
(level 2b)	DES (95 patients)	revascularization	DES 0	– CABG should
	with no differences			remain the
	in clinical features	Follow-up		preferred
				revascularization
	Higher prevalence	Mortality	BMS 16%	treatment in good
	of 3-vessel disease		DES 14%	surgical candidates
	and bifurcation			presenting with
	stenting in the DES	AMI	BMS 12%	LM coronary
	group		DES 4%	artery disease
			P=0.006
	Follow-up: mean
	503 days (range	Target vessel	BMS 23%
	331–873)	revascularization	DES 6%
			P=0.004
Agostoni et al.,	58 patients	30 days		– When ostial or
(2005), Am J	electively treated			mid-LM disease is
Cardiol, The	for ULMS	Mortality	3%	treated with DESs,
Netherlands, [13]	(2002–2003)			the rate of cardiac
				events is
	24 procedures with			particularly low
Retrospective	IVUS aid
cohort study		Follow-up		– In patients with
(level 2b)	FU: mean 433 days	(Kaplan–Meier)		distal LM involvement,
	(range 178–780)			the rate of events
		Mortality	5%	was significantly
				higher, but also in
		AMI	3%	this instance, no
				significant clinical
		Target vessel	7%	benefit occurred
		revascularization		in the IVUS subgroup
Jonsson et al.,	1888 patients who	30 days		During the period
(2006), Eur J	had CABG for LM			1970–1999 there
Cardiothorac	stenosis from	Mortality	Overall	was a decrease of
Surg, Sweden,	(1970–1999)	(1970–1999)	LM 2.7%	early and five-year
[19]			No LM 2%	mortality in
	8759 patients		Males	patients with LM
Retrospective	undergone CABG		LM 2.2%	after CABG despite
cohort study	for coronary		No LM 1.9%	increases of patient
(level 2b)	disease with no		Females	age and risk factors
	LM		LM 4.7%
			No LM 2.6%	An increased risk of
	Follow-up: 5 years			early and late
		Follow-up		deaths after CABG
				in patients with
		5-year mortality	Overall	LM stenosis
			LM 10%	compared with
			No LM 8.1%	patients without
			Males	LM stenosis in the
			LM 10.1%	1970s and 1980s
			No LM 8.2%	was neutralised
			Females	during the 1990s.
			LM 9.6%	There has been an
			No LM 7.8%	improvement of
				peri- and
				postoperative
				management of
				patients undergoing
				CABG during this
				time period
Ellis et al.,	107 patients	In-hospital results	4 deaths in Cath lab	Very small numbers
(1997),	treated for LMS		20% in-hospital death	from each centres
Circulation,	disease from 16		10% Q wave MI
USA, [5]	centres		5% CABG
Cohort study	These patients	Event-free survival	88.8±3.5% at 1 month
(level 2b)	represented 0.2%		72.6±5% at 6 months
	of all procedures		71±5% at 12 months
	performed in these
	hospitals	>4 month	22% had restenosis
		angioplasty
	27% were
	inoperable
	30% high risk for
	surgery
	15% prev CABG
	15% acute MI
	Age mean 66
	50% BMS
	24% atherectomy
	20% balloon
	angioplasty
	All had aspirin, 26
	Ticlopidine, 2
	abciximab
	Follow-up
	15±8 months
Park et al.,	1995–2000, 270	Hospital	3 stent thromboses,	Pre-DES era
(2003), Am J	consecutive	complications	3 Q-Wave MIs
Cardiol, South	patients with		No deaths
Korea, [14]	unprotected LMS		3 emergency CABG
	and normal LV
Cohort study	at 4 centres	Angiographic	Restenosis rate
(level 2b)		follow-up	21.1%
	Mean follow-up
	32±18 months	Deaths over mean	20 deaths
		3 years	8 cardiac deaths
	Mean age
	61 years	Target vessel	45 patients (17%)
		revascularization
		3-year freedom	77.7%±2.7%
		from major
		cardiac events
Price et al.,	50 patients with	In-lesion restenosis	21/50 (42%)	84% bifurcational
(2006), J Am	unprotected left			LMS stenting
Coll Cardiol,	main stenosis who	Target lesion	19 (38%)
USA, [17]	had a Sirolimus	revascularization
	eluting stent
Cohort study		Death	5 (10%)
(level 2b)	Patients too high
	risk for CABG or	MACE, death, MI,	22/50 (44%)
	refused CABG	TLR, Thormbosis
	58% had
	EuroSCORE
	predicted mortality
	>5%
	Repeat
	angiography at 3
	and 9 months
Lee et al.,	187 patients	6 months	Restenosis rate 33%	After 2 years there
(2007), Int	undergoing elective	angiography	at 6 months on	were no further
J Cardiol	BMS unprotected		angiography	MIs, deaths or
South Korea,	LMCA stenting			revascularization
[16]	with normal LV	5-year mortality	Mortality 7.6%	procedures
	function from 1995	and MI rate	6/13 cardiac deaths
Cohort study	to 2001
(level 2b)			2 non-fatal MIs
	Follow-up: 5 years
	(71 months	Repeat	Target lesion
	45–117 months)	revascularization	36 patients (21%)
	angiography at		New lesion
	6 months		13 patients (7.6%)
	Mean age 56		20 had PCI, 16 had
	Prev MI 6%		CABG
	EF mean 62%
		Freedom from	1 year – 80%
		MACE	3 years – 78%
			5 years – 78%

BMS, bare metal stent; BS, bifurcation stenting; DES, drug eluting stent; LMCA, left main coronary artery; MACE, major cardiac events; PCI, percutaneous coronary intervention; TLR, target lesion revascularization; SVS, single vessel stenting; TVR, target vessel revascularization; ULMS, unprotected left main stenosis.

