LEFT MAIN PCI, LEFT MAIN STENTING

1. LEFT MAIN PCI
Dr Virbhan Balai
FNB (Interventional Cardiology) Fellow
MSSH, Saket, New Delhi

2. INTRODUCTION
LMCA ds was first described by James
Herrick in 1912.
First LM PCI done by Andreas Gruntzig in
1978 using POBA.
Clinically sig. LMCA ds is found in 3% - 5%
of all pt`s who undergo CAG, and in 10% -
30% of pt`s who undergo CABG.

3. ANATOMY AND PATHOLOGY
LMCA supplies on av. 75% of the LV.
Examination of 100 autopsy cases found that
LMCA had an av. length of 10.8 ±5.2 mm
(range 2-23 mm), an av. diameter of 4.9 (±0.8)
mm, with an av. br`s angle of 86.70 ±28.8
(range 40 - 1650).
Clin Anat. 2004;17:6–13

4. LMCA is divided into three anatomic regions:
1.Ostium (26%) 2. Midshaft (8%) 3. Distal
bifurcation (66% Atherosclerosis- i.e 2/3rd)
Distal bif. of LMCA is most susceptible to the
dev. of an atherosclerosis bcz of low shear flow
disturbance.
In bif. Lat. wall (wall opp. the flow divider)- is
the most freq site of atherosclerotic plaque
accumulation, ,whereas the flow divider (the bif.
carina) is usually spared bcz of high shear stress.

5. Several etiologies contribute to LMCA
stenosis.
The most frequent cause is atherosclerosis.
IVUS analysis demonstrates the diffuse nature
of LMCA ds, LMCA to the LAD in 90% of
pt`s and to the LCX in 62% of p`ts.
Cardiovasc Interv.2010;3:105–112

6. Causes of LMCA Stenosis

7. Definition of Sig. LMCA Stenosis
Int. LMCA stenosis can be directly assessed by
FFR.
FFR <0.80 = sig. LMCA stenosis.
LMCA with downstream stenoses in the LAD
and/or LCX, FFR measured across the LMCA
stenosis will be increased leading to
underestimation of the lesion significance.
However, in vivo study found that unless
downstream stenosis is very sig. its impact is
clinically negligible.

8. Indications for revasc. in pt`s with stable angina
ESC 2018

9.  IVUS -: useful tool to determine the significance of LMCA stenosis.
 Jasti and colleagues reported that a MLA of 5.9 mm2 had the highest sensitivity and
specificity (93% and 95%, respectively) for determining a sig. LMCA stenosis,
compared with FFR as the gold standard.
Circulation. 2004;110:2831-2836.
 Park and colleagues found the IVUS MLA < 4.5 mm2 in LMCA, best predicted
FFR < 0.80
JACC Cardiovasc Interv. 2014;7:868–874.
 PPV of IVUS- MLA < 4.5 mm2 is 84%.
 Thus, if an FFR measurement is not feasible or unreliable, IVUS MLA criteria can
be used.

10. Indications for LM treatment
Angiographic stenosis >50% and the proof of
myocardial ischemia.
If there is angiographic ambiguity,, IVUS
derived MLA < 6 mm2 and FFR < 0.80.
Evaluation of a LM stenosis with FFR may be
inaccurate if LAD or CX disease is present.

11. STENTING TECHNIQUES
Ostial and Shaft Lesion
LMCA ostial and shaft lesion stenting can be
performed safely- JL GC, 7F
Coaxial alignment of the guiding catheter is imp
to minimize ostial injury and to ensure proper
positioning of the stent.
Once the balloon or stent is properly positioned,
the GC can be gently retracted 1- 2 cm into the
aorta with gentle forward pressure on the device
catheter.

12. In case of ostial lesion, Prox. stent edge is
positioned slightly outside the ostium and
flaring is done against the aortic wall.
Balloon inflations (<30 sec) to avoid
prolonged global ischemia.
High-pressure post dilation - to achieve an
optimal stent CSA.

13. Bifurcation Lesion
High rate of adverse clinical events.
Sig. ds in the LCX ostium is an imp. factor in
choosing a stenting strategy.
Elective two-stent tech. is preferred in pt`s with
sig. LCX ostial stenosis with a dominant LCS .
When there is angio ambiguity of LCX ostium,
direct imaging of LCX ostium using IVUS may
prevent LCX occlusion or unnecessary complex
bif. intervention.

