Stenting of left main coronary artery stenosis: A to Z

Abstract

For several decades, coronary artery bypass grafting (CABG) has been considered as the gold standard treatment of unprotected left main coronary artery (LMCA) disease. The marked improvement in technique and technology makes percutaneous coronary interventions (PCIs) feasible for patients with unprotected LMCA stenosis. The recent introduction of drug-eluting stents (DESs), together with advances in periprocedural and postprocedural adjunctive pharmacotherapies, has improved outcomes of PCIs of these lesions. Recent studies comparing efficacy and safety of PCIs using drug-eluting stents and CABG revealed comparable results in terms of safety and a lower need for repeat revascularisation for CABG. Patient selection for both the techniques directly impacts clinical outcome. Despite improvement in stent technology and operator experience, management can be challenging especially in LMCA bifurcation lesions and, therefore, an integrated approach combining advanced devices, tailored techniques, adjunctive support of physiological evaluation, and adjunctive pharmacological agents should be reinforced to improve clinical outcome.

Keywords: Allied Specialities; Interventional Cardiology.

Figure 1

Provisional stenting. (A) Baseline angiogram showing tight distal left main (LM) lesion with near normal (left circumflex) LCx ostium. (B) Intravascular ultrasound (IVUS) showing severely diseased left anterior descending (LAD) ostium. (C) IVUS revealing minimally diseased LCx ostium. (D) Stenting left main coronary artery (LMCA-LAD) crossover. (E) In-stent dilatation with bigger non-complaint balloon. (F)Final result after kissing balloon inflation. (G) IVUS showing well expanded stent at LAD ostium. (H) No carina shift from main branch stent as reflected by IVUS.

Figure 2

Culotte stenting. (A) Baseline angiogram. (B) Predilataion of left main-left anterior descending (LM-LAD) artery. (C) First stent deployed in LM-left circumflex (LCx) artery. (D) Second stent deployment in LM-LCx artery after wire exchange and predilation. (E) Kissing balloon inflation. (F) Final result.

Figure 3

T and protrusion technique. (A) Baseline angiogram showing significant stenosis of ostium and distal trifurcation of left main (LM), ostioproximal left anterior descending (LAD) and left circumflex (LCx). (B) Predilataion of LAD and left main coronary artery (LMCA) with 3.0X20 mm balloon. (C) 3.5×23 mm drug-eluting stent (DES) implanted at proximal LAD. (D) Implantation of 3.5×18 mm DES into LM-LAD artery. (E) After predilation of LM-LCx artery with 2.5×20 mm balloon through stent struts, implantation of 2.75×18 mm DES in LCx with proximal edge inside LM and deflated 3.5×18 mm balloon in LM artery. (F) Final kissing balloon inflation. (G) Final result.

Figure 4

Mini-crush technique (figure 4 in new folder). (A) Baseline angiogram revealing significant stenosis of left-main (LM) bifurcation involving proximal left anterior descending (LAD) and left circumflex (LCx) artery. (B) Predilatation of LCx artery. (C) Predilatation of LAD artery. (D) Stent to LCx with protrusion into LAD artery. (E) Crushing of LCx stent with left main coronary artery (LMCA) to LAD stent. (F) Rewiring of LCx followed by final kissing balloon inflation. (G) Final angiographic result.

Figure 5

Double kiss crush technique. (A) Baseline angiography showing critical distal left main (LM), proximal left anterior descending (LAD) and ostioproximal left circumflex (LCx) artery. (B) Predilatation followed by stenting of proximal LAD. (C) Predilatation followed by subsequent stenting of LM-LCx. (D) Crushing of LCx stent with non-compliant balloon placed in LM-LAD artery. (E) First kissing balloon inflation. (F) Deployment of stent from LM-LAD with second crushing of LCx stent. (G) Second kissing balloon inflation. (H) Final result.

Figure 6

Simultaneous kissing stent technique (figure 6 in new folder). (A) Baseline angiogram showing tight stenosis at left main (LM) bifurcation. (B) Implantation of two drug-eluting stents (DES) in left anterior descending (LAD) and left circumflex (LCx) artery simultaneously. (C) Following sequential postdilatation and kissing balloon inflation.