Elective stenting of "unprotected" left main coronary stenosis in patients without contraindication to bypass surgery

Coronary surgery is at this point of time the standard therapy of unprotected left main coronary artery stenosis. Coronary angioplasty (PTCA) is performed only in bail out situations. The number of publications of successful percutaneous intervention in unprotected left main coronary stenosis is increasing because of increasing use of stents and ticlopidine to avoid stent-thrombosis. From 9/96 to 7/98, 13 patients with unprotected left main coronary stenosis were treated with stents. All of them were accepted by the heart surgeon for bypass surgery but were not considered to be optimal candidates due to advanced age of more than 80 years (n = 5), significant co-morbidity (n = 2) or diffuse diseased peripheral coronary segments (n = 6). Mean age of patients was 74 +/- 10 years, 9 were male, and all patients presented with angina III-IV (CCS). Mean ejection fraction was 55 +/- 15%. Localization of stenoses were classified as ostial (n = 5), middle (n = 3), and bifurcational (n = 6). One patient had stenoses both in the ostium and in the bifurcation. In all cases a PTCA of the culprit stenosis was performed prior to stent implantation. The mean diameter of the stents used was 3.3 +/- 0.3 mm and the mean length was 11 +/- 4 mm. In 6 patients a PTCA of either left anterior descendens (LAD) or right coronary artery was performed in the same session. In 4 of these patients it was followed by a stent implantation. All procedures were performed with surgical stand-by, an intraaortal balloon pump war available, but was not used prophylactically. Stent implantation could be performed successfully in 12 out of the 13 patients (success rate 92%). In bifurcational stenoses stents were positioned with the proximal end in the left main and the distal end in the LAD. Significant injury or occlusion of the circumflex artery was not observed. In one patient with bifurcational stenosis with severe calcification it was not possible to cross the lesion with an accurate sized balloon. Trying to cross with a smaller balloon (2.5 mm) resulted in dissection of the left main coronary artery which could not be reopened again by catheter technique. This patient was transferred to the operating room under conditions of cardiopulmonary resuscitation and a bypass surgery was performed. He was dismissed from the hospital with no evidence of perioperative myocardial infarction. The mean time for follow-up was 12 +/- 7 months, all patients are still alive. In 6 patients an angiography was performed during follow-up because of suspicion of recurrent ischemia. Two patients out of these 6 had restenoses in the left main coronary artery which were re-dilated (17%). Another 2 patients had stenoses in other coronary segments and were also dilated. Thus, stenting of left main coronary artery stenoses is feasable, however, with acceptable risks and could be considered in selected patients as an alternative to coronary artery surgery.