Figure 1
SYNTAX, SYNTAX II (for PCI and CABG, with respective predicted mortality) and EuroSCORE II scores of patients with unprotected left main coronary artery disease according to the stent strategy
| Balloon-expandable stents | Self-apposing stents | Total | p value | |
|---|---|---|---|---|
| SYNTAX | 23.5 (16.5–30.5) | 17.5 (11–25.5) | 21 (13–29) | 0.004 |
| SYNTAX-2 PCI | 34.1 (25.6–45.4) | 28.9 (22.1–40.7) | 32.2 (23.6–43.6) | 0.04 |
| Estimated PCI mortality | 9.8 (4.9–22.7) | 6.2 (3.6–15.9) | 8.3 (4.1–19.9) | 0.03 |
| SYNTAX-2 CABG | 31.5 (23.3–40.9) | 25.3 (16.4–33.6) | 28.9 (19.4–38) | 0.01 |
| Estimated CABG mortality | 7.7 (3.9–16.2) | 4.6 (2.2–10.3) | 6.2 (2.9–13.6) | 0.01 |
| EUROSCORE II | 1.6 (1–3.3) | 1.1 (0.8–2.5) | 1.3 (0.9–2.8) | 0.1 |
Angiographic findings of patients with unprotected left main coronary artery disease according to the type of implanted stent (LM – left main; LAD – left anterior descending artery; LCX – left circumflex artery; RCA – right coronary artery)
| Balloon-expandable stents | Self-apposing stents | Total | p value | |
|---|---|---|---|---|
| Arterial access site | ||||
| Radial | 16 (19.1) | 18 (29) | 34 (23.3) | 0.2 |
| Femoral | 68 (80.9) | 44 (71) | 112 (76.6) | 0.2 |
| Left main lesion localization | ||||
| Ostial | 10 (11.9) | 0 (0) | 10 (6.9) | |
| Middle segment | 1 (1.2) | 0 (0) | 1 (0.7) | |
| Distal | 58 (69) | 54 (87.1) | 112 (76.7) | |
| Ostial and distal | 1 (1.2) | 3 (4.8) | 4 (2.7) | |
| Whole length | 14 (16.7) | 5 (8.1) | 19 (13) | 0.009 |
| Bifurcation | 63 (75) | 52 (83.9) | 115 (78.8) | 0.2 |
| Trifurcation | 21 (25) | 10 (16.1) | 31 (21.2) | 0.2 |
| Other lesions | ||||
| None | 24 (28.6) | 25 (40.3) | 49 (33.6) | |
| One vessel | 27 (32.1) | 17 (27.4) | 44 (30.1) | |
| Two vessels | 23 (27.4) | 16 (25.8) | 39 (26.7) | |
| Three vessels | 10 (11.9) | 4 (6.5) | 14 (9.6) | 0.4 |
| Chronic total occlusion | 17 (20.2) | 14 (22.6) | 31 (21.2) | 0.8 |
| LAD ostium involved | 45 (53.6) | 50 (80.6) | 95 (65.1) | 0.001 |
| LCX ostium involved | 36 (42.9) | 24 (38.7) | 60 (41.1) | 0.7 |
| LAD non-ostial lesion | 41 (48.8) | 23 (37.1) | 64 (43.8) | 0.2 |
| LCX non-ostial lesion | 27 (312.1) | 13 (21) | 40 (27.4) | 0.2 |
| RCA lesion | 28 (33.3) | 20(32.3) | 48 (32.9) | 0.5 |
| Left main lesion characteristics | ||||
| Diffuse lesion | 49 (5.3) | 27 (43.5) | 76 (52.1) | 0.09 |
| Eccentric lesion | 64 (76.2) | 43 (69.4) | 107 (73.3) | 0.4 |
| Calcified lesion | 29 (34.5) | 14 (22.6) | 43 (29.4) | 0.1 |
| Ulcerated lesion | 21 (25) | 15 (24.2) | 26 (25.7) | 0.5 |
| Carina involved | 4 (4.8) | 5 (8.1) | 9 (6.2) | 0.5 |
| Medina classification (only distal Left main lesions) | ||||
| 1/1/1 | 22 (30.1) | 12 (19.4) | 34 (25.2) | |
| 1/0/0 | 17 (23.3) | 6 (9.7) | 23 (17.1) | |
| 1/1/0 | 10 (13.7) | 6 (9.7) | 16 (11.9) | |
| 1/0/1 | 6 (8.2) | 3 (4.8) | 6 (6.7) | |
