Trifurcation left main coronary artery percutaneous revascularization—Pushing catheters and envelopes

Registry data from high-volume centers have shown that percutaneous coronary intervention (PCI) of unprotected left main coronary artery lesions among select patients to be feasible and yield an outcome respectably similar to that anticipated following coronary artery bypass grafting (CABG). For example, Chieffo et al. [1] pooled prospective registry data from five centers including 731 consecutive patients receiving a drug-eluting stent (DES) for unprotected left main coronary artery disease (ULMCAD). At approximately 2.5-year follow-up, the authors reported that cardiac death occurred in 4.2%, whereas subsequent target vessel revascularization (either percutaneous or surgical) was needed in 13.0%. These findings are very impressive, and likely reflect expert care and detailed attention to patient characteristics. Chieffo et al. noted that predictors of cardiac death included low left ventricular ejection fraction, presence of unstable angina, and a higher EuroSCORE [2]. Another noteworthy report included patients with ULMCAD in a PCI registry who were systematically matched with a cohort of surgical patients. Specifically, Seung et al. [3] collected data from 12 medical centers in Korea and compared the outcome among 2,240 patients who underwent percutaneous or surgical revascularization for ULMCAD. Considering PCI patients who received a DES, 396 were able to be well matched using propensity scores with 396 patients undergoing CABG. At 3-year follow-up total mortality (cardiac and non-cardiac) was 9.0 and 6.9% for the PCI-DES group and the matched CABG group, respectively. During this same interval, the corresponding rates of target vessel revascularization were 9.3 and 1.6%, respectively. The authors concluded that for their patients with ULMCAD, the rates of death or a composite of death, myocardial infarction, and stroke were similar overall between those who received a stent versus bypass surgery, but the stent group (both bare-metal and drug-eluting) had higher rates of target vessel revascularization compared with those undergoing CABG. Most recently The Synergy Between PCI with TAXUS and Cardiac Surgery (SYNTAX) trial investigators [4] reported their preliminary findings from 705 patients with ULMCAD who were randomized to PCIDES (paclitaxel-eluting) or CABG. At 1-year followup, mortality rates were similar for those receiving DES versus CABG (4.2 and 4.4%, respectively) as were the composite rates of death, myocardial infarction, and stroke (7.0 and 9.1%, respectively). As in prior studies, the occurrence of target vessel revascularization was more frequent among those randomized to DES as compared with CABG (12.0 vs. 6.7%). Importantly, in an analysis of the SYNTAX dataset stratifying patients who had isolated ULMCAD or left main disease along with single-, double-, or triplevessel CAD, adverse event rates were progressively greater among those randomized to DES as the distribution of disease increased. In this issue of Catheterization and Cardiovascular Interventions, Sheiban et al. [5] report their 5-year experience with PCI of ULMCAD involving trifurcation disease. Among the 27 patients studied, 14 had true trifurcation stensoses (i.e. involving the distal left main and the ostia of the left anterior descending, circumflex, and ramus intermedius coronary arteries). All but one patient received a DES, though 29% of patients also received a bare-metal stent. Eleven patients (40%) received a main branch stent only, and a T-stent or V-stent technique was used in the remainder. At 2.3-year follow-up, cardiac death occurred in 14.8% of patients, and surgical or percutaneous target vessel revascularization was needed