Is stenting a preferred option for unprotected left main coronary artery disease in the drug-eluting stent era?

ABSTRACT

Coronary artery bypass graft (CABG) has been the established treatment for left main coronary artery (LMCA) disease. However, despite continuous evolution of CABG including arterial grafting, advancement of cardioplegia, introduction of off-pump CABG, and improved pre-operative risk assessment, CABG has inherent limitations related to operation, such as peri-operative mortality, prolonged hospital stay and rehabilitation, and long-term graft patency. LMCA disease has been considered to be a challenge for interventional cardiologist for more than 25 years. In the bare metal stent (BMS) era, early results were very promising, but the long-term results were not sufficient to replace CABG, mainly because of the high restenosis rate. The early experience with drug-eluting stent (DES) in unprotected LMCA reveals reduced rates of restenosis and associated clinical outcomes when compared with patients who were treated with BMS. Moreover, recent non-randomized study demonstrated that no differences in either mortality or the combined occurrence of major adverse cardiovascular and cerebrovascular events were observed at the 1-year follow-up between DES and CABG. However, up to now, effectiveness of DES is not enough to replace CABG in LMCA revascularization. The ongoing randomized trial comparing DES vs. CABG (PRE-COMBAT and SYNTAX) may help to address this issue. Based on these trials, it is likely that, for selected patients, DES may be regarded as a preferred revascularization strategy for LMCA disease.