| 0/1/0 | 11 (15.1) | 26 (41.9) | 37 (27.4) | |
| 0/1/1 | 4 (5.5) | 6 (9.8) | 10 (7.4) | |
| 0/0/1 | 3 (4.1) | 3 (4.8) | 6 (4.4) | 0.01 |
| True bifurcation (1/1/1, 0/1/1) | 26 (35.6) | 18 (29) | 44 (32.6) | 0.5 |
| Left main take-off angle >700 | 22 (32.8) | 22 (37.9) | 44 (35.2) | 0.6 |
| Bifurcation angle | ||||
| >90 degrees | 5 (8.1) | 7 (12.1) | 12 (10) | |
| 70–90 | 24 (38.7) | 24 (41.4) | 48 (40) | |
| 45–69 | 11 (17.7) | 10 (17.2) | 21 (17.5) | |
| <45 | 22 (35.5) | 17 (29.3) | 39 (32.5) | 0.8 |
| LM stenosis, % (median, IQR) | 67 (45–89) | 30 (11–57) | 55 (20–80) | <0.001 |
| LAD stenosis, % (median, IQR) | 83 (58–90) | 86 (71–93) | 85 (66–92) | 0.006 |
| LCX stenosis, % (median, IQR) | 71 (43–84) | 63 (18–86) | 70 (30–86) | 0.4 |
Procedural outcomes and post-procedural complications according to the type of implanted stent in patients with unprotected left main coronary artery disease (LM – left main; SB – side branch; TIA – transient ischemic attack; PCI – percutaneous coronary intervention; CIN – contrast induced nephropathy)
| Balloon-expandable stents | Self-apposing stents | Total | p value | |
|---|---|---|---|---|
| Unaffected LM ostium covered by implanted stent | 12 (14.3) | 6 (9.7) | 18 (13.3) | 0.4 |
| LM lesion covered | 84 (100) | 60 (96.8) | 133 (98.5) | 0.2 |
| SB residual stenosis | ||||
| None | 50 (67.5) | 36 (58.1) | 83 (62.4) | |
| <50% | 17 (23) | 21 (33.9) | 38 (28.6) | |
| >50% | 7 (9.5) | 5 (8) | 12 (9) | 0.4 |
| Procedural success | 81 (96.4) | 57 (91.9) | 138 (94.5) | 0.3 |
| Complete revascularization | 63 (75) | 46 (74) | 109 (74.7) | 0.5 |
| TIMI flow at the of the procedure | ||||
| 1 | 1 (1.2) | 3 (4.8) | 4 (2.7) | |
| 2 | 3 (3.6) | 1 (1.6) | 4 (2.7) | |
| 3 | 80 (95.2) | 58 (93.6) | 138 (94.5) | 0.4 |
| Peri-procedural complications | ||||
| Hematoma | 3 (3.6) | 3 (4.8) | 6 (4.1) | 0.7 |
| Stroke/TIA | 1 (1.2) | 0 (0) | 1 (0.7) | 0.6 |
| MI | 1 (1.2) | 3 (4.8) | 4 (2.7) | 0.2 |
| Afib | 1 (1.2) | 1 (1.6) | 2 (1.5) | 0.8 |
| Need for external electric shock | 1 (1.2) | 3 (4.8) | 4 (2.7) | 0.3 |
| Bradi-arrhythmia | 3 (3.6) | 7 (11.3) | 10 (6.9) | 0.1 |
| Death during PCI | 1 (1.2) | 2 (3.2) | 3 (2) | 0.6 |
| CIN* | 9 (16.4) | 5 (13.2) | 14 (15.1) | 0.8 |
Procedural characteristics according to the type of implanted in patients with unprotected left main coronary artery disease (PCI – percutaneous coronary intervention; IABP – intra-aortic balloon pump; LAD – left anterior descending artery; LCX – left circumflex artery; POT – proximal optimization technique; KBPD – kissing balloon post dilatation; TKBPD – triple kissing balloon post dilatation; MV – main vessel; SB – side branch; iFR - instantaneous wave-free ratio; IVUS – intravascular ultrasound)
| Balloon-expandable stents | Self-apposing stents | Total | p value | |
|---|---|---|---|---|
