PROVISIONAL STENTING IN LEFT MAIN STEM DISEASE: LONG-TERM OUTCOMES AND IMPACT ON SIDE BRANCH PERFUSION

Authors

  • SN KHATTAK Department of Cardiology, Peshawar Institute of Cardiology Peshawar, Pakistan
  • F RAJA Department of Cardiology, Peshawar Institute of Cardiology Peshawar, Pakistan
  • M WALEED Department of Cardiology, Peshawar Institute of Cardiology Peshawar, Pakistan
  • A KHAN Department of Cardiology, Peshawar Institute of Cardiology Peshawar, Pakistan

DOI:

https://doi.org/10.54112/bcsrj.v2024i1.1180

Keywords:

Left main stem disease, Provisional stenting, Side branch perfusion, In-stent restenosis, Major adverse cardiac events, Fractional flow reserve, Kaplan-Meier survival

Abstract

Left main stem disease (LMSD) is a severe form of coronary artery disease (CAD) that involves a significant risk of mortality if not treated effectively. Traditionally, coronary artery bypass grafting (CABG) has been the primary method for revascularization in LMSD. However, percutaneous coronary intervention (PCI), especially provisional stenting using drug-eluting stents (DES), has gained popularity for its minimal invasiveness and comparable clinical outcomes. Provisional stenting allows treatment of the main vessel with additional side branch stenting only when needed, reducing complications and stent usage. Objective: The primary objective of this study is to evaluate the long-term outcomes of provisional stenting in patients with LMSD, focusing on its impact on side branch perfusion, in-stent restenosis (ISR), and major adverse cardiac events (MACE). Methods: This retrospective cohort study was conducted at a tertiary care hospital specializing in cardiology between January 2023 and December 2023. A total of 284 patients who underwent provisional stenting for LMSD were included. Fractional flow reserve (FFR) and quantitative coronary angiography (QCA) were used to assess side branch perfusion, with follow-up data including clinical outcomes such as ISR, MACE, and survival rates. Multivariate regression analysis was used to identify predictors of poor outcomes, and Kaplan-Meier survival curves were generated to compare outcomes based on side branch perfusion status. Results: The study found that 77.5% of patients achieved adequate side branch perfusion (FFR > 0.80) after provisional stenting, while 22.5% had impaired perfusion (FFR ≤ 0.80). The incidence of MACE was 10.6%, and ISR was reported in 7.0% of patients during the one-year follow-up period. Kaplan-Meier analysis showed a significant survival benefit for patients with adequate side branch perfusion (Log-Rank p < 0.001). Age and diabetes mellitus were significant predictors of MACE. Conclusion: Provisional stenting in LMSD provides favourable long-term outcomes, particularly in terms of side branch perfusion and reduced MACE. However, a subset of patients, particularly those with diabetes, may require additional interventions. Future studies should focus on improving outcomes in patients with impaired side branch perfusion and exploring the role of advanced imaging techniques in optimizing stenting strategies.

Downloads

Download data is not yet available.

References

Hildick-Smith D, Egred M, Banning A, et al. The stepwise provisional approach to left main stem bifurcations in Europe. Eur Heart J. 2022;43(21):2079-2089. doi:10.1093/eurheartj/ehac080.

Kandzari DE, Gershlick AH, Serruys PW, et al. Outcomes among patients undergoing distal left main percutaneous coronary intervention. Circ Cardiovasc Interv. 2018;11. doi:10.1161/CIRCINTERVENTIONS.118.007007.

Zhang J, Liu S, Geng T, et al. One-stent versus two-stent techniques for distal unprotected left main coronary artery bifurcation lesions. Int J Clin Exp Med. 2015;8:14363-14370.

Choi KH, Song YB, Lee JM, et al. Prognostic effects of treatment strategies for left main versus non-left main bifurcation percutaneous coronary intervention with current-generation drug-eluting stents. Circ Cardiovasc Interv. 2020;13.

Chen SL, Zhang JJ, Han Y, et al. Three-year outcomes of the DKCRUSH-V trial comparing DK crush with provisional stenting for left main bifurcation lesions. JACC Cardiovasc Interv. 2019;12:1927-1937. doi:10.1016/j.jcin.2019.04.056.

Cho S, Kang TS, Kim JS, et al. Long-term clinical outcomes and optimal stent strategy in left main coronary bifurcation stenting. JACC Cardiovasc Interv. 2018;11:1247-1258.

David Hildick-Smith, Teh stepwise provisional approach to left main stem bifurcations in Europe, European Heart Journal, Volume 43, Issue 21, 1 June 2022, Page 2079, https://doi.org/10.1093/eurheartj/ehac080

Meng S, Kong X, Nan J, Yang X, Li J, Yang S, Zhao L, Jin Z. Comparing the clinical outcomes of single vs. systematic dual stenting strategies for unprotected left main bifurcation lesion: a systematic review and meta-analysis. Frontiers in Cardiovascular Medicine. 2023 Jul 24;10:1145412

Chen SL, Zhang JJ, Han Y, et al. Three-year outcomes of the DKCRUSH-V trial comparing DK crush with provisional stenting for left main bifurcation lesions. JACC Cardiovasc Interv. 2019;12:1927-1937. doi:10.1016/j.jcin.2019.04.056.

Zhang J, Liu S, Geng T, et al. One-stent versus two-stent techniques for distal unprotected left main coronary artery bifurcation lesions. Int J Clin Exp Med. 2015;8:14363-14370.

Généreux P, Kumsars I, Erglis A, et al. Side branch compromise after stenting of coronary bifurcation lesions in the Nordic Bifurcation Study: angiographic predictors and 5-year follow-up. Eur Heart J. 2016;37:1923-1931. doi:10.1093/eurheartj/ehw028.

Gwon HC, Choi SH, Lee SH, et al. Provisional versus routine two-stent strategies for coronary bifurcation lesions in patients with unprotected left main disease: outcomes from the SMART-STRATEGY study. Am J Cardiol. 2013;111:1296-1303. doi:10.1016/j.amjcard.2013.01.290.

Lee CH, Ahn JM, Kang DY, et al. Comparison of simple versus complex stenting in patients with true distal left main bifurcation lesions. Catheter Cardiovasc Interv. 2021;97:1-10. doi:10.1002/ccd.29420.

Généreux P, Kumsars I, Erglis A, et al. Impact of side branch occlusion on clinical outcomes after stenting coronary bifurcation lesions: insights from the NORDIC Bifurcation Study. JACC Cardiovasc Interv. 2013;6:134-141. doi:10.1016/j.jcin.2012.09.011.

Burzotta F, Trani C, Todaro D, et al. Coronary bifurcations treated with a dedicated bifurcation stent: clinical outcome and predictors of side branch restenosis and thrombosis. EuroIntervention. 2019;14. doi:10.4244/EIJ-D-18-01196.

Choi KH, Song YB, Lee JM, et al. Prognostic effects of treatment strategies for left main versus non-left main bifurcation percutaneous coronary intervention with current-generation drug-eluting stents. Circ Cardiovasc Interv. 2020;13.

Downloads

Published

2024-10-06

How to Cite

KHATTAK , S., RAJA, F., WALEED , M., & KHAN , A. (2024). PROVISIONAL STENTING IN LEFT MAIN STEM DISEASE: LONG-TERM OUTCOMES AND IMPACT ON SIDE BRANCH PERFUSION. Biological and Clinical Sciences Research Journal, 2024(1), 1180. https://doi.org/10.54112/bcsrj.v2024i1.1180

Most read articles by the same author(s)

<< < 1 2 3 > >>