Table 1

Open in new tab

Best evidence papers

Author, date,	Patient group	Outcomes	Key results	Comments
and country
Study type
(level of evidence)
ACC/AHA/SC	Report of the	CABG using IMA grafting is the ‘gold standard’ for treatment of ULM disease and has
AI guidelines,	American	proven benefit on long-term outcomes. The use of DES has shown encouraging short-term
(2005), J Am	College of	outcomes, but long-term follow-up is needed. Nevertheless, the use of PCI for
Coll Cardiol,	Cardiology/	patients with significant ULM stenosis who are candidates for revascularization
USA, [2]	American Heart	but not suitable for CABG can improve cardiovascular outcomes and is a reasonable
	Association	revascularization strategy in carefully selected patients
Guideline	Task Force on
(level 2a)	Practice	PCI is not recommended in patients with asymptomatic ischemia or CCS class I or II
	Guidelines	angina, left main disease and eligibility for CABG
	Practice	Use of PCI is reasonable in patients with CCS class III angina with significant
	guideline group	left main CAD (>50% diameter stenosis) who are candidates for revascularization
	consisted entirely	but are not eligible for CABG. (Level of Evidence: B)
	of cardiologists
	from the 3	PCI is not recommended for patients with CCS class III angina and significant left
	organisations	main CAD and candidacy for CABG. (Level of Evidence: C)
	involved
		Use of PCI is reasonable in patients with UA/NSTEMI with significant left main
		CAD (>50% diameter stenosis) who are candidates for revascularization but are not
		eligible for CABG. (Level of Evidence: B)
		In patients with cardiogenic shock and significant left main disease or severe 3-vessel
		disease and without right ventricular infarction or major comorbidities such as
		renal insufficiency or severe pulmonary disease, CABG can be considered as the
		revascularization strategy
European	Report of the	The presence of a left main (LM) coronary artery stenosis identifies an anatomic subset
Society for	European Society	still requiring bypass surgery for revascularization. PCI of protected LMS (i.e. by a distal graft)
Cardiology	of Cardiology	can be performed although a 1-year MACE of 25% is still rather high, which may
guidelines,		reflect an increased mortality in patients with severe CAD with previous CABG.
(2005),
Eur Heart J, [3]		Stenting for unprotected LM disease should only be considered in the absence of other
		revascularization options. Therefore, PCI can be recommended in these subsets
Guidelines		when bypass surgery has a very high perioperative risk (e.g. EuroSCORE >10%)
(level 2a)
		Until proved otherwise, PCI should be used only with reservation in diabetics with multi-vessel
		disease and in patients with unprotected left main stenosis
Erglis et al., (2007),	103 patients	Myocardial infarction	BMS 7/50 (14%)	Patient population
J Am Coll	with unprotected	by 6 months	PES 5/53 (10%)	is those also ideal
Cardiol,	LMS disease,			for surgery
Australia and	2004–2006	Restenosis	BMS 11/50 patients	Mean age 62
Latvia, [4]			(22%)	Only 6 had previous
	All patients		PES 3/53 patients (6%)	CABG, mean
PRCT	were good		P=0.021	LVEF 54%
(level 1b)	candidates for
	CABG	6 months adverse	BMS 15/50 (30%)
		cardiac-event free	PES 7/53 (13%)
	Randomized to	survival	P=0.036
	express or
	liberte BMS	Mortality at	BMS and PES 1
	or Paclitaxel	6 months	patient each (2%)
	eluting stent
	(PES) with
	cutting balloon
	pre-treatment
	under IVUS
	control
	Clopidogrel,
	Heparin,
	GpIIb/IIIa
	given
	BMS n=50
	PES n=53
Palmerini et al.,	154 patients	30 days		– Short-term
(2006),	underwent			follow-up
Am J Cardiol,	CABG and	Overall mortality	CABG 4.5%
Italy, [6]	157 patients		PCI 3.2%	– Early and
	underwent PCI		P=NS	long-term
Prospective	for left main			mortality were not
cohort study	stenosis (94 DES)	Cardiac related	CABG 3.9%	significantly
(level 2b)		mortality	PCI 2.5%	different between
	From		P=NS	CABG and PCI
	2002–2005
		Myocardial	CABG 1.9%	– Target lesion
	Mean age±S.D.:	infarction at	PCI 4.5%	revascularization
	CABG	30 days	P=NS	was significantly
	69.3±9.5			higher in PCI-treated
	PCI 73.0±10.9	Target lesion	CABG 0.6%	patients
		revascularization	PCI 0.6%
	Left main		P=NS	– Although patients
	disease alone:	Follow-up		treated with drug-eluting
	CABG 5.2%			stents had a
	PCI 12.7%	Overall mortality	CABG 12.3%	25% relative risk
	P<0.001		PCI 13.4%	reduction in the
			P=0.861	rate of major adverse
	Left main lesions			cardiac events
	locations:		CABG 12.3%	compared with
	P=0.742		PCI-DES 11.7%	patients treated
