Three-Year Outcomes Post Percutaneous Coronary Intervention for Left Main Coronary Artery Disease
Abstract
Introduction: To identify the safety and long-term outcomes of percutaneous coronary intervention (PCI) using drug-eluting stents for unprotected left main coronary artery disease (ULMCAD) and to compare outcomes between provisional single-stent and double-stent techniques.
Methods: In this observational study, patients diagnosed with ULMCAD who underwent PCI were enrolled. Clinical data, angiographic characteristics, and outcomes at 1 and 3 years-including cardiac admission, cardiac death, target lesion revascularization (TLR), and major adverse cardiac and cerebrovascular events (MACCE)-were collected and analyzed at Al-Najaf Cardiac Center.
Results: Between January 2014 and January 2017, 500 patients were included in the study. Mean (SD) age was 65 (11) years, 364 patients (72.8%) were male, and hypertension was the most common risk factor, occurring in 353 patients (70.5%). Distal left main lesions were predominant, occurring in 425 patients (84.9%), and the double-stenting technique was used in 356 cases (71.3%). Procedural success was 100%, with no in-hospital mortality or major complications. At 1-year follow-up, cardiac death was recorded in 4 patients (0.8%), TLR in 8 patients (1.6%), and MACCE in 16 patients (3.1%). At 3-year follow-up, cardiac death increased to 8 patients (1.6%), TLR to 20 patients (4.4%), and MACCE to 41 patients (8.2%). Patients treated with a provisional single stent had significantly lower rates of cardiac hospital admission and MACCE compared with double stenting (1 [0.7%] vs 32 [9%]; P=.0403 and 3 [2.1%] vs 70 [20%]; P=.0054, respectively).
Conclusion: PCI with drug-eluting stents for ULMCAD was safe and effective, with favorable long-term outcomes in patients who were unfit for surgery or refused surgery. The provisional single-stent technique demonstrated better clinical outcomes than the double-stent approach.
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3. Taylor HA, Deumite NJ, Chaitman BR, Davis KB, Killip T, Rogers WJ. Asymptomatic left main coronary artery disease in the Coronary Artery Surgery Study (CASS) registry. Circulation. 2018; 79(6):1171-9.
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9. Dodge JT Jr, Brown BG, Bolson EL, Dodge HT. Lumen diameter of normal human coronary arteries. Influence of age, sex, anatomic variation, and left ventricular hypertrophy or dilation. Circulation. 2000;86(1):232-46.
10. James TN. Anatomy of coronary arteries. New York: Paul B Hoeber; 1999. p. 12-18.
11. Friedman T, Mani A, Elefteriades JA. Bicuspid aortic valve: clinical approach and scientific review of a common clinical entity. Expert Rev Cardiovasc Ther. 2008;6(2):235-8.
12. Bergelson BA, Tommaso CL. Left main coronary artery disease: assessment, diagnosis, and therapy. Am Heart J. 1995;129(2):350-9.
13. Reese DE, Mikawa T, Bader DM. Development of the coronary vessel system. Circ Res. 2002; 91(9):761-8.
14. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn. 1990; 21(1):28-40.
15. 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:e166-e286.
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17. Atay Y, Yagdi T, Turkoglu C, Altintig A, Buket S. Spontaneous dissection ofthe left main coronary artery: a case report and review of the literature. J Card Surg. 1996;11:371-5.
18. Kallikazaros I, Tsioufis C, Sideris S, Stefanadis C, Toutouzas P. Carotidartery disease as a marker for the presence of severe coronary arterydisease in patients evaluated for chest pain. Stroke. 1999; 30(5):1002-7.
19. Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, et al. ACC/AHA 2004 guideline update for coronary arterybypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committeeto Update the 1999 Guidelines for Coronary Artery Bypass GraftSurgery). Circulation 2004;110:e340-e437.
20. Serruys PW, Onuma Y, Garg S, Sarno G, van den Brand M, Kappetein AP, et al. Assessment of the SYNTAX score in the Syntax study. EuroIntervention. 2009;5(1):50-56.
21. Sianos G, Morel MA, Kappetein AP, Morice MC, Colombo A, Dawkins K, et al. The SYNTAX Score: an angiographic tool grading the complexity of coronary artery disease. EuroIntervention. 2005; 1(2):219-27.
