Left Main madrid 2013, Dr Antonio Colombo

Antonio Colombo
Centro Cuore Columbus and
S. Raffaele Scientific Institute, Milan, Italy
Madrid: 2-4 October 2013
Speaker – 15’
Complex Coronary Interventions – PART 2
Round Table 1 –Left Main Coronary Treatment

A case for surgery even in the era
of Drug Eluting Stent

ESC guidelines 2010 – CABG vs. PCI
• Left main (isolated or 1VD ,ostium/shaft)
- CABG = IA, PCI = IIa B
• Left main (isolated or 1VD, distal bifurcation)
- CABG = IA, PCI = IIb B
• Left main + 2VD or 3VD,SYNTAX score < 32
- CABG = IA, PCI = IIb B
• Left main + 2VD or 3VD,SYNTAX score 33
- CABG = IA, PCI = III B
* I/IIb/III = recommendation class, A/B = level of evidence

Guidelines summary
• CABG gold standard but PCI good option in
ostial/shaft disease or when SYNTAX ≤ 22 and risk of
surgical complications is relatively high
• PCI also acceptable in high surgical risk patients with
distal LM disease or when SYNTAX ≤ 32
• PCI should not be performed in patients who can
undergo CABG and have unfavourable anatomy
(SYNTAX > 33)

SYNTAX 0-22
SYNTAX 23-32
SYNTAX ≥ 33
SYNTAX trial MACE subanalysis – LMS and SYNTAX score
CABG
PCI

DELTA substudy – ostial/midshaft vs. distal LMS
Difference in MACE driven by TVR with no difference in all-cause death
or composite of all-cause death and MI
Distal
Ostial
/midshaft

5 yrs. results in the LM COMPARE trial,
SJ Park et al. JACC Inter

PCI and CABG do not work by intention to treat
The most important issue is long term results
In PCI success is “WRONGLY” defined
as successful stent placement
Optimal: IVUS confirmed stent placement,
should be (in my view) the gold standard

591 (85.8%) patients treated with DES for ULM
between April 2002 and December 2010
349 (55%) patients treated using 1-stent 266 (45%) patients treated using 2-stent
Exclusion criteria
Acute MI, ISR, dissection and CABG
75 (28.2%) Mini-crush or T-stenting
52 (19.5%) Culotte stenting
32 (12.0%) SKS or V-stenting
51 (19.2%) Crush stenting
29 (10.9%) Provisional T, TAP-stenting
325 (93.1%) LM-LAD stenting
24 (6.9%) LM-LCx stenting
494 patients (84.0%) with angiographic follow-up
84 ostial/ body ULM lesion
14 ULM treated with 3-stent
689 patients treated with DES for ULM
between April 2002 and December 2010
In Milan and New-Tokyo
The overall cardiac-death, MI and MACE during
the follow-up (median 24 months) occurred in 4
(5.1±2.5%), 2 (2.9±2.0%) and 31 (38.2±5.4%)
patients respectively. Repeat-TLR occurred in 28
(34.7±5.3%) patients.

Main findings
• The main issue in LM disease is not LM
disease but associated 3V disease
• In LM bifurcation lesions restenosis of the
LCx is frequent but does not impact on
mortality (the obsession of LCx restenosis)

Index procedure
Baseline
September 2004

Left Main restenosis
September 2004
Final Result
Cypher Mini-Crush

Routine follow-up, pt. asymtomatic
Febr 2005
5- Month FU No Treatment

Left Main restenosis
Febr 2005
5- Month FU No Treatment

2nd FU: pt asymptomatic
June 2005
8- Month After LM stent

June 2005
8- Month After LM stent

LCx restenosis
June 2005
8- Month After
Cypher V-Stenting
Final Result

LCx restenosis
March 2006 17- Month After first PCI
No Treatment
9- Month After Second PCI

LCx restenosis
November 2008
Baseline

LCx restenosis
November 2008
Endeavor Resolute Culotte

LCx restenosis
November 2008
Final Result

Baseline Angiographic and Procedural Characteristics of
Patients Treated for UDLM According to Original
1-Stent Strategy or 2-Stent Strategy (I)
Patients: n (%)
All patients
(n=474)
1-Stent Strategy
(n=280)
2-Stent Strategy
(n=194)
P value
LM+ 3VD 168 (41.4) 90 (36.9) 78 (48.1) 0.03
High SYNTAX
score
144 (39.2) 88 (38.6) 56 (40.3) 0.83
Stenosis of Left
circumflex >75%
176 (37.4) 71 (25.4) 105 (54.1) 0.001
Stenosis Length of
Left circumflex
>10mm
93 (22.1) 38 (15.3) 55 (32.2) 0.003
True-Bifurcation
Medina 111,101,011
291 (61.4) 134 (47.9) 157 (80.9) 0.001
ISR=In-stent Restenosis. UDLM=Unprotected Distal Bifurcation Left Main. LM= Left Main Coronary
Artery. VD= Vessel Disease. IABP= Intra Aorta Balloon Pumping. IVUS=Intra Vascular Ultra Sound