14. Single-Stent Crossover Stenting in the Tt of ULMCA
Stenosis

15. Provisional One-Stent Strategy
To facilitate rewiring, a wire is placed in the
LCX before stenting LAD when there is
1. Narrowing at the LCX ostium
2. Severe stenosis of the main branch, with a
large plaque burden at risk for plaque
shifting.
3. Narrow angle of the LCX origin
4. Deterioration of the LCX ostium after
predilation of the main branch.

16. Pt`s who develop ischemic symptoms require
further SB intervention.
As a bailout procedure for a suboptimal balloon
result or sig. dissection at the ostial LCX,
provisional T-stenting or a reverse crush tech. are
often used, in which case a FKBI is mandatory.
FKBI after single-stent crossover in LMCA bif. is
not routinely performed unless the LCX flow is
compromised.
FFR-guided decision for LCX intervention after
main vessel stenting is often helpful.

17. Compared with two-stent tech. the provisional
one-stent approach for distal LMCA bif. is
associated with more favorable outcomes, and
lower MACE, death, MI, stent thrombosis, and
target-vessel revas..
Therefore, the provisional one-stent approach
has been preferred in the Tt of LMCA bif.
stenosis.

18. Elective Two-Stent Strategy
If the LCX is large (left-dominant system) and at
high risk of flow compromise after crossover
stenting (narrow angle, sig. ostial stenosis), an
initial two-stent tech is preferred.
These tech fall mainly into four broad categories:
T-stenting
Crush stenting and its variants
Culotte stenting
Simultaneous kissing stenting

19. Two-Stent Techniques
Advantages Disadvantage

20. Although better outcomes were reported with
the DK-crush tech than with the culotte tech in
the randomized trial, no consensus has been
reached as to which two-stent approach might
be better than others.
Selecting proper stenting tech should depend
on the pt’s clinical manifestations, LMCA bif.
morphology, and the operator’s preference.

21. FKBI should be done in all two-stent tech to
avoid mal apposition or under expansion of stents.
POT is also imp bcz it promotes adequate stent
apposition in the LM, helps avoid abluminal
rewiring, and facilitates rewiring the LCX through
a distal stent cell.
Post stent, high pressure ballooning to achieve
sufficient stent expansion. Confirmed by final
IVUS.
Several dedicated stents for bifurcations have
been tested for the Tt of LMCA ds.

22. IVUS Guided LM Stenting
IVUS - lumen size, plaque characterization,
and disease distribution, result in optimal stent
sizing, length, and positioning.

23. MSA for the prediction of angiographic ISR

24. IVUS MSA correlating with lower angiographic
restenosis are 5.0 mm2 for the LCX ostium, 6.3
mm2 for the LAD ostium, 7.2 mm2 for the
polygon of confluence, and 8.2 mm2 for the
proximal LMCA (5-6-7-8 rule of criteria)
IVUS evaluation after stent implantation and
should make an effort to achieve above stent areas
using adjunctive high pressure balloon dilations.
Currently, all studies uniformly indicate that
IVUS guided LMCA stenting plays a role in
improving long-term clinical outcomes.

25. In a multicentre, prospective study,
revascularization was mainly deferred if the MLA
was > 6 mm2 and performed in cases of an
MLA> 6 mm2.
After a 2 year follow-up, cardiac death-free
survival was similar in both groups (98 and 95%,
respectively).
• J Am Coll Cardiol 2011; 58:351–358
Asian pt`s with generally smaller heart sizes,
studies have suggested that an IVUS MLA of 4.5–
4.8 mm2 may be the most appropriate.
JACC Cardiovasc Interv 2014;7:868–874

26. Recommendations on functional testing and
IVUS for lesion assessment- ESC 2018

27. Hemodynamic Support and
Cardiogenic Shock
 Pt`s with normal LV function tolerate global ischemia
during balloon and stent occlusion.
 IABP should be used to prevent hemodynamic collapse in
Pt`s with severely depressed LV function.
 More advanced support (e.g., Impella; Abiomed, Danvers,
MA) may be indicated for high-risk pt`s - : low LVEF, very
calcified stenosis, or thrombus-containing LMCA stenosis.
 Despite the remarkable advancement of hemodynamic
support, outcomes of card. shock due to LMCA ds have not
much improved.
 Heart transplantation or LVAD should be considered earlier

