Percutaneous Coronary Intervention Options in LMCA (Left Main Coronary Artery) Bifurcation Lesions

Dr. Yunus Emre Özbebek

Ankara Etlik City Hosital, Department of Cardiology, Ankara, Türkiye

ABSTRACT

The left main coronary artery (LMCA) bifurcation lesions pose significant challenges in cardiovascular inter- ventions. These lesions are clinically important and lead to extensive discussions regarding the choice of per- cutaneous coronary intervention (PCI) strategies. While provisional stenting is typically the primary strategy for addressing bifurcation lesions, double stenting techniques are preferred for more complex scenarios. This chapter provides a comparison of provisional stenting and double stenting strategies, highlighting their re- spective advantages and limitations. Additionally, clinical study data is reviewed to assess the most effective strategies for managing LMCA bifurcation lesions. The role of invasive imaging techniques, such as intravas- cular ultrasound (IVUS) and optical coherence tomography (OCT), in optimizing treatment strategies is also discussed. In conclusion, selecting the most suitable treatment strategy should be based on the individual patient’s condition.

Keywords: Coronary artery disease; Percutaneous coronary intervention; Tomography; Optical coherence; Ultrasonography; Interventional; LMCA (left main coronary artery) bifurcation

Referanslar

  1. Paradies V, Banning A, Cao D, Chieffo A, Daemen J, Diletti R, et al. Provisional Strategy for Left Main Stem Bifurcation Disease: A State-of-the-Art Review of Technique and Out- comes. JACC Cardiovasc Interv. 2023;16(7):743-58. [Crossref]  [PubMed]
  2. Park S, Park SJ, Park DW. Percutaneous Coronary Interven- tion for Left Main Coronary Artery Disease: Present Status and Future Perspectives. JACC Asia. 2022;2(2):119-38. [Crossref]  [PubMed]  [PMC]
  3. Aedma SK, Naik A, Kanmanthareddy A. Coronary Bifurca- tion Stenting: Review of Current Techniques and Evidence. Curr Cardiol Rev. 2023;19(1):e060422203185. [Crossref]  [PubMed]  [PMC]
  4. Darremont O, Leymarie JL, Lefevre T, Albiero R, Mortier P, Louvard Y. Technical aspects of the provisional side branch stenting strategy. EuroIntervention. 2015;11 Suppl V:V86-90. [Crossref]  [PubMed]
  5. Kumsars I, Holm NR, Niemela M, Erglis A, Kervinen K, Christiansen EH, et al. Randomised comparison of provi- sional side branch stenting versus a two-stent strategy for treatment of true coronary bifurcation lesions involving a large side branch: the Nordic-Baltic Bifurcation Study IV. Open Heart. 2020;7(1):e000947. [Link]
  6. Burzotta F, Louvard Y, Lassen JF, Lefevre T, Finet G, Collet C, et al. Percutaneous coronary intervention for bifurcation coronary lesions using optimised angiographic guidance: the 18th consensus document from the European Bifurcation Club. EuroIntervention. 2024;20(15):e915-e26. [Crossref]  [PubMed]
  7. Allali A, Abdel-Wahab M, Traboulsi H, Hemetsberger R, Mankerious N, Byrne R, et al. Impact of Lesion Prepara- tion Technique on Side Branch Compromise in Calcified Coronary Bifurcations: A Subgroup Analysis of the PRE- PARE-CALC Trial. J Interv Cardiol. 2020;2020:9740938. [Crossref]  [PubMed]  [PMC]
  8. Lassen JF, Burzotta F, Banning AP, Lefevre T, Darremont O, Hildick-Smith D, et al. Percutaneous coronary intervention for the left main stem and other bifurcation lesions: 12th con- sensus document from the European Bifurcation Club. Euro- Intervention. 2018;13(13):1540-53. [Crossref]  [PubMed]
  9. Chen SL. Selection of stenting approach for coronary bi- furcation lesions. EuroIntervention. 2021;16(16):1295-6. [Crossref]  [PubMed]  [PMC]
  10. Raphael CE, O'Kane PD. Contemporary ap- proaches to bifurcation stenting. JRSM Cardio- vasc Dis. 2021;10:2048004021992190. [Crossref]  [PubMed]  [PMC]