Patients: n (%)
All patients
(n=474)
1-Stent Strategy
(n=280)
2-Stent Strategy
(n=194)
P value
IABP 66 (14.5) 27 (10.3) 39 (20.4) 0.003
IVUS 230 (48.5) 147 (52.5) 83 (42.8) 0.04
Rotational
Atherectomy
34 (7.5) 23 (8.4) 11 (6.0) 0.37
Total Stent Length 25.97±12.05 22.47±7.19 30.85±15.35 0.001
Baseline Angiographic and Procedural Characteristics of
Patients Treated for UDLM According to Original
1-Stent Strategy or 2-Stent Strategy (II)

Outcome at 3 Years of Patients Treated for UDLM
According to Original 1-Stent Strategy or
2-Stent Strategy
Patients: n (%)
All patients
(n=474)
1-Stent Strategy
(n=280)
2-Stent Strategy
(n=194)
P value
Angiographic
follow-up
405(89.8) 234 (89.3) 171 (90.5) 0.48
All-death 38 (8.5) 24 (9.0) 14 (7.7) 0.74
Cardiac-death 21 (4.5) 14 (5.1) 7 (3.6) 0.37
Non Cardiac death 17 (3.6) 10 (3.6) 7 (3.6) 0.49
In-stent restenosis 85 (17.9) 35 (12.5) 50 (25.8) 0.01
In-stent restenosis
at the ostial LCX
41 (8.6%) 14 (5.0%) 27 (13.9%) 0.001
Myocardial
Infarction
6 (1.3) 3 (1.1) 3 (1.6) 0.10

IVUS evaluation mandatory
every time 2 stents are
implanted:
If IVUS cath does not cross the
stent perform a better postdilatation

Before
After
After appropriate
sizing

Distal Left Main Bifurcation in
a Patient with Low EF
 87 Y old Gentleman High 160 cm –Weight 59 Kg
 Effort Angina Class III
 Hypertension
 No Diabetes
 Creatinine 2.0 mg%-ml
 No prior PCI
 No associated medical condition
 Positive Exsercise Test at Low Level
 EF 25%
 Mitral Insufficent grade III
 45 mmHg Pulmonary Pressure
67198/12 HSR
History

Baseline – IABP in place
67198/12 HSR

Rotablator – 1.5 mm BURR
67198/12 HSR

Following Rotablator toward LCX
67198/12 HSR

67198/12 HSR
Following Rotablator toward LAD

3.0mm NC Balloon to LAD
67198/12 HSR
2.5 mm NC Balloon to LCX

67198/12 HSR
Kissing Balloon
3.0mm NC Balloon to LAD
2.5 mm NC Balloon to LCX
Stenting LAD
3.0 - 14 mm

67198/12 HSR
Post Dilatation
Prox-LAD Stent with
3.0 mm NC Balloon Following LAD Post Dilatation

67198/12 HSR
Struts open toward LCX

67198/12 HSR
2.5 – 8 mm to LCX
With TAP Technique

67198/12 HSR
Stenting LCX Kissing Balloon

67198/12 HSR
Final Result

67198/12 HSRFinal Result

Baseline
27287/09CCC
After stent
Resolute 2.5x12mm

27287/09CCC
Predilation of LAD with wire protection of 2
Septals, Intermediate and Circumflex

27287/09CCC
Kissing Inflation after stenting of LAD towards LM
LAD 3.5mm balloon
LCX 2.5mm balloon
Ramus 2.0mm balloon

27287/09CCC
After Kissing Inflation and LAD stenting

27287/09CCC
After Kissing
Inflation
intermediate
Distal LM

27287/09CCC
T stenting towards Cx and Intermediate
with 4 mm Balloon inflated in LAD

27287/09CCC
LAD: 4.0mm
balloon
LCX : 2.5x30mm
Resolute
Ramus : 2.5x30mm
Resolute

27287/09CCC
LAD: 4.0mm Quantum -23 Atm
LCX : 2.5mm Quantum 25Atm
Ramus : 2.5mm Quantum 25Atm
High pressure NC Balloons postdilation

27287/09CCC
Intermediate
LCX
Distal LM

27287/09CCC
Distal LM
Intermediat
e

1. Occlusion of the LAD or of the RCA which cannot be opened by
PCI and with viable myocardium. Chronic occlusion of the RCA and
sometimes even of the LAD can left untreated in elderly people
with reduced physical activity.
2. Complex and calcific distal left main bifurcation and the PCI
operator does not feel confident to treat or she/he does not expect
to obtain a good final result
3. Long diffuse disease in the proximal LAD (needs a stent longer
than 30-35 mm) in a patient with diabetes mellitus
4. A patient who has or may have problems with dual antiplatelet
therapy
Conditions were CABG may be a better choice
compared to PCI in patients with Left Main Stenosis:

Left Main madrid 2013, Dr Antonio Colombo

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