28. Medical Treatment Vs
Revascularization
Prognosis of pt`s with medically treated LMCA ds is
very poor: early observational studies found 3-year
survival rates of 50%.
Small controlled trials to compare CABG with medical
therapy found that CABG provided a survival benefit in
pt`s with angio sig. LMCA stenosis.
Meta-analysis of seven randomized trials demonstrated
that the 5-year RR reduction for mortality provided by
CABG over medical therapy was greater for LMCA ds
than for TVD or 1VD- or 2VD.

29. Distal LM bifurcation lesions

30. LM Bifurcation Intervention

31. PCI for ULMCA
Balloon Angioplasty and Bare-Metal Stenting
Attractive target for balloon angioplasty bcz of its
large caliber, short lesion length, and lack of
tortuosity,
Adoption of metallic stents overcame the inherent
limitations of balloon angioplasty (i.e., acute
recoil, abrupt closure, or dissection).
Excessive risks of restenosis and repeat revas.
With BMS hampered the LMCA stenting.

32. Drug-Eluting Stent Implantation
The I/C Stenting and Angio Results: DES for
Unprotected Coronary Left Main Lesions 2
(ISAR LEFT MAIN 2) trial : found that the
zotarolimus-eluting stent and the everolimus-
eluting stent for Tt of ULMCA ds provided
comparable clinical and angiographic
outcomes at 1-year follow-up.
J Am Coll Cardiol. 2013;62:2075–2082

33. STENT THROMBOSIS AND ANTIPLATELET THERAPY
AFTER DES IMPLANTATION
SYNTAX trial found LMCA PCI with DES was
associated with a lower risk of ST.
Rates of ST in pt`s who received DES
implantation for LMCA ds among several large
observational and randomized studies have been
lower or, at worst, similar to rates of ST compared
with pt`s with other coronary lesions in routine
clinical practice.
Therefore, prolonged DAPT therapy or a more
potent regimen may not be necessary for the
prevention of ST after LMCA stenting.

34. ISR After LMCA DES
Rates of angiographic restenosis after LMCA
stenting with a DES vary widely, from 8% -42%.
J Am Coll Cardiol. 2011;57:1349–1358.
Restenotic lesions, complex stenting with two or
more stents in a bif. lesion, the total number of
stents, and bif. lesions were identified as
independent predictors of ISR.
LCX ostium was the most common location of
the restenosis.

35. Underexpansion of stents and neointimal hyperplasia
are the most imp. mech of ISR.
Real world registry studies reported that most pt`s with
left main ISR were treated by PCI, and approximately
10% of pt`s received CABG as an initial Tt strategy.
Long-term outcome was favorable regardless of revas.
strategies.
Angiographic surveillance did not affect the pt’s long-
term outcomes; therefore, routine angio follow-up is
not recommended after LMCA PCI.
J Am Coll Cardiol. 2011;57:1349–1358.

36. PCI Vs CABG in LMCA Stenosis
Registry Data
Revascularization for ULMCA Stenosis: Comparison
of PCI Vs Surgical Revascularization
(MAINCOMPARE) registry included 2240 pt`s with
unprotected LMCA ds who underwent stenting (BMS:
n = 318, first-gen DES: n = 784) or CABG (n = 1138)
at 12 major cardiac centers.
5-year f/u results found that the risk of mortality and
composite of death, Q-wave MI, or stroke were similar
b/w the PCI and CABG groups; however, the rate of
repeat revas. was sig. higher in the PCI group.
J Am Coll Cardiol. 2010;56: 117–124.

37. DES for LMCA (DELTA 1) registry: included 1874 pt`s
who underwent LM PCI with mostly first-gen DES and
900 pt`s who underwent CABG.
No difference was observed in the occurrence of death,
stroke, and MI b/w PCI and CABG at a median f/u of
3.5 years.
TVR was higher in the PCI group.
For the Tt of LMCA ostial and shaft lesions, PCI
showed very favorable clinical outcomes, comparable
to CABG.
JACC Cardiovasc Interv. 2012;5:718–727.