			P=0.968	with bare metal
	Follow-up:			stents, event survival
	430 days	Cardiac related	CABG 9.7%	was still higher in
	(105–730)	mortality	PCI 9.5%	the CABG group
			P=0.994	than in the drug
				eluting stent group
			CABG 9.7%
			PCI-DES 7.4%
			P=0.667
		Myocardial	CABG 4.5%
		infarction	PCI 8.3%
			P=0.170
			CABG 4.5%
			PCI-DES 5.3%
			P=0.690
		Target lesion	CABG 2.6%
		revascularization	PCI 25.5%
			P=0.0001
Chieffo et al.,	142 patients	30 days		The patients
(2006),	underwent			receiving DES
Circulation,	CABG (86	Mortality	CABG 2.1%	were significantly
Italy, [7]	patients had		PCI 0	younger than
	on-pump			CABG patients
Prospective	CABG, 56	Myocardial	CABG 26.5%	(64 vs. 68 years),
Cohort study	patients	infarction	PCI 9.3%	had lower incidence
(level 2b)	underwent off-pump		P=0.0009	of smoking,
	CABG)			significantly less
		Q-wave MI	CABG 3.5%	hypertension, less
	107 patients		PCI 0	diabetes, and
	underwent		P=0.07	significantly less
	PCI-DES for			renal failure
	left main	Target lesion	CABG 2.1%
	stenosis	revascularization	PCI 0	The PCI patients
	(2002–2004)			were therefore
	81.3% of	TVR	CABG 2.1%	fitter than the
	patients		PCI 0	CABG patients
	treated with
	PCI had distal	Follow-up		26% perioperative
	LMCA			MI rate after CABG is
		Mortality	CABG 6.4%	incredibly high, due to
	Mean age±S.D.:		PCI 2.8%	their definition of MI
	CABG		P=0.07
	67.5±9.7
	PCI 63.6±10.3	Myocardial	CABG 1.4%
		infarction	PCI 0.9%
	Renal failure:
	CABG 8.4%	Target lesion	CABG 3.6%
	PCI 1.9%	revascularization	PCI 15.8%
	P=0.02		P=0.001
	Follow-up:	TVR	CABG 3.6%
	1-year		PCI 19.6%
			P=0.0001
Lee et al.,	123 patients	30 days		– PCI with DES is a
(2006), J Am	underwent			viable alternative
Coll Cardiol,	CABG and 50	Mortality	CABG 5%	to CABG for
USA, [8]	patients PCI		PCI 2%	treatment of left
	with DES for		P=0.34	main coronary
Prospective	left main stenosis			artery when
cohort study	(2003–2006)	Myocardial	CABG 2%	clinical judgment
(level 2b)		infarction	PCI 0	was used for
	Mean age±S.D.:		P>0.9	patients allocation
	CABG 70±10
	PCI 72±15	Target vessel	CABG 1%	– There may be an
		revascularization	PCI 0	incidence of late
	Parsonnet score:		P>0.9	complications
	CABG 13.7±9.7			associated with
	PCI 18.3±10.9	In-hospital length	CABG 7.6±4.9	DES that will be
	P<0.01	of stay (days	PCI 3.9±4.5	defined with a
		mean±S.D.)		longer-term
	Follow-up:			follow-up
	CABG 6.7±6.2 months	Follow-up
	PCI 5.6±3.9	(Kaplan–Meier)
		Freedom from	6 months
		mortality	CABG 87%
			PCI 96%
			P=0.861
			1-year
			CABG 85%
			PCI 96%
			P=0.18
		Freedom from TVR	6 months
			CABG 99%
			PCI 93%
			1-year
			CABG 93%
			PCI 87%
			P=0.22
		Target lesion	CABG 3.6%
		revascularization	PCI 15.8%
			P=0.001
		TVR	CABG 3.6%
			PCI 19.6%
			P=0.0001
Tan et al.,	279 patients who	30 days		Complete data
(2001),	had ULMS			regarding RCA are
Circulation,	PCI from 1 of	Mortality	13.7%	unavailable
USA, Europe,	25 sites of	Follow-up
Japan, Korea, [9]	multicenter study			CABG is the first
	(1993–1998)	Mortality	12.2%	choice for ULMS
Prospective
multicenter	46% of patients	Cardiac related	9.1%	PCI is a viable
cohort study	were deemed	mortality		option in AMI,
(level 2b)	inoperable or at			inoperable patients
	high surgical risk	AMI	8.7%	or low-risk patients
	50% had a post	CABG	8.7%
	procedure IABP
	Follow-up:
	1-year (97.1%
	complete)
Kelley et al.,	142 patients	30 days		– Stenting for
(2003), Eur	treated with			unprotected
Heart J, USA,	BMS for LMS	Mortality	LMS 2.1%	LMCA disease in
France, [10]	(1997–2003)		ULMS 9.3%	a high risk
	99 patients with	Follow-up		population is
Retrospective	protected LMS			associated with a
cohort study	43 patients with	Mortality	LMS 5%	poor one-year
(level 2b)	ULMS		ULMS 28%	survival and should
			P<0.0001	only be considered
	ULMS cohort			in the absence
	had significant			of other
	higher age and			revascularization
	percentage of	MI	LMS 3%	options
	AMI and 20%		ULMS 7%
	were in cardiogenic			– BMS procedure
	shock	Target lesion	LMS 18%	for protected
		revascularization	ULMS 23%	LMCA disease is
	MACE:			still associated
	death+non-fatal	MACE	LMS 25%	with increased
	MI+TLR		ULMS 49%	mortality and
			P=0.005	MACE rates
	Follow-up:			compared to PCI
	1-year (96% complete)			of other coronary
				lesions
Valgimigli et al.,	181 patients	30 days		– The use of DES as
(2005),	underwent PCI for			a default strategy
Circulation,	LMS (2002–2003)	Mortality	BMS 7%	to treat LM
Italy, The	95 patients were		DES 11%	disease was
Netherlands,	treated with DES			associated with a
[12]	(52 SES, 43 PES)	MI	BMS 9%	significant
			DES 4%	reduction in
