Yonsei Med J.  2009 Dec;50(6):739-743. 10.3349/ymj.2009.50.6.739.

Stenting versus Bypass Surgery for the Treatment of Left Main Coronary Artery Disease

• Park SJ

• KMID: 1777084
• DOI: http://doi.org/10.3349/ymj.2009.50.6.739

Abstract

Based on data comparing coronary-artery bypass grafting (CABG) with medical therapy, the current guidelines recommend CABG as the treatment of choice for patients with left main coronary artery (LMCA) disease. Percutaneous coronary intervention (PCI) can be selectively performed in patients who are candidates for revascularization but who are ineligible for CABG. Current evidence indicates that stenting results in mortality and morbidity rates compared favorably with those seen after CABG. Data from several extensive registries and a large clinical trial may have prompted many interventional cardiologists to choose PCI with stenting as an alternative treatment option for such patients. In addition, these data may inform future guidelines and support the need for well-designed, adequately powered, prospective, randomized trials comparing the two revascularization strategies.

Keyword

Bypass surgery; stents; coronary disease

MeSH Terms

Angioplasty, Transluminal, Percutaneous Coronary/adverse effects/*methods
Coronary Artery Bypass/*methods
Coronary Artery Disease/*surgery/*therapy
Humans
Stents/adverse effects

Reference

1. Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation. 2004. 110:e340–e437.

2. Smith SC Jr, Feldman TE, Hirshfeld JW Jr, Jacobs AK, Kern MJ, King SB 3rd, et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention). Circulation. 2006. 113:e116–e286.

3. Tan WA, Tamai H, Park SJ, Plokker HW, Nobuyoshi M, Suzuki T, et al. Long-term clinical outcomes after unprotected left main trunk percutaneous revascularization in 279 patients. Circulation. 2001. 104:1609–1614.

4. Park SJ, Hong MK, Lee CW, Kim JJ, Song JK, Kang DH, et al. Elective stenting of unprotected left main coronary artery stenosis: effect of debulking before stenting and intravascular ultrasound guidance. J Am Coll Cardiol. 2001. 38:1054–1060.

5. Park SJ, Park SW, Hong MK, Cheong SS, Lee CW, Kim JJ, et al. Stenting of unprotected left main coronary artery stenoses: immediate and late outcomes. J Am Coll Cardiol. 1998. 31:37–42.

6. Silvestri M, Barragan P, Sainsous J, Bayet G, Simeoni JB, Roquebert PO, et al. Unprotected left main coronary artery stenting: immediate and medium-term outcomes of 140 elective procedures. J Am Coll Cardiol. 2000. 35:1543–1550.

7. Black A, Cortina R, Bossi I, Choussat R, Fajadet J, Marco J. Unprotected left main coronary artery stenting: correlates of mid-term survival and impact of patient selection. J Am Coll Cardiol. 2001. 37:832–838.

8. Takagi T, Stankovic G, Finci L, Toutouzas K, Chieffo A, Spanos V, et al. Results and long-term predictors of adverse clinical events after elective percutaneous interventions on unprotected left main coronary artery. Circulation. 2002. 106:698–702.

9. Park SJ, Kim YH, Lee BK, Lee SW, Lee CW, Hong MK, et al. Sirolimus-eluting stent implantation for unprotected left main coronary artery stenosis: comparison with bare metal stent implantation. J Am Coll Cardiol. 2005. 45:351–356.

10. Valgimigli M, van Mieghem CA, Ong AT, Aoki J, Granillo GA, McFadden EP, et al. Short- and long-term clinical outcome after drug-eluting stent implantation for the percutaneous treatment of left main coronary artery disease: insights from the Rapamycin-Eluting and Taxus Stent Evaluated At Rotterdam Cardiology Hospital registries (RESEARCH and T-SEARCH). Circulation. 2005. 111:1383–1389.

11. Chieffo A, Stankovic G, Bonizzoni E, Tsagalou E, Iakovou I, Montorfano M, et al. Early and Mid-term results of drug-eluting stent implantation in unprotected left main. Circulation. 2005. 111:791–795.

12. Erglis A, Narbute I, Kumsars I, Jegere S, Mintale I, Zakke I, et al. A randomized comparison of paclitaxel-eluting stents versus bare-metal stents for treatment of unprotected left main coronary artery stenosis. J Am Coll Cardiol. 2007. 50:491–497.