38. DELTA 2 registry, which enrolled 3986 pt`s
who underwent LMCA PCI with 2nd gen DES,
compared outcomes with the CABG cohort
from the DELTA 1 registry.
PCI was associated with a similar rate of death
or MI,, but stroke was higher in CABG and
TVR was higher in PCI.
JACC Cardiovasc Interv. 2017;10:2401–2410.

39.  Large, multinational, all-comers Interventional Research
Incorporation Society-Left MAIN Revascularization (IRISMAIN)
registry evaluated secular trends in pt. characteristics, Tt, and
outcomes over the last two decades.
 Showed that over time, the proportion of PCI Tt has progressively
increased, whereas the opposite trend has been noted for CABG Tt.
 Risk-adjusted survival, composite outcomes, and repeat revas. have
significantly improved for PCI over time, but remained stable for
CABG.
 Although the outcomes of medical therapy alone also observed to
improve, medical therapy has always been inferior to revas.
strategies in LMCA.
J Am Coll Cardiol. 2016;68:1233–1246.

40. Randomized Trials
The Left Main Coronary Artery Stenting (LE MANS)
trial was the first randomized comparison of PCI with
stenting (52 pt`s) and CABG (53 pt`s) for Tt of LMCA
stenosis with or without MV CAD.
DES in 35% of PCI pt`s, LIMA grafts were used in
72% of CABG pts.
At 1 year, pri. end point of absolute change in LVEF
was sig. greater in the PCI group compared with the
CABG group, whereas the sec. end points—survival
and MACCEs—were comparable in the two groups.

41. SYNTAX trial, LM subgroup no sig. diff. in the
pri. end point of MACCE (37% vs. 31%), death
(13% vs. 15%), or MI (8% vs. 5%) b/w PCI with
paclitaxel-eluting stent and CABG of up to 5
years.
PCI pts had a lower stroke (2% vs. 4%), but a
higher revas. (27% vs. 16%) compared with
CABG pts.
Pts with high SYNTAX scores (≥33)—had higher
death and revas. rates in the PCI arm.

42. The Premier of Randomized Comparison of
Bypass Surgery Vs Angioplasty Using SES in Pt`s
With LMCA Disease (PRECOMBAT) trial:
first, LMCA-specified, moderate-sized, RCT
comparing PCI with SES & CABG.
At 5 years, the rates of MACCE (18% vs. 14%),
death (6% vs. 8%), MI (2% vs. 2%), or stroke
(1% vs. 1%) were similar b/w PCI and CABG.
However, TVR occurred more commonly after
PCI than after CABG (11% vs. 6%).
J Am Coll Cardiol. 2015;65:2198–2206.

43. At 10 years, primary outcome of death, MI,
stroke, or ischemia driven TVR occurred in
29.8% vs 24.7% (p=NS) resp for PCI Vs
CABG.
Death 14.5% Vs 13.8% (p=NS), MI 3.2% Vs
2.8% (p=NS), Stroke 1.9% Vs 2.2% (p=NS),
ischemia driven TVR 16.1% vs 8% (p=< 0.05)
resp PCI Vs CABG.

44.  The Everolimus-Eluting Stents or Bypass Surgery for Left Main
Coronary Artery Disease (EXCEL) trial :
 1,905 pts with LMCA ds and low or int. anatomical complexity
(SYNTAX score ≤32), PCI group= 948 pts, CABG group= 957 pts.
 PCI was performed with a 2nd gen. everolimus-eluting stent.
 At 3 years, PCI was noninferior to CABG with respect to the pri.
composite end point of death, stroke, or MI (15.4% vs. 14.7%).
 At 30 days, primary end point was lower after PCI than after CABG
(4.9% vs. 7.9%), b/w 30 days and 3 years, fewer primary end point
events occurred in the CABG group than in the PCI group.
N Engl J Med. 2016;375:2223–2235.