Retrospective	2 cohorts BMS			adverse events
cohort study	(86 patients) and	Target vessel	BMS 2%
(level 2b)	DES (95 patients)	revascularization	DES 0	– CABG should
	with no differences			remain the
	in clinical features	Follow-up		preferred
				revascularization
	Higher prevalence	Mortality	BMS 16%	treatment in good
	of 3-vessel disease		DES 14%	surgical candidates
	and bifurcation			presenting with
	stenting in the DES	AMI	BMS 12%	LM coronary
	group		DES 4%	artery disease
			P=0.006
	Follow-up: mean
	503 days (range	Target vessel	BMS 23%
	331–873)	revascularization	DES 6%
			P=0.004
Agostoni et al.,	58 patients	30 days		– When ostial or
(2005), Am J	electively treated			mid-LM disease is
Cardiol, The	for ULMS	Mortality	3%	treated with DESs,
Netherlands, [13]	(2002–2003)			the rate of cardiac
				events is
	24 procedures with			particularly low
Retrospective	IVUS aid
cohort study		Follow-up		– In patients with
(level 2b)	FU: mean 433 days	(Kaplan–Meier)		distal LM involvement,
	(range 178–780)			the rate of events
		Mortality	5%	was significantly
				higher, but also in
		AMI	3%	this instance, no
				significant clinical
		Target vessel	7%	benefit occurred
		revascularization		in the IVUS subgroup
Jonsson et al.,	1888 patients who	30 days		During the period
(2006), Eur J	had CABG for LM			1970–1999 there
Cardiothorac	stenosis from	Mortality	Overall	was a decrease of
Surg, Sweden,	(1970–1999)	(1970–1999)	LM 2.7%	early and five-year
[19]			No LM 2%	mortality in
	8759 patients		Males	patients with LM
Retrospective	undergone CABG		LM 2.2%	after CABG despite
cohort study	for coronary		No LM 1.9%	increases of patient
(level 2b)	disease with no		Females	age and risk factors
	LM		LM 4.7%
			No LM 2.6%	An increased risk of
	Follow-up: 5 years			early and late
		Follow-up		deaths after CABG
				in patients with
		5-year mortality	Overall	LM stenosis
			LM 10%	compared with
			No LM 8.1%	patients without
			Males	LM stenosis in the
			LM 10.1%	1970s and 1980s
			No LM 8.2%	was neutralised
			Females	during the 1990s.
			LM 9.6%	There has been an
			No LM 7.8%	improvement of
				peri- and
				postoperative
				management of
				patients undergoing
				CABG during this
				time period
Ellis et al.,	107 patients	In-hospital results	4 deaths in Cath lab	Very small numbers
(1997),	treated for LMS		20% in-hospital death	from each centres
Circulation,	disease from 16		10% Q wave MI
USA, [5]	centres		5% CABG
Cohort study	These patients	Event-free survival	88.8±3.5% at 1 month
(level 2b)	represented 0.2%		72.6±5% at 6 months
	of all procedures		71±5% at 12 months
	performed in these
	hospitals	>4 month	22% had restenosis
		angioplasty
	27% were
	inoperable
	30% high risk for
	surgery
	15% prev CABG
	15% acute MI
	Age mean 66
	50% BMS
	24% atherectomy
	20% balloon
	angioplasty
	All had aspirin, 26
	Ticlopidine, 2
	abciximab
	Follow-up
	15±8 months
Park et al.,	1995–2000, 270	Hospital	3 stent thromboses,	Pre-DES era
(2003), Am J	consecutive	complications	3 Q-Wave MIs
Cardiol, South	patients with		No deaths
Korea, [14]	unprotected LMS		3 emergency CABG
	and normal LV
Cohort study	at 4 centres	Angiographic	Restenosis rate
(level 2b)		follow-up	21.1%
	Mean follow-up
	32±18 months	Deaths over mean	20 deaths
		3 years	8 cardiac deaths
	Mean age
	61 years	Target vessel	45 patients (17%)
		revascularization
		3-year freedom	77.7%±2.7%
		from major
		cardiac events
Price et al.,	50 patients with	In-lesion restenosis	21/50 (42%)	84% bifurcational
(2006), J Am	unprotected left			LMS stenting
Coll Cardiol,	main stenosis who	Target lesion	19 (38%)
USA, [17]	had a Sirolimus	revascularization
	eluting stent
Cohort study		Death	5 (10%)
(level 2b)	Patients too high
	risk for CABG or	MACE, death, MI,	22/50 (44%)
	refused CABG	TLR, Thormbosis
	58% had
	EuroSCORE
	predicted mortality
	>5%
	Repeat
	angiography at 3
	and 9 months
Lee et al.,	187 patients	6 months	Restenosis rate 33%	After 2 years there
(2007), Int	undergoing elective	angiography	at 6 months on	were no further
J Cardiol	BMS unprotected		angiography	MIs, deaths or
South Korea,	LMCA stenting			revascularization
[16]	with normal LV	5-year mortality	Mortality 7.6%	procedures
	function from 1995	and MI rate	6/13 cardiac deaths
Cohort study	to 2001
(level 2b)			2 non-fatal MIs
	Follow-up: 5 years
	(71 months	Repeat	Target lesion
	45–117 months)	revascularization	36 patients (21%)
	angiography at		New lesion
	6 months		13 patients (7.6%)
	Mean age 56		20 had PCI, 16 had
	Prev MI 6%		CABG
	EF mean 62%
		Freedom from	1 year – 80%
		MACE	3 years – 78%
			5 years – 78%

