Percutaneous vs. surgical revascularization for patients with unprotected left main stenosis: a meta-analysis of 5 years follow-up RCTs

Introduction 5-year survival of patients with ULM (Unprotected Left Main) stenosis according to the choice of revascularization (percutaneous vs. surgical) remains to be defined. Methods and results Randomized Controlled Trials (RTCs) comparing Percutaneous Coronary Intervention (PCI) vs. Coronary Artery Bypass Graft (CABG) with a follow-up of at least 5 years were included. All-cause death was the primary endpoint. MACCE (a composite endpoint of all-cause mortality, myocardial infarction [MI], stroke and repeat revascularization) along with its single components and cardiovascular (CV) death were the secondary ones. Analyses were stratified according to use of first vs. last generation coronary stents. Subgroup comparisons were performed according to Syntax Score (below or above 33) and to age (using cutoffs of each trial's subgroup analysis). 4 RCTs with 4394 patients were identified: 2197 were treated with CABG, 657 with first generation and 1540 with last generation stents. At 5 years rates of all-cause death did not differ (OR 0.93: 0.71–1.21), as those of CV death and stroke. CABG reduced rates of MACCE (OR 0.69: 0.60–0.79), mainly driven by MI (OR 0.48: 0.36–0.65) and revascularization (OR 0.53: 0.45–0.64). Benefit of CABG for MACCE was consistent, although with different extent, across values of Syntax Score (OR 0.76: 0.59–0.97 for values <32 and OR 0.63: 0.47–0.84 for values ≥33) while was not evident for “younger” patients (OR 0.83: 0.65–1.07 vs. OR 0.65: 0.51–0.84 for “older” patients, all CI 95%). Conclusion For patients with ULM disease, PCI and CABG yielded same survival benefit at 5 years. CABG reduced risk of MI, revascularization and MACCE especially in older patients and in those with diffuse coronary disease. Funding Acknowledgement Type of funding source: None

Feasibility, Safety, and Clinical Performance of Self-apposing Stents for Left Main Stenosis

Drug-eluting stents (DES) are the gold standard for percutaneous coronary interventions (PCI); however, technical and anatomical challenges need to be addressed to ensure optimal apposition and prevent late adverse events. Complex vessel anatomies, including ectatic or aneurysmatic vessels, or significant differences in diameter in left main stenosis of the coronary artery, are clinical indications in which current PCI techniques attempt to shape conventional DES to follow vessel anatomy, thus modifying the original stent scaffold and its properties. However, due to their design, balloon-expandable cobalt–chromium and cobalt–nickel DES have limitations regarding their expansion capacity, which can result in undersizing and malapposition. New stent scaffolds have recently been introduced into clinical practice to address these challenging anatomies, including a drug-eluting nitinol stent platform. The nature of the nitinol device allows conformability to the native vessel, covering complex anatomies without manual adaptation. In this article, the authors present the rationale and current data on self-apposing nitinol DES in left main stenosis, and suggest that the device may be safely and effectively used with comparable rates of adverse cardiovascular events, as seen with second-generation balloon-expandable DES.