22. Garg S, Sarno G, Garcia-Garcia HM, Girasis C, Wykrzykowska J, Dawkins KD, et al. A new tool for the risk stratification of patients with complex coronary artery disease: the Clinical SYNTAX Score. Circ Cardiovasc Interv. 2010;3(4):317-26.
23. Campos CM, van Klaveren D, Iqbal J, Onuma Y, Zhang YJ, Garcia-Garcia HM, et al. Predictive performance of SYNTAX Score II in patients with left main and multivessel coronary artery disease: analysis of CREDO-Kyoto registry. Circ J. 2014;78(8):1942-9.
24. Kim YH, Ahn JM, Park DW, Lee BK, Lee CW, Hong MK, et al. EuroSCORE as a predictor of death and myocardial infarction after unprotected left main coronary stenting. Am J Cardiol. 2006;98 (12):1567-70.
25. Mintz GS, Popma JJ, Pichard AD, Kent KM, Satler LF, Chuang YC, et al. Patterns of calcification in coronary artery disease. A statistical analysis of intravascular ultrasound and coronary angiography in 1155 lesions. Circulation. 1995;91(7):1959-65.
26. O’Keefe JH Jr, Hartzler GO, Rutherford BD, McConahay DR, Johnson WL, Giorgi LV, et al. Left main coronary angioplasty: early and late results of 127 acute and elective procedures. Am J Cardiol. 1999;64(3):144-7.
27. Eldar M, Schulhoff RN, Hertz I, Frankel R, Feld H, Shani J. Results of percutaneous transluminal coronary angioplasty of the left main coronary artery. Am J Cardiol. 2000;68(2):255-6.
28. Schomig A, Neumann FJ, Kastrati A, Schuhlen H, Blasini R, Hadamitzky M, et al. A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. N Engl J Med. 2001;334(17):1084-9.
29. Chieffo A, Magni V, Latib A, Maisano F, Ielasi A, Montorfano M, et al. 5-year outcomes following percutaneous coronary intervention with drug-eluting stent implantation versus coronary artery bypass graft for unprotected left main coronary artery lesions: the Milan experience. JACC Cardiovasc Interv. 2010;3(6):595-601.
30. Morice MC, Serruys PW, Kappetein AP, Feldman TE, Stahle E, Colombo A, et al. Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation. 2010;121(24):2645-53.
31. Pavei A, Oreglia JA, Martin G, Tousek P, Sharif F, Farah B, et al. Long-term follow-up of percutaneous coronary intervention of unprotected left main lesions with drug eluting stents: predictors of clinical outcome. EuroIntervention. 2009;4(4):457-63.
32. Vaquerizo B, Lefevre T, Darremont O, Silvestri M, Louvard Y, Leymarie JL, et al. Unprotected left main stenting in the real world: two-year outcomes of the French left main taxus registry. Circulation. 2009; 119(17):2349-56.
33. Steigen TK, Maeng M, Wiseth R, Erglis A, Kumsars I, Narbute I, et al. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation. 2006;114(18):1955-61.
34. Baim DS, Mauri L, Cutlip DC. Drug-eluting stenting for unprotected left main coronary artery disease: are we ready to replace bypass surgery? J Am Coll Cardiol. 2006;47(4):878-81.
35. Karrowni W, Makki N, Dhaliwal AS, Vyas A, Blevins A, Dughman S, et al. Single versus double stenting for unprotected left main coronary artery bifurcation lesions: A systematic review and meta-analysis. J Invasive Cardiol. 2014;26(6):229-33.
36. Hildick-Smith D, de Belder AJ, Cooter N, Curzen NP, Clayton TC, Oldroyd KG, et al. Randomized trial of simple versus complex drug-eluting stenting for bifurcation lesions: the British Bifurcation Coronary Study: old, new, and evolving strategies. Circulation. 2010;121(10):1235-43.
37. Colombo A, Bramucci E, Saccà S, Violini R, Lettieri C, Zanini R, et al. Randomized study of the crush technique versus provisional side-branch stenting in true coronary bifurcations: the CACTUS (Coronary Bifurcations: Application of the Crushing Technique Using Sirolimus-Eluting Stents) study. Circulation. 2009;119(1):71-8.