Author, date,	Patient group	Outcomes	Key results	Comments
and country
Study type
(level of evidence)
ACC/AHA/SC	Report of the	CABG using IMA grafting is the ‘gold standard’ for treatment of ULM disease and has
AI guidelines,	American	proven benefit on long-term outcomes. The use of DES has shown encouraging short-term
(2005), J Am	College of	outcomes, but long-term follow-up is needed. Nevertheless, the use of PCI for
Coll Cardiol,	Cardiology/	patients with significant ULM stenosis who are candidates for revascularization
USA, [2]	American Heart	but not suitable for CABG can improve cardiovascular outcomes and is a reasonable
	Association	revascularization strategy in carefully selected patients
Guideline	Task Force on
(level 2a)	Practice	PCI is not recommended in patients with asymptomatic ischemia or CCS class I or II
	Guidelines	angina, left main disease and eligibility for CABG
	Practice	Use of PCI is reasonable in patients with CCS class III angina with significant
	guideline group	left main CAD (>50% diameter stenosis) who are candidates for revascularization
	consisted entirely	but are not eligible for CABG. (Level of Evidence: B)
	of cardiologists
	from the 3	PCI is not recommended for patients with CCS class III angina and significant left
	organisations	main CAD and candidacy for CABG. (Level of Evidence: C)
	involved
		Use of PCI is reasonable in patients with UA/NSTEMI with significant left main
		CAD (>50% diameter stenosis) who are candidates for revascularization but are not
		eligible for CABG. (Level of Evidence: B)
		In patients with cardiogenic shock and significant left main disease or severe 3-vessel
		disease and without right ventricular infarction or major comorbidities such as
		renal insufficiency or severe pulmonary disease, CABG can be considered as the
		revascularization strategy
European	Report of the	The presence of a left main (LM) coronary artery stenosis identifies an anatomic subset
Society for	European Society	still requiring bypass surgery for revascularization. PCI of protected LMS (i.e. by a distal graft)
Cardiology	of Cardiology	can be performed although a 1-year MACE of 25% is still rather high, which may
guidelines,		reflect an increased mortality in patients with severe CAD with previous CABG.
(2005),
Eur Heart J, [3]		Stenting for unprotected LM disease should only be considered in the absence of other
		revascularization options. Therefore, PCI can be recommended in these subsets
Guidelines		when bypass surgery has a very high perioperative risk (e.g. EuroSCORE >10%)
(level 2a)
		Until proved otherwise, PCI should be used only with reservation in diabetics with multi-vessel
		disease and in patients with unprotected left main stenosis
Erglis et al., (2007),	103 patients	Myocardial infarction	BMS 7/50 (14%)	Patient population
J Am Coll	with unprotected	by 6 months	PES 5/53 (10%)	is those also ideal
Cardiol,	LMS disease,			for surgery
Australia and	2004–2006	Restenosis	BMS 11/50 patients	Mean age 62
Latvia, [4]			(22%)	Only 6 had previous
	All patients		PES 3/53 patients (6%)	CABG, mean
PRCT	were good		P=0.021	LVEF 54%
(level 1b)	candidates for
	CABG	6 months adverse	BMS 15/50 (30%)
		cardiac-event free	PES 7/53 (13%)
	Randomized to	survival	P=0.036
	express or
	liberte BMS	Mortality at	BMS and PES 1
	or Paclitaxel	6 months	patient each (2%)
	eluting stent
	(PES) with
	cutting balloon
	pre-treatment
	under IVUS
	control
	Clopidogrel,
	Heparin,
	GpIIb/IIIa
	given
	BMS n=50
	PES n=53
Palmerini et al.,	154 patients	30 days		– Short-term
(2006),	underwent			follow-up
Am J Cardiol,	CABG and	Overall mortality	CABG 4.5%
Italy, [6]	157 patients		PCI 3.2%	– Early and
	underwent PCI		P=NS	long-term
Prospective	for left main			mortality were not
cohort study	stenosis (94 DES)	Cardiac related	CABG 3.9%	significantly
(level 2b)		mortality	PCI 2.5%	different between
	From		P=NS	CABG and PCI
	2002–2005
		Myocardial	CABG 1.9%	– Target lesion
	Mean age±S.D.:	infarction at	PCI 4.5%	revascularization
	CABG	30 days	P=NS	was significantly
	69.3±9.5			higher in PCI-treated
	PCI 73.0±10.9	Target lesion	CABG 0.6%	patients
		revascularization	PCI 0.6%
	Left main		P=NS	– Although patients
	disease alone:	Follow-up		treated with drug-eluting
	CABG 5.2%			stents had a
	PCI 12.7%	Overall mortality	CABG 12.3%	25% relative risk
	P<0.001		PCI 13.4%	reduction in the
			P=0.861	rate of major adverse
	Left main lesions			cardiac events
	locations:		CABG 12.3%	compared with
	P=0.742		PCI-DES 11.7%	patients treated
			P=0.968	with bare metal
	Follow-up:			stents, event survival
	430 days	Cardiac related	CABG 9.7%	was still higher in
	(105–730)	mortality	PCI 9.5%	the CABG group
			P=0.994	than in the drug
				eluting stent group
			CABG 9.7%
			PCI-DES 7.4%
			P=0.667
		Myocardial	CABG 4.5%
		infarction	PCI 8.3%
			P=0.170
			CABG 4.5%
			PCI-DES 5.3%
			P=0.690
		Target lesion	CABG 2.6%
		revascularization	PCI 25.5%
			P=0.0001
Chieffo et al.,	142 patients	30 days		The patients
(2006),	underwent			receiving DES
Circulation,	CABG (86	Mortality	CABG 2.1%	were significantly
Italy, [7]	patients had		PCI 0	younger than
	on-pump			CABG patients
Prospective	CABG, 56	Myocardial	CABG 26.5%	(64 vs. 68 years),
Cohort study	patients	infarction	PCI 9.3%	had lower incidence
(level 2b)	underwent off-pump		P=0.0009	of smoking,
	CABG)			significantly less
		Q-wave MI	CABG 3.5%	hypertension, less
	107 patients		PCI 0	diabetes, and
	underwent		P=0.07	significantly less
	PCI-DES for			renal failure
	left main	Target lesion	CABG 2.1%
	stenosis	revascularization	PCI 0	The PCI patients
	(2002–2004)			were therefore
	81.3% of	TVR	CABG 2.1%	fitter than the
	patients		PCI 0	CABG patients
	treated with
	PCI had distal	Follow-up		26% perioperative
	LMCA			MI rate after CABG is
		Mortality	CABG 6.4%	incredibly high, due to
	Mean age±S.D.:		PCI 2.8%	their definition of MI
	CABG		P=0.07
	67.5±9.7
	PCI 63.6±10.3	Myocardial	CABG 1.4%
		infarction	PCI 0.9%
	Renal failure:
	CABG 8.4%	Target lesion	CABG 3.6%
	PCI 1.9%	revascularization	PCI 15.8%
	P=0.02		P=0.001
	Follow-up:	TVR	CABG 3.6%
	1-year		PCI 19.6%
			P=0.0001
Lee et al.,	123 patients	30 days		– PCI with DES is a
(2006), J Am	underwent			viable alternative
Coll Cardiol,	CABG and 50	Mortality	CABG 5%	to CABG for
USA, [8]	patients PCI		PCI 2%	treatment of left
	with DES for		P=0.34	main coronary
Prospective	left main stenosis			artery when
cohort study	(2003–2006)	Myocardial	CABG 2%	clinical judgment
(level 2b)		infarction	PCI 0	was used for
	Mean age±S.D.:		P>0.9	patients allocation
	CABG 70±10
	PCI 72±15	Target vessel	CABG 1%	– There may be an
		revascularization	PCI 0	incidence of late
	Parsonnet score:		P>0.9	complications
	CABG 13.7±9.7			associated with
	PCI 18.3±10.9	In-hospital length	CABG 7.6±4.9	DES that will be
	P<0.01	of stay (days	PCI 3.9±4.5	defined with a
