Lessons from Studies with Bare Metal Stents

Randomized Studies

Thus far, there have been no randomized studies comparing coronary stent placement with CABG for left main disease. It is therefore unknown whether the survival benefit after coronary stenting is similar to that after CABG in patients with left main coronary artery disease.

Registries

Various groups have reported favorable results after stenting of unprotected left main stenoses.74-79 The efficiency of stents in reducing acute complications and restenosis, particularly in large-diameter vessels, explains the attractiveness of stenting for percutaneous treatment of left main disease. Moreover, stents overcome the elastic recoil within the aortic wall, which represents a major problem with left main PTCA. Accordingly, reported rates of restenosis at 6-month follow-up have ranged between 7% and 22% for stenting of unprotected left main stenosis,76,77,80 corresponding to a rate of repeat revascularization between 10% and 17%.74-77,81-83 The risk of restenosis appears to be the highest in lesions involving the distal part of the left main coronary artery.80 In patients with elective stenting of unprotected left main disease, mortality varies considerably, depending on the clinical setting, with an early (<30 days) mortality rate ranging from 0% to 6%74,76,77 and a late (>6 months) mortality rate ranging between 2% and 32%.74-77,81,83 In the Korean experience of 270 consecutive patients with stent treatment of unprotected left main disease, the 3-year cardiac mortality rate was 3.2% ± 1.1%, and the rate of survival without MI or reintervention was 77.7% ± 2.7%. The majority of events occurring during the first 3 years were reinterventions within the first 6 months (17.2%).79 Similar results were obtained at 5-year follow-up.78

Strong predictors of late mortality include LVEF less than 40%74 and increased risk for CABG.75 Among poor candidates for surgery, stenting of the left main coronary artery carried a 9% mortality risk in the first month and an 11% risk in the first year.75 On the other hand, stenting of the left main in 93 patients who were good candidates for surgery was associated with a 30-day mortality rate of 0% and a 1-year mortality rate of 2.5% in a single-center series.75

The registry data suggest that, similar to CABG, PCI carries a higher long-term and short-term risk in the presence of left main disease, compared with more distal coronary lesions. The findings also indicate that the risk for major complications after PCI, at least during the mid-term up to 5 years, appears to be on the same order of magnitude as that after CABG. Obviously, the registry data cannot establish equivalence to surgery. Nevertheless, the data indicate that stenting of the left main coronary artery may be a reasonable option if there is good reason to avoid surgery, such as severe concomitant disease or advanced age.

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