Buja, Paolo (2008) Stent medicati e rivascolarizzazione del tronco comune coronarico. [Tesi di dottorato]
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AIMS. Although the revascularization of left main coronary artery disease is surgical, the percutaneous treatment with drug-eluting stents seems to be safe and feasible. We reported our clinical experience in this context, adopting a provisional stenting strategy and comparing these therapeutical options.
MATERIAL AND METHODS. Between November 2003 and September 2007, all patients with symptomatic left main disease were evaluated for drug-eluting stent implantation. Unprotected procedures were considered if a suitable anatomy was associated to contraindication to surgery or patient preference; all cases were discussed with the surgeon. Myocardial infarctions presenting with ST-elevation were excluded. A provisional stenting strategy was adopted in case of bifurcation involvement.
According to the type of percutaneous procedure, patients were divided in protected left main group (PLM) and in unprotected left main one (UPLM); as comparison, we selected a matched cohort from the surgical database who received a coronary artery by-pass graft (CABG). Follow-up was clinical and included the occurrence of major adverse events (MAE), i.e. cardiac death, myocardial infarction, stent thrombosis, major bleedings, major periprocedural complications and target vessel revascularizations; moreover, we observed the total mortality rate.
RESULTS. Sixty-nine patients were enrolled: 19 in the PLM group, 25 in the UPLM one and 25 in the CABG one; the distal bifurcation was involved in more than 85% of them and the side branch needed for stent implantation in 15.9% of patients. Angiographic success was achieved in all cases; only the CABG group had in-hospital MAE (16%, p<0.01) with the longer hospital stay (PLM 3.9, UPLM 4.1, CABG 8.4, days, mean, p=0.059). At a median time of 24.1 months, the CABG group had more MAE than the other ones (PLM 21.1%, UPLM 24%, CABG 28%, p ns): no stent thrombosis occurred, but 4 patients had a non ST-elevation myocardial infarction (PLM 10.5%, UPLM 4%, CABG 4.2%, p ns). The total rate of target vessel revascularizations was 21.1% in the PLM group, 24% in the UPLM one and 16% in the CABG one (p ns): a new percutaneous intervention was performed in most of them (69.2%). The total mortality was superior in the UPLM group (PLM 5.3%, UPLM 12%, CABG 8%, p ns) but the only cardiac death occurred during the perioperative phase of a surgical patient.
CONCLUSIONS. Our experience suggests that a provisional stenting strategy with drug-eluting stents for selected patients with left main coronary disease appears to be safe and effective with a low need for side branch stenting. Clinical results are good also in case of unprotected procedures and at follow-up. Surgical revascularization seems to have an higher rate of in-hospital complications with a lower rate of target vessel revascularizations, compared to percutaneous treatment.
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