2. DeMots H, Rosch J, McAnulty JH, Rahimtoola SH. Left main coronary artery disease. Cardiovasc Clin. 1997;9(2):201-11.
3. Taylor HA, Deumite NJ, Chaitman BR, Davis KB, Killip T, Rogers WJ. Asymptomatic left main coronary artery disease in the Coronary Artery Surgery Study (CASS) registry. Circulation. 2018; 79(6):1171-9.
4. Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW, et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet. 2013; 629-38.
5. Chaitman BR, Fisher LD, Bourassa MG, Davis K, Rogers WJ, Maynard C. Effect of coronary bypass surgery on survival patterns in subsets of patients with left main coronary artery disease. Report of the Collaborative Study in Coronary Artery Surgery (CASS). Am J Cardiol. 2006;98(1):54-9.
6. 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(14):1609-14.
7. Caracciolo EA, Davis KB, Sopko G, Kaiser GC, Corley SD, Schaff H, et al. Comparison of surgical and medical group survival in patients with left main coronary artery disease. Long-term CASS experience. Circulation. 1995; 91(9):2325-34.
8. Niemelä M, Kervinen K, Erglis A, Holm NR, Maeng M, Christiansen EH, et al. Randomized comparison of final kissing balloon dilatation versus no final kissing balloon dilatation in patients with coronary bifurcation lesions treated with main vessel stenting: the Nordic-Baltic Bifurcation Study III. Circulation. 2011; 123(1):79-86.
9. Dodge JT Jr, Brown BG, Bolson EL, Dodge HT. Lumen diameter of normal human coronary arteries. Influence of age, sex, anatomic variation, and left ventricular hypertrophy or dilation. Circulation. 2000;86(1):232-46.
10. James TN. Anatomy of coronary arteries. New York: Paul B Hoeber; 1999. p. 12-18.
11. Friedman T, Mani A, Elefteriades JA. Bicuspid aortic valve: clinical approach and scientific review of a common clinical entity. Expert Rev Cardiovasc Ther. 2008;6(2):235-8.
12. Bergelson BA, Tommaso CL. Left main coronary artery disease: assessment, diagnosis, and therapy. Am Heart J. 1995;129(2):350-9.
13. Reese DE, Mikawa T, Bader DM. Development of the coronary vessel system. Circ Res. 2002; 91(9):761-8.
14. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn. 1990; 21(1):28-40.
15. 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:e166-e286.
16. Tavora F, Burke A. Review of isolated ascending aortitis: differential diagnosis, including syphilitic, Takayasu’s and giant cell aortitis. Pathology. 2006;38(4):302-08.
17. Atay Y, Yagdi T, Turkoglu C, Altintig A, Buket S. Spontaneous dissection ofthe left main coronary artery: a case report and review of the literature. J Card Surg. 1996;11:371-5.
18. Kallikazaros I, Tsioufis C, Sideris S, Stefanadis C, Toutouzas P. Carotidartery disease as a marker for the presence of severe coronary arterydisease in patients evaluated for chest pain. Stroke. 1999; 30(5):1002-7.
19. Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, et al. ACC/AHA 2004 guideline update for coronary arterybypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committeeto Update the 1999 Guidelines for Coronary Artery Bypass GraftSurgery). Circulation 2004;110:e340-e437.
20. Serruys PW, Onuma Y, Garg S, Sarno G, van den Brand M, Kappetein AP, et al. Assessment of the SYNTAX score in the Syntax study. EuroIntervention. 2009;5(1):50-56.
21. Sianos G, Morel MA, Kappetein AP, Morice MC, Colombo A, Dawkins K, et al. The SYNTAX Score: an angiographic tool grading the complexity of coronary artery disease. EuroIntervention. 2005; 1(2):219-27.
22. Garg S, Sarno G, Garcia-Garcia HM, Girasis C, Wykrzykowska J, Dawkins KD, et al. A new tool for the risk stratification of patients with complex coronary artery disease: the Clinical SYNTAX Score. Circ Cardiovasc Interv. 2010;3(4):317-26.
23. Campos CM, van Klaveren D, Iqbal J, Onuma Y, Zhang YJ, Garcia-Garcia HM, et al. Predictive performance of SYNTAX Score II in patients with left main and multivessel coronary artery disease: analysis of CREDO-Kyoto registry. Circ J. 2014;78(8):1942-9.