13. Lagerqvist B, James SK, Stenestrand U, Lindbäck J, Nilsson T, Wallentin L. SCAAR Study Group. Long-term outcomes with drug-eluting stents versus bare-metal stents in Sweden. N Engl J Med. 2007. 356:1009–1019.

14. Stone GW, Moses JW, Ellis SG, Schofer J, Dawkins KD, Morice MC, et al. Safety and efficacy of sirolimus- and paclitaxel-eluting coronary stents. N Engl J Med. 2007. 356:998–1008.

15. Mauri L, Hsieh WH, Massaro JM, Ho KK, D'Agostino R, Cutlip DE. Stent thrombosis in randomized clinical trials of drug-eluting stents. N Engl J Med. 2007. 356:1020–1029.

16. Chieffo A, Park SJ, Meliga E, Sheiban I, Lee MS, Latib A, et al. Late and very late stent thrombosis following drug-eluting stent implantation in unprotected left main coronary artery: a multicentre registry. Eur Heart J. 2008.

17. Meliga E, Garcia-Garcia HM, Valgimigli M, Chieffo A, Biondi-Zoccai G, Maree AO, et al. Longest available clinical outcomes after drug-eluting stent implantation for unprotected left main coronary artery disease: the DELFT (Drug Eluting stent for LeFT main) Registry. J Am Coll Cardiol. 2008. 51:2212–2219.

18. Seung KB, Park DW, Kim YH, Lee SW, Lee CW, Hong MK, et al. Stents versus coronary-artery bypass grafting for left main coronary artery disease. N Engl J Med. 2008. 358:1781–1792.

19. Daemen J, Wenaweser P, Tsuchida K, Abrecht L, Vaina S, Morger C, et al. Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: data from a large two-institutional cohort study. Lancet. 2007. 369:667–678.

20. Laskey WK, Yancy CW, Maisel WH. Thrombosis in coronary drug-eluting stents: report from the meeting of the Circulatory System Medical Devices Advisory Panel of the Food and Drug Administration Center for Devices and Radiologic Health, December 7-8, 2006. Circulation. 2007. 115:2352–2357.

21. Eisenstein EL, Anstrom KJ, Kong DF, Shaw LK, Tuttle RH, Mark DB, et al. Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA. 2007. 297:159–168.

22. Airoldi F, Colombo A, Morici N, Latib A, Cosgrave J, Buellesfeld L, et al. Incidence and predictors of drug-eluting stent thrombosis during and after discontinuation of thienopyridine treatment. Circulation. 2007. 116:745–754.

23. Brar SS, Kim J, Brar SK, Zadegan R, Ree M, Liu IL, et al. Long-term outcomes by clopidogrel duration and stent type in a diabetic population with de novo coronary artery lesions. J Am Coll Cardiol. 2008. 51:2220–2227.

24. Park SJ, Park DW. Drug-eluting stents for left main coronary artery stenosis: case selection and technical issues. Am Heart Hosp J. 2008. 6:21–29.

25. Chieffo A, Morici N, Maisano F, Bonizzoni E, Cosgrave J, Montorfano M, et al. Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience. Circulation. 2006. 113:2542–2547.

26. Lee MS, Kapoor N, Jamal F, Czer L, Aragon J, Forrester J, et al. Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease. J Am Coll Cardiol. 2006. 47:864–870.

27. Palmerini T, Marzocchi A, Marrozzini C, Ortolani P, Saia F, Savini C, et al. Comparison between coronary angioplasty and coronary artery bypass surgery for the treatment of unprotected left main coronary artery stenosis (the Bologna Registry). Am J Cardiol. 2006. 98:54–59.

28. Sanmartin M, Baz JA, Claro R, Asorey V, Duran D, Pradás G, et al. Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease. Am J Cardiol. 2007. 100:970–973.

29. Buszman PE, Kiesz SR, Bochenek A, Peszek-Przybyla E, Szkrobka I, Debinski M, et al. Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization. J Am Coll Cardiol. 2008. 51:538–545.

30. Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009. 360:961–972.

31. Biondi-Zoccai GG, Lotrionte M, Moretti C, Meliga E, Agostoni P, Valgimigli M, et al. A collaborative systematic review and meta-analysis on 1278 patients undergoing percutaneous drug-eluting stenting for unprotected left main coronary artery disease. Am Heart J. 2008. 155:274–283.

32. Taggart DP, Kaul S, Boden WE, Ferguson TB Jr, Guyton RA, Mack MJ, et al. Revascularization for unprotected left main stem coronary artery stenosis stenting or surgery. J Am Coll Cardiol. 2008. 51:885–892.