PCI for unprotected left main coronary artery stenosis still performed infrequently

1. Revascularization with percutaneous coronary intervention (PCI) of unprotected left main (ULM) artery remains an infrequently performed procedure in the United States.

2. The patients undergoing PCI for ULM disease are older, with greater comorbidities, and more adverse outcomes than the clinical trial populations.

Evidence Rating Level: 3 (Average)       

Study Rundown: Left main coronary artery stenosis, referred to as unprotected left main artery disease if it has not been revascularized with a bypass graft, has traditionally been treated by surgical intervention with coronary artery bypass grafting (CABG) as the preferred management. Use of PCI for ULM disease has usually been reserved for those not felt to be surgical candidates. Recent trials have examined the efficacy of PCI for left main disease in a time period of modern PCI technology. While producing conflicting results, these trials provide data that implies PCI is a reasonable management option for patient with ULM disease. The current study sought to evaluate the impact of these modern trials on practice patterns in the United States. The study found that PCI for ULM disease is still uncommonly performed and that the people receiving PCI were older, with more comorbidities and had more adverse events than the population included in recent clinical trials.

The strengths of the study included the large study population in a modern cohort receiving current PCI technology. The main limitations of the study included the observational, cross-section design, and lack of long-term follow-up for included patients. Data on anatomic complexity, an important determinant of PCI feasibility, was also not available.

Click to read the study in JAMA Cardiology

Relevant Reading: Left Main Revascularization With PCI or CABG in Patients With Chronic Kidney Disease – EXCEL Trial

In-Depth [cross-sectional study]: The study looked at trends for PCI and CABG for patients with unprotected left main artery disease. Patients were included if they received PCI between 2009 and 2016, and were excluded if they had prior CABG, presented with cardiogenic shock, or cardiac arrest, or received angioplasty alone without stenting. The study included patients at more than 1600 institutions across the United States. The main outcome was in-hospital major adverse clinical events (MACE), which was a composite of death, myocardial infarction (MI), stroke, or emergent CABG.

For the 3,342,162 patients who underwent PCI only 33,128 (1%) underwent unprotected left main PCI. The rate of ULM PCI increased over time from 0.7% to 1.3%. Patients who had ULM PCI had higher rates of MACE compared to the other patients receiving PCI (9.0% [2993] vs 2.6% [86 940]; P < .001). Compared with modern clinical trials, the cohort receiving ULM PCI in this study were older and had more medical comorbidities.

Image: PD

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