24. Kim YH, Ahn JM, Park DW, Lee BK, Lee CW, Hong MK, et al. EuroSCORE as a predictor of death and myocardial infarction after unprotected left main coronary stenting. Am J Cardiol. 2006;98 (12):1567-70.
25. Mintz GS, Popma JJ, Pichard AD, Kent KM, Satler LF, Chuang YC, et al. Patterns of calcification in coronary artery disease. A statistical analysis of intravascular ultrasound and coronary angiography in 1155 lesions. Circulation. 1995;91(7):1959-65.
26. O’Keefe JH Jr, Hartzler GO, Rutherford BD, McConahay DR, Johnson WL, Giorgi LV, et al. Left main coronary angioplasty: early and late results of 127 acute and elective procedures. Am J Cardiol. 1999;64(3):144-7.
27. Eldar M, Schulhoff RN, Hertz I, Frankel R, Feld H, Shani J. Results of percutaneous transluminal coronary angioplasty of the left main coronary artery. Am J Cardiol. 2000;68(2):255-6.
28. Schomig A, Neumann FJ, Kastrati A, Schuhlen H, Blasini R, Hadamitzky M, et al. A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. N Engl J Med. 2001;334(17):1084-9.
29. Chieffo A, Magni V, Latib A, Maisano F, Ielasi A, Montorfano M, et al. 5-year outcomes following percutaneous coronary intervention with drug-eluting stent implantation versus coronary artery bypass graft for unprotected left main coronary artery lesions: the Milan experience. JACC Cardiovasc Interv. 2010;3(6):595-601.
30. Morice MC, Serruys PW, Kappetein AP, Feldman TE, Stahle E, Colombo A, et al. Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation. 2010;121(24):2645-53.
31. Pavei A, Oreglia JA, Martin G, Tousek P, Sharif F, Farah B, et al. Long-term follow-up of percutaneous coronary intervention of unprotected left main lesions with drug eluting stents: predictors of clinical outcome. EuroIntervention. 2009;4(4):457-63.
32. Vaquerizo B, Lefevre T, Darremont O, Silvestri M, Louvard Y, Leymarie JL, et al. Unprotected left main stenting in the real world: two-year outcomes of the French left main taxus registry. Circulation. 2009; 119(17):2349-56.
33. Steigen TK, Maeng M, Wiseth R, Erglis A, Kumsars I, Narbute I, et al. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation. 2006;114(18):1955-61.
34. Baim DS, Mauri L, Cutlip DC. Drug-eluting stenting for unprotected left main coronary artery disease: are we ready to replace bypass surgery? J Am Coll Cardiol. 2006;47(4):878-81.
35. Karrowni W, Makki N, Dhaliwal AS, Vyas A, Blevins A, Dughman S, et al. Single versus double stenting for unprotected left main coronary artery bifurcation lesions: A systematic review and meta-analysis. J Invasive Cardiol. 2014;26(6):229-33.
36. Hildick-Smith D, de Belder AJ, Cooter N, Curzen NP, Clayton TC, Oldroyd KG, et al. Randomized trial of simple versus complex drug-eluting stenting for bifurcation lesions: the British Bifurcation Coronary Study: old, new, and evolving strategies. Circulation. 2010;121(10):1235-43.
37. Colombo A, Bramucci E, Saccà S, Violini R, Lettieri C, Zanini R, et al. Randomized study of the crush technique versus provisional side-branch stenting in true coronary bifurcations: the CACTUS (Coronary Bifurcations: Application of the Crushing Technique Using Sirolimus-Eluting Stents) study. Circulation. 2009;119(1):71-8.
| Files | ||
| Issue | Vol 21 No 3 (2026) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/rhythm.v21i3.22561 | |
| Keywords | ||
| Left Main Coronary Artery Disease Percutaneous Coronary Intervention Drug Eluting Stents | ||
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How to Cite
1.
Aljabry KN, Abeid S, Yasseen Y, Al-obaidi F. Three-Year Outcomes Post Percutaneous Coronary Intervention for Left Main Coronary Artery Disease. Res Heart Yield Transl Med. 2026;21(3):189-196.