		mean±S.D.)		longer-term
	Follow-up:			follow-up
	CABG 6.7±6.2 months	Follow-up
	PCI 5.6±3.9	(Kaplan–Meier)
		Freedom from	6 months
		mortality	CABG 87%
			PCI 96%
			P=0.861
			1-year
			CABG 85%
			PCI 96%
			P=0.18
		Freedom from TVR	6 months
			CABG 99%
			PCI 93%
			1-year
			CABG 93%
			PCI 87%
			P=0.22
		Target lesion	CABG 3.6%
		revascularization	PCI 15.8%
			P=0.001
		TVR	CABG 3.6%
			PCI 19.6%
			P=0.0001
Tan et al.,	279 patients who	30 days		Complete data
(2001),	had ULMS			regarding RCA are
Circulation,	PCI from 1 of	Mortality	13.7%	unavailable
USA, Europe,	25 sites of	Follow-up
Japan, Korea, [9]	multicenter study			CABG is the first
	(1993–1998)	Mortality	12.2%	choice for ULMS
Prospective
multicenter	46% of patients	Cardiac related	9.1%	PCI is a viable
cohort study	were deemed	mortality		option in AMI,
(level 2b)	inoperable or at			inoperable patients
	high surgical risk	AMI	8.7%	or low-risk patients
	50% had a post	CABG	8.7%
	procedure IABP
	Follow-up:
	1-year (97.1%
	complete)
Kelley et al.,	142 patients	30 days		– Stenting for
(2003), Eur	treated with			unprotected
Heart J, USA,	BMS for LMS	Mortality	LMS 2.1%	LMCA disease in
France, [10]	(1997–2003)		ULMS 9.3%	a high risk
	99 patients with	Follow-up		population is
Retrospective	protected LMS			associated with a
cohort study	43 patients with	Mortality	LMS 5%	poor one-year
(level 2b)	ULMS		ULMS 28%	survival and should
			P<0.0001	only be considered
	ULMS cohort			in the absence
	had significant			of other
	higher age and			revascularization
	percentage of	MI	LMS 3%	options
	AMI and 20%		ULMS 7%
	were in cardiogenic			– BMS procedure
	shock	Target lesion	LMS 18%	for protected
		revascularization	ULMS 23%	LMCA disease is
	MACE:			still associated
	death+non-fatal	MACE	LMS 25%	with increased
	MI+TLR		ULMS 49%	mortality and
			P=0.005	MACE rates
	Follow-up:			compared to PCI
	1-year (96% complete)			of other coronary
				lesions
Valgimigli et al.,	181 patients	30 days		– The use of DES as
(2005),	underwent PCI for			a default strategy
Circulation,	LMS (2002–2003)	Mortality	BMS 7%	to treat LM
Italy, The	95 patients were		DES 11%	disease was
Netherlands,	treated with DES			associated with a
[12]	(52 SES, 43 PES)	MI	BMS 9%	significant
			DES 4%	reduction in
Retrospective	2 cohorts BMS			adverse events
cohort study	(86 patients) and	Target vessel	BMS 2%
(level 2b)	DES (95 patients)	revascularization	DES 0	– CABG should
	with no differences			remain the
	in clinical features	Follow-up		preferred
				revascularization
	Higher prevalence	Mortality	BMS 16%	treatment in good
	of 3-vessel disease		DES 14%	surgical candidates
	and bifurcation			presenting with
	stenting in the DES	AMI	BMS 12%	LM coronary
	group		DES 4%	artery disease
			P=0.006
	Follow-up: mean
	503 days (range	Target vessel	BMS 23%
	331–873)	revascularization	DES 6%
			P=0.004
Agostoni et al.,	58 patients	30 days		– When ostial or
(2005), Am J	electively treated			mid-LM disease is
Cardiol, The	for ULMS	Mortality	3%	treated with DESs,
Netherlands, [13]	(2002–2003)			the rate of cardiac
				events is
	24 procedures with			particularly low
Retrospective	IVUS aid
cohort study		Follow-up		– In patients with
(level 2b)	FU: mean 433 days	(Kaplan–Meier)		distal LM involvement,
	(range 178–780)			the rate of events
		Mortality	5%	was significantly
				higher, but also in
		AMI	3%	this instance, no
				significant clinical
		Target vessel	7%	benefit occurred
		revascularization		in the IVUS subgroup
Jonsson et al.,	1888 patients who	30 days		During the period
(2006), Eur J	had CABG for LM			1970–1999 there
Cardiothorac	stenosis from	Mortality	Overall	was a decrease of
Surg, Sweden,	(1970–1999)	(1970–1999)	LM 2.7%	early and five-year
[19]			No LM 2%	mortality in
	8759 patients		Males	patients with LM
Retrospective	undergone CABG		LM 2.2%	after CABG despite
cohort study	for coronary		No LM 1.9%	increases of patient
(level 2b)	disease with no		Females	age and risk factors
	LM		LM 4.7%
			No LM 2.6%	An increased risk of
	Follow-up: 5 years			early and late
		Follow-up		deaths after CABG
				in patients with
		5-year mortality	Overall	LM stenosis
			LM 10%	compared with
			No LM 8.1%	patients without
			Males	LM stenosis in the
			LM 10.1%	1970s and 1980s
			No LM 8.2%	was neutralised
			Females	during the 1990s.
			LM 9.6%	There has been an
			No LM 7.8%	improvement of
				peri- and
				postoperative
				management of
				patients undergoing
				CABG during this
				time period
Ellis et al.,	107 patients	In-hospital results	4 deaths in Cath lab	Very small numbers
(1997),	treated for LMS		20% in-hospital death	from each centres
Circulation,	disease from 16		10% Q wave MI
USA, [5]	centres		5% CABG
Cohort study	These patients	Event-free survival	88.8±3.5% at 1 month
(level 2b)	represented 0.2%		72.6±5% at 6 months
	of all procedures		71±5% at 12 months
	performed in these
	hospitals	>4 month	22% had restenosis
		angioplasty
	27% were
	inoperable
	30% high risk for
	surgery
	15% prev CABG
	15% acute MI
	Age mean 66
	50% BMS
	24% atherectomy
	20% balloon
	angioplasty
	All had aspirin, 26
	Ticlopidine, 2
	abciximab
	Follow-up
	15±8 months
Park et al.,	1995–2000, 270	Hospital	3 stent thromboses,	Pre-DES era
(2003), Am J	consecutive	complications	3 Q-Wave MIs
Cardiol, South	patients with		No deaths
Korea, [14]	unprotected LMS		3 emergency CABG
	and normal LV
Cohort study	at 4 centres	Angiographic	Restenosis rate
(level 2b)		follow-up	21.1%
	Mean follow-up
	32±18 months	Deaths over mean	20 deaths
		3 years	8 cardiac deaths
	Mean age
	61 years	Target vessel	45 patients (17%)
		revascularization
		3-year freedom	77.7%±2.7%
		from major
		cardiac events
Price et al.,	50 patients with	In-lesion restenosis	21/50 (42%)	84% bifurcational
(2006), J Am	unprotected left			LMS stenting
Coll Cardiol,	main stenosis who	Target lesion	19 (38%)
USA, [17]	had a Sirolimus	revascularization
	eluting stent
Cohort study		Death	5 (10%)
(level 2b)	Patients too high
	risk for CABG or	MACE, death, MI,	22/50 (44%)
	refused CABG	TLR, Thormbosis
	58% had
	EuroSCORE
	predicted mortality
	>5%
	Repeat
	angiography at 3
	and 9 months
Lee et al.,	187 patients	6 months	Restenosis rate 33%	After 2 years there
(2007), Int	undergoing elective	angiography	at 6 months on	were no further
J Cardiol	BMS unprotected		angiography	MIs, deaths or
South Korea,	LMCA stenting			revascularization
[16]	with normal LV	5-year mortality	Mortality 7.6%	procedures
	function from 1995	and MI rate	6/13 cardiac deaths
Cohort study	to 2001
(level 2b)			2 non-fatal MIs
	Follow-up: 5 years
	(71 months	Repeat	Target lesion
	45–117 months)	revascularization	36 patients (21%)
	angiography at		New lesion
	6 months		13 patients (7.6%)
	Mean age 56		20 had PCI, 16 had
	Prev MI 6%		CABG
	EF mean 62%
		Freedom from	1 year – 80%
		MACE	3 years – 78%
			5 years – 78%