  11. Park TK, Song YB, Yang JH, Lee JM, Hahn JY, Choi SH, et al. Two-stent techniques for coronary bifurcation lesions (main vessel first versus side branch first): results from the COBIS (COronary BIfurcation Stenting) II registry. Euro- Intervention. 2017;13(7):835-42. [Crossref]  [PubMed]
  12. Burzotta F, Gwon HC, Hahn JY, Romagnoli E, Choi JH, Trani C, et al. Modified T-stenting with intentional protru- sion of the side-branch stent within the main vessel stent to ensure ostial coverage and facilitate final kissing balloon: the T-stenting and small protrusion technique (TAP-stent- ing). Report of bench testing and first clinical Italian-Ko- rean two-centre experience. Catheter Cardiovasc Interv. 2007;70(1):75-82. [Crossref]  [PubMed]
  13. Moroni F, Shue-Min Yeh J, Attallah A, Santiago R, Martins Filho E, Hall J, et al. Crush techniques for percutaneous cor- onary intervention of bifurcation lesions. EuroIntervention. 2022;18(1):71-82. [Crossref]  [PubMed]  [PMC]
  14. Erglis A, Lassen JF, Di Mario C. Technical aspects of the culotte technique. EuroIntervention. 2015;11 Suppl V:V99-101. [Crossref]  [PubMed]
  15. Seth A, Gupta S, Pratap Singh V, Kumar V. Expert Opinion: Optimising Stent Deployment in Contemporary Practice: The Role of Intracoronary Imaging and Non-compliant Balloons. Interv Cardiol. 2017;12(2):81-4. [Crossref]  [PubMed]
  16. Lassen JF, Albiero R, Johnson TW, Burzotta F, Lefevre T, Iles TL, et al. Treatment of coronary bifurcation lesions, part II: implanting two stents. The 16th expert consensus docu- ment of the European Bifurcation Club. EuroIntervention. 2022;18(6):457-70. [Crossref]  [PubMed]  [PMC]
  17. Lozano I, Vegas JM, Rondan J, Segovia E. Percutaneous Intervention in Bifurcations After the DKCRUSH-V Trial: Case Closed? JACC Cardiovasc Interv. 2020;13(1):141-2. [Crossref]  [PubMed]
  18. Maznyczka A, Arunothayaraj S, Egred M, Banning A, Brunel P, Ferenc M, et al. Bifurcation left main stenting with or without intracoronary imaging: Outcomes from the EBC MAIN trial. Catheter Cardiovasc Interv. 2023;102(3):415-29. [Crossref]  [PubMed]
  19. Zhang JJ, Ye F, Xu K, Kan J, Tao L, Santoso T, et al. Multi- centre, randomized comparison of two-stent and provision- al stenting techniques in patients with complex coronary bifurcation lesions: the DEFINITION II trial. Eur Heart J. 2020;41(27):2523-36. [Link]
  20. Mintz GS, Lefevre T, Lassen JF, Testa L, Pan M, Singh J, et al. Intravascular ultrasound in the evaluation and treat- ment of left main coronary artery disease: a consensus statement from the European Bifurcation Club. EuroInt- ervention. 2018;14(4):e467-e74. [Crossref]  [PubMed]
  21. Banning AP, Serruys P, De Maria GL, Ryan N, Walsh S, Gon- zalo N, et al. Five-year outcomes after state-of-the-art percu- taneous coronary revascularization in patients with de novo three-vessel disease: final results of the SYNTAX II study. Eur Heart J. 2022;43(13):1307-16. [Link]
  22. Hunter GW, Sharma V, Varma C, Connolly D. The EXCEL Trial: The Interventionalists' Perspective. Eur Cardiol. 2021;16:e01. [Crossref]  [PubMed]  [PMC]
  23. Araki M, Park SJ, Dauerman HL, Uemura S, Kim JS, Di Mario C, et al. Optical coherence tomography in coronary atherosclerosis assessment and intervention. Nat Rev Car- diol. 2022;19(10):684-703. [Crossref]  [PubMed]  [PMC]
  24. Roland R, Veselka J. Optical Coherence Tomography of the Coronary Arteries. Int J Angiol. 2021;30(1):29-39. [Crossref]  [PubMed]  [PMC]
  25. Min SY, Park DW, Yun SC, Kim YH, Lee JY, Kang SJ, et al. Major predictors of long-term clinical outcomes after coronary revascularization in patients with unprotected left main coronary disease: analysis from the MAIN-COMPARE study. Circ Cardiovasc Interv. 2010;3(2):127-33. [Crossref]  [PubMed]