45.  At 5 years, pri. outcome event had occurred in 22.0% of the
pts in the PCI group and in 19.2% of the pts in the CABG
group (; P=0.13).
Death from any cause occurred more frequently in the PCI group
than in the CABG group (in 13.0% vs. 9.9%; difference, 3.1
percentage points; 95% CI, 0.2 to 6.1).
PCI and CABG groups, the incidences of definite CV death
(5.0% and 4.5%, resp;) and MI (10.6% and 9.1%) were not
significantly different.
All cerebrovascular events were less freq after PCI than after
CABG (3.3% vs. 5.2%), although the incidence of stroke was
not significantly diff b/w the two groups (2.9% and 3.7%).
Ischemia-driven revas. was more freq after PCI than after CABG
(16.9% vs. 10.0%).

46.  The Nordic-Baltic-British left main revascularization study
(NOBEL) trial
 1201 pts, PCI (n=598),CABG (n=603), biolimus-eluting
stent (89%).
 5-year rate of the pri. end point of MACCE (death,
nonprocedural MI, repeat revas, or stroke) was significantly
higher after PCI compared with CABG (28% vs. 18%).
 5-year rate of nonprocedural MI (6% vs. 2%) and any revas.
(15% vs. 10%) were also higher after PCI.
 Unexpectedly, at 5-year follow-up, the rate of stroke tended
to be higher in PCI pts than in CABG pts (5% vs. 2%).
 However, the 5-year rate of death was similar b/w PCI and
CABG (36% vs. 32%).

47. RCT`s to compare PCI with CABG
SYNTAX PRECOMBAT

48. EXCEL NOBLE

49. Meta-analysis
 A metanalysis of six randomized trials found at a median f/u
of 39 months, there were no sig b/w-group differences in the
risk of all-cause mortality, cardiac mortality, MI, or stroke.
 PCI was associated with higher rates of repeat revas. compared
with CABG in all tertiles of SYNTAX score, and therefore
is associated with a greater risk for the long-term composite
end point of death, MI, stroke, or repeat revas.
 Based on SYNTAX score cat. there were no sig. differences
in the incidence of all cause mortality, MI, or stroke.
 However, the incidence of repeat revas was lower in the
CABG group regardless of SYNTAX score.
Am Heart J. 2017;190:54–63.

50. Meta-analysis of six RCT`s

51. CURRENT STATUS OF LM-PCI
AND SELECTION OF REVAS. STRATEGY
 2018 ESC and ACC/AHA Guidelines, CABG
is a class IA for LMCA revasc.
 LM-PCI is a I A, IIa, or III B based on
SYNTAX score.

52. Recommendation for the type of revasc. in pt`s with stable CAD
with suitable coronary anatomy for both procedures and low
predicted surgical mortality

53.  2014 US focused update for the diagnosis and
management of pt`s with stable IHD are
currently
1) Class IIa if SYNTAX score is low
2) Class IIb if SYNTAX score is intermediate
3) Class III if SYNTAX score is high
 Both US and European guidelines emphasize
the need for a Heart Team approach for
deciding revasc. strategies for LMCA disease.

57. CONCLUSIONS
CAG has limitations in assessing LMCA ds and guiding
Tt.
Current evidence from clinical trials and extensive off-
label experience indicates that LMCA PCI shows
mortality and morbidity rates comparable to CABG,
esp in pt`s with low and int. lesion complexity.
An integrated approach that combines more advanced
devices with specialized tech`s, adjunctive physiologic
and imaging support, and adjunctive pharmacologic
agents has greatly improved PCI success rates and long
term clinical outcomes for these complex lesions.

58.  Coronary physiology and imaging modalities is helpful to
improve outcomes following LMCA stenting.
 Long-term prognosis following ostial or shaft LMCA
stenting is excellent.
 Achieving sufficient MSA after LMCA stenting is of
paramount importance to prevent ISR & adverse clinical
outcomes.
 PCI offers early safety advantages, whereas CABG offers
greater durability with respect to freedom from repeat revas.
 Optimal choice of revas. modality for LMCA ds should take
into account the specific circumstances of each pt, pt
preferences, and suitability of PCI or CABG.

59. THANK YOU

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67. Recommendation for the type of revascularization in patients with stable
coronary artery disease with suitable coronary anatomy for both procedures
and low predicted surgical mortalityd