BMS, bare metal stent; BS, bifurcation stenting; DES, drug eluting stent; LMCA, left main coronary artery; MACE, major cardiac events; PCI, percutaneous coronary intervention; TLR, target lesion revascularization; SVS, single vessel stenting; TVR, target vessel revascularization; ULMS, unprotected left main stenosis.

6. Comment

In 2005 the ACC/AHA Task Force on Practice Guidelines updated their guidelines for percutaneous intervention [2]. They provided extensive guidance for patients with left main stem disease. They reiterate that CABG remains the gold standard for the treatment of the unprotected left main coronary artery. PCI should only be considered for patients with or without angina if the patient is a candidate for revascularization but who is not eligible for CABG. They further state that patients with unstable angina or NSTEMI with cardiogenic shock and left main stem disease should still undergo CABG.

The European Society of Cardiology Task Force for percutaneous interventions also published practice guidelines in 2005 [3]. They recommended that patients with left main stem disease or diabetics with multivessel disease undergo CABG rather than PCI. They additionally state that PCI could be contemplated in patients with a prohibitively high risk and cited a EuroSCORE risk of over 10% as a guide figure. Of note, in the UK we now perform at around half the EuroSCORE and thus a risk of 10% for CABG would equate to a EuroSCORE of approaching 20.

