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Technical Feasibility, Safety, and Clinical Outcome of Stenting of Unprotected Left Main Coronary Artery Bifurcation Narrowing
Technical Feasibility, Safety, and Technical Feasibility, Safety, and Clinical Outcome of Clinical Outcome of Stenting Stenting of of Unprotected Left Main Coronary Unprotected Left Main Coronary Artery Bifurcation NarrowingArtery Bifurcation Narrowing
Seung-Jung Park, MD, PhD, FACCSeungSeung--Jung Park, MD, PhD, FACCJung Park, MD, PhD, FACC
Cardiovascular Center, Asan Medical Center University of Ulsan, Seoul, Korea
Cardiovascular Center, Cardiovascular Center, AsanAsan Medical Center Medical Center University of University of UlsanUlsan, , Seoul, KoreaSeoul, Korea
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
PCI for LMCA Narrowing
Advances in techniques and equipment make it possible to expand the use of angioplasty to unprotected LMCA stenosis.
Advances in techniques and Advances in techniques and equipment make it possible to expand equipment make it possible to expand the use of angioplasty to unprotected the use of angioplasty to unprotected LMCA LMCA stenosisstenosis..
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
LMCA Bifurcation NarrowingLMCA Bifurcation Narrowing
•It has been regarded as absolute contraindication of PCI because the occlusion of side branches could lead to disastrous clinical events.
••It has been regarded as absolute It has been regarded as absolute contraindication of PCI because the contraindication of PCI because the occlusion of side branches could lead to occlusion of side branches could lead to disastrous clinical events.disastrous clinical events.
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
LMCA Bifurcation NarrowingLMCA Bifurcation Narrowing
•But, stenting was supposed to be safe and effective treatment in selected group of patients who have normal LV function and lesions confined to distal left main with large reference size.
••But,But, stentingstenting was supposed to be safe and was supposed to be safe and effective treatment in selected group of effective treatment in selected group of patients who have normal LV function patients who have normal LV function and lesions confined to distal left main and lesions confined to distal left main with large reference size.with large reference size.
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
PurposePurpose
•This study was performed to evaluate the acute and long-term clinical results of stenting for unprotected LMCA lesions.
••This study was performed to evaluate the This study was performed to evaluate the acute and longacute and long--term clinical results of term clinical results of stenting stenting for unprotected LMCA lesions.for unprotected LMCA lesions.
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
SubjectsSubjects
•From Nov 1995 to Nov 2001, 63 consecutive patients with unprotected LMCA bifurcation lesions who underwent stenting with (n=32) or without debulkingatherectomy (n=31).
••From Nov 1995 to Nov 2001, 63 From Nov 1995 to Nov 2001, 63 consecutive patients with unprotected consecutive patients with unprotected LMCA bifurcation lesions who underwent LMCA bifurcation lesions who underwent stenting stenting with (n=32) or without with (n=32) or without debulkingdebulkingatherectomyatherectomy (n=31). (n=31).
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Inclusion CriteriaInclusion CriteriaInclusion Criteria
Good Candidate for SurgeryGood Candidate for Surgery(Diameter (Diameter stenosis stenosis >> 50% involving both a 50% involving both a LMCA and/or the LMCA and/or the ostium ostium of LAD or LCX of LAD or LCX with Objective with Objective IschemiaIschemia))
•• Normal LV functionNormal LV function
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Bifurcation Types
Type 1 Type 2 Type 3
Lefevre T. Cathet Cardiovasc Intervent 2000;49:274-83
PCI Strategy for Bifurcation lesion
PCI Strategy for Bifurcation lesion
Stenting with or without debulkingStenting cross over LCX with
optional kissing balloon inflationT(Y)-stent techniqueKissing stent techniqueBifurcation stent (SLK-View stent)
StentingStenting with or without with or without debulkingdebulkingStenting Stenting cross over LCX with cross over LCX with
optional kissing balloon inflationoptional kissing balloon inflationT(Y)T(Y)--stent stent techniquetechniqueKissing Kissing stent stent techniquetechniqueBifurcation Bifurcation stent stent (SLK(SLK--View View stentstent))
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Stenting Cross Over Tube stenting cross over LCX with optional kissing balloon dilatation
LMCA
LAD
LMCA
LAD
LCX LCX
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Stenting Cross Over Tube stenting cross over LCX with optional kissing balloon dilatation
LMCA
LAD
LMCA
LAD
LCX LCX
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
T Stenting
LMCA
LAD
LMCA
LAD
LCXLCX
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