The most recent study is by Erglis et al. [4] published in August 2007. They performed an RCT of Paclitaxel-eluting stent vs. bare-metal stent in 103 patients who were also good candidates for CABG with mean EF 54%. There were no immediate procedural complications. The 6-month mortality was 2% in both groups. MI rate at 6 months was 14% for BMS and 9% for PES. MACE at 6 months was 30% for BMS and 13% for PES.

Ellis et al. [5] reported the results of 107 patients not eligible for CABG who had LMS disease prior to 1997. Survival was 70% at 12 months and of those who survived to 4 months for an angiogram, 20% had restenosis >50%. Fifty per cent of these patients had BMS, with the remainder having angioplasty or atherectomy.

Palmerini et al. [6] reported a contemporary cohort study of patients with LMS disease. One hundred and fifty-four patients underwent CABG and 157 patients PCI. On mean follow-up of just over a year, 25% of patients undergoing PCI required target vessel revascularization compared to 2.6% in the CABG group (P=0.0001), and 8.3% had an MI compared to 4.5% (P=0.17). One-year PCI mortality was 13%.

Chieffo et al. [7] reported a similar cohort of LMS patients. One hundred and forty-two patients were treated with CABG and 107 a DES during PCI. Of note the PCI patients were younger, had less diabetes, hypertension and smoking than CABG patients. Also the perioperative-MI rate of the CABG patients was reported as 26% at 30 days which seems extraordinary. At one year there was a 20% revascularization rate with PCI vs. 3.6% for CABG. There was no mortality or MI difference at one year. Mortality in the PCI group was 2.8% at 1 year in this group of patients with a mean EuroSCORE of 4.4.

Lee et al. [8] published results of patients with LMS disease followed up for 6 months. The only significant differences between the 123 patients CABG group and the 50 patients DES-PCI group was for target vessel revascularization (CABG 3.6%; DES 19.6%; P=0.0001). Mortality and MI rates were similar. Mortality from PCI was 4% at six months in this group with mean Parsonnet score of 18.

Tan et al. [9] reported their results of BMS-PCI in 279 patients deemed too high risk for CABG from 25 centres. The 1-year mortality/MI/CABG rate in the PCI group was 24% and death was 12%. Their risk scores were not given but 20% were in cardiogenic shock at PCI and 50% had an IABP.

Kelley et al. [10] evaluated clinical outcomes of protected and unprotected left main coronary bare-metal stenting in patients unsuitable for CABG. At 1 year 43 ULMS stents had a 28% mortality and 48% MACE.

Valgimigli et al. [11,12] assessed clinical outcomes of left main stem stenting with 86 DES and 95 BMS patients over a mean of nearly two years. There were significant higher rates of myocardial infarction (DES 4%; BMS 12%; P=0.006) and target vessel revascularization (DES 6%; BMS 23%, P=0.004) for BMS. Mortality at a mean two years was DES 14% and BMS 16%. Mean Parsonnet in the DES group was 19.

Agostoni et al. [13] achieved a 2-year mortality of only 5% in 58 patients undergoing PCI for LMS disease.

Price et al. [17] reported the angiographic findings of LMS stenting with a serolimus stent in 50 patients. At nine months, 38% required revascularization and there was a 44% MACE.

LMS stenting is also not being commonly performed. In a registry of current practice of 7752 patients undergoing PCI treated in 140 centres over 6 months in 2005, 90% received drug-eluting stents but only 110 patients had LMS stenting (2%) [18].

The results of surgery of left main stenosis were reviewed by Jonsson et al. [19]. They compared 1888 patients who underwent CABG for left-main stenosis with 8759 patients who had CABG for coronary disease without left-main disease. During 1970–1984 early mortality was 5.8% in patients with left-main stenosis vs. 1.5% in patients without left-main stenosis. The corresponding rates during 1995–1999 were 2.0% vs. 2.2%. Five-year survival in males with left-main stenosis was 88% after operations performed during 1994–1999. The continuous decline of mortality during three decades most likely reflects improvement of the peri- and postoperative management of patients undergoing CABG during this period.

7. Clinical bottom line

If a bare-metal stent is used for left main stenting the mortality at 1 year may be from 3% to over 28% in reported series. The restenosis rate of the bare-metal stent in the left main position is around 20% at one year. There are some early series and RCTs of drug eluting stents for LMS lesions and the restenosis rate is reported to be around 10%. The European Society of Cardiology in their 2005 PCI guidelines state that CABG is the procedure of choice for left main stem disease and only patients with a prohibitively high surgical risk should be considered. We consider that with such prohibitively high restenosis rates, and with short-term follow-up in such low numbers and short periods compared to coronary artery bypass grafting, left main stenting should only be used as a last resort in patients turned down for coronary artery bypass grafting after full assessment by a cardiac surgeon due to prohibitive co-morbidities.

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Article Contents

For which patients with left main stem disease is percutaneous intervention rather than coronary artery bypass grafting the better option?

Abstract

1. Introduction

2. Clinical scenario

3. Three-part question

4. Search strategy

5. Search outcome

6. Comment

7. Clinical bottom line

References

Citations

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Article Contents

For which patients with left main stem disease is percutaneous intervention rather than coronary artery bypass grafting the better option? Free

Abstract

1. Introduction

2. Clinical scenario

3. Three-part question

4. Search strategy

5. Search outcome

6. Comment

7. Clinical bottom line

References

Citations

Views

Altmetric

Email alerts

Related articles in

Citing articles via

Latest

Most Read

Most Cited

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For which patients with left main stem disease is percutaneous intervention rather than coronary artery bypass grafting the better option?