T Stenting
LMCA
LAD
LMCA
LAD
LCXLCX
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
T Stenting
LMCA
LCX
LAD
LMCA
LAD
LCX
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Y (Culotte) Stenting
LMCA
LAD
LMCA
LAD
LCXLCX
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Y (Culotte) Stenting
LMCA
LAD
LMCA
LAD
LCXLCX
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Y (Culotte) Stenting
LMCA
LAD
LCX
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Kissing Stenting
Kissing stents with optional stent on the Main
LMCA
LAD
LMCA
LAD
LCXLCX
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Kissing Stenting
Kissing stents with optional stent on the Main
LMCA
LCX
LAD
LMCA
LAD
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
LCX
Bifurcation StentSLK-View Stent
Side holeSeung-Jung Park Am J Cardiol 2002;104:1609-1614
Initial OutcomesInitial Outcomes
Procedural Success Rate:Procedural Success Rate:
InIn--Hospital Clinical ComplicationsHospital Clinical ComplicationsDeathDeathStentStent thrombosis thrombosis Q wave myocardial infarctionQ wave myocardial infarctionEmergency CABGEmergency CABG
100 %
0%0%0%0%
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Clinical CharacteristicsClinical Characteristics
41 (65%)Unstable angina pectoris31 (49%)Current smoker28 (44%)Total cholesterol > 200mg/dL14 (22%)Diabetes mellitus20 (33%)Systemic hypertension
53 / 10Male / women58 ± 10Age
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Angiographic Angiographic CharacteristicsCharacteristics
7 (11%)Type 329 (46%)Type 227 (43%)Type 1
Bifurcation types20 (33%)left main and RCA
53 / 10Left main onlyExtent of coronary disease
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Angiographic Angiographic CharacteristicsCharacteristicsSide branchSide branchParent vesselParent vessel((mm)mm)
2.8 2.8 ±± 1.01.04.1 4.1 ±± 0.70.71.1 1.1 ±± 0.5 0.5
3.3 3.3 ±± 0.70.73.8 3.8 ±± 0.6 0.6 4.4 4.4 ±± 0.70.7
1.9 1.9 ±± 0.90.9FollowFollow--upup2.7 2.7 ±± 0.80.8FinalFinal2.0 2.0 ±± 1.01.0BaselineBaseline
MLDMLDMeanMean
3.0 3.0 ±± 0.80.8DistalDistalProximalProximal
Reference artery Reference artery
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Angiographic Angiographic CharacteristicsCharacteristics
Side branchParent vessel(%)
26.4 ± 25.9-8.6 ± 15.8 70.9 ± 12.7
36.9 ± 26.5Follow-up9.9 ± 19.5Final33.8 ± 27.6Baseline
Diameter stenosis
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Procedural DataProcedural Data
Side branchParent vessel
32 (51%)
63 (100%)
15.0 ± 2.5
6 (10%)Debulking procedure
22 (35%)Stent use
Maximum pressure (atm)
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
0
10
20
30
40
50
60
70
Stentingcross over
T- Stent Kissing stent
SLK-View stent
34 (54%)34 (54%)
14 (22%)14 (22%)
6 (10%)6 (10%) 9 (14%)9 (14%)
Different Technique Different Technique Different Technique
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Angiographic RestenosisAngiographic Restenosis
6-Month follow-up rate : 86% (43 / 50 eligible patients)
Parent vessel only : 14%Side branch only : 9%Both restenosis : 5%Overall Overall restenosis restenosis : 28%: 28%
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Predictors of Predictors of RestenosisRestenosis
0.560.230.96
0.032
pNo restenosis(n=35)
Restenosis(n=8)
03 (18%)5 (23%)
3.9 ± 0.71.0 ± 0.8
3.4 ± 0.6
4 (100%)Type 314 (82%)Type 217 (77%)Type 1
Bifurcation types4.3 ± 0.7Final1.1 ± 0.5Baseline
MLD (mm)3.9 ± 0.6Reference vs (mm)
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
6 month Angiographic Restenosis 6 6 month month Angiographic Restenosis Angiographic Restenosis
%
0
10
20
30
Stenting cross overStenting cross over
T(Y) or Kissing stent
T(Y) or Kissing stent
17%17%
4 / 24
4 / 19
21%21%
SLK-View stentSLK-View stent
??
P = 0.7P = 0.7
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Effect of DebulkingRestenosis Rate of Parent Vessel
0
10
20
30
40
(%)
33%
7 / 14
Non-DebulkingDebulking
1 / 26
5%
P = 0.02
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Protective Factor of RestenosisBy multivariate analysis
Debulking procedure
Odds ratio ; 0.1095% CI ; 0.01 to 0.91P =0.04
Seung-Jung Park Am J Cardiol 2002;104:1609-1614
Two-year MACE-Free SurvivalTwo-year MACE-Free Survival% 100
P = NS 89.2 ± 5.9 %90
80 84.1 ± 7.3 %
Stenting with debulking70
Stenting only 60
0 6 12 18 24
Duration of Follow-Up (month)Seung-Jung Park Am J Cardiol 2002;104:1609-1614
ConclusionsConclusions
•• StentingStenting with or without with or without debulkingdebulkingatherectomyatherectomy is technically feasible and is technically feasible and may be an effective strategy for treatment may be an effective strategy for treatment of unprotected LMCA bifurcation lesions. of unprotected LMCA bifurcation lesions.
•• Furthermore, Furthermore, debulkingdebulking atherectomyatherectomybefore before stentingstenting might reduce the late might reduce the late restenosis, providing new insight in the restenosis, providing new insight in the approach.approach.