| Time from coronary angiogram to PCI, days (median, IQR) | 2 (0–22.5) | 2.5 (0–20) | 2 (0–20) | 0.8 |
| Arterial acces site | ||||
| Femoral | 81 (96.4) | 50 (80.6) | 131 (89.7) | 0.004 |
| Radial | 3 (3.6) | 12 (19.4) | 15 (10.3) | 0.004 |
| Pre-PCI IABP | 5 (5.9) | 1 (1.6) | 6 (4.1) | 0.2 |
| Guide catheter | ||||
| 6F | 47 (55.9) | 31 (50) | 78 (53.4) | |
| 7F | 37 (44.1) | 29 (46.8) | 66 (45.2) | |
| 8F | 0 (0) | 2 (3.2) | 2 (1.4) | 0.2 |
| Rotational atherectomy | 2 (2.4) | 1 (1.6) | 3 (2.1) | 0.6 |
| Two stent technique | 35 (41.7) | 25 (40.3) | 0.5 | |
| Provisional stenting | 1 (3.1) | 0 (0) | 1 (1.7) | |
| TAP | 10 (31.2) | 10 (40) | 20 (35.1) | |
| Minicrush | 14 (43.7) | 4 (16) | 18 (31.6) | |
| DK-Crush | 3 (9.4) | 0 (0) | 3 (5.3) | |
| Cullotte | 3 (9.4) | 10 (40) | 13 (22.8) | |
| V-stenting | 1 (3.1) | 1 (4) | 2 (3.5) | 0.03 |
| MV predilatation | 62 (78.5) | 49 (79) | 111 (78.7) | 0.5 |
| SB predilatation* | 29 (40.9) | 19 (30.7) | 48 (36.1) | 0.4 |
| Predilatation at nominal pressure** | 21 (30.4) | 24 (46.1) | 40 (36) | 0.3 |
| Dissection | 19 (26.4) | 9 (17.3) | 26 (23.4) | 0.2 |
| POT* | 57 (81.4) | 28 (45.2) | 87 (64.4) | <0.001 |
| POT after first stent*** | 46 (78) | 22 (78.6) | 68 (50.4) | 0.6 |
| POT after KBPD*** | 32 (54.2) | 6 (21.4) | 38 (28.2) | 0.005 |
| POT balloon diameter*, mm (median, IQR) | 4 (4–4.5) | 4 (4–4.5) | 4 (4–4.5) | 0.9 |
| KBPD* | 42 (62.7) | 19 (30.6) | 62 (45.9) | <0.001 |
| TKBPD* | 5 (7.2) | 0 (0) | 5 (3.7) | 0.03 |
| MV stent diameter | ||||
| 3 | 14 (16.7) | 18 (29.3) | 32 (21.9) | |
| 3.5 | 53 (63.1) | 44 (71) | 97 (66.4) | |
| 4 | 17 (20.2) | 0 (0) | 17 (11.6) | <0.001 |
| MV stent length, mm (median, IQR) | 24 (16–29) | 22 (18–25) | 22 (18–28) | |
| SB stent diameter, mm (median, IQR) | 3 (3–3.5) | 3.5 (3–3.5) | N/A | 0.5 |
| SB stent length, mm (median, IQR) | 19 (13–23) | 22 (18–27) | N/A | 0.06 |
| Under expansion of >30% | 6 (7.1) | 8 (12.9) | 14 (9.6) | 0.3 |
| IFR used pre-PCI | 2 (2.4) | 4 (6.5) | 6 (4.1) | 0.4 |
| IFR used post-PCI | 0 (0) | 4 (6.5) | 4 (2.8) | 0.03 |
| IVUS used pre-PCI | 2 (2.4) | 0 (0) | 2 (1.4) | 0.5 |
| IVUS used post-PCI | 12 (14.3) | 14 (22.6) | 26 (17.8) | 0.3 |
Demographic and baseline clinical characteristics according to the type of the implanted stent in patients with unprotected left main coronary artery disease (ACS – acute coronary syndrome; NSTEMI – non-ST segment elevation myocardial infarction; STEMI – ST segment elevation myocardial infarction; PCI – percutaneous coronary intervention; TIA – transient ischemic attack; COPD - chronic obstructive pulmonary disease; PAD – peripheral artery disease; LBBB – left bundle branch block; RBBB – right bundle branch block; LVEF – left ventricular ejection fraction; HB – hemoglobin)
| Balloon-expandable stents | Self-apposing stents | Total | p value | |
|---|---|---|---|---|
| Age, y (median, IQR) | 63 (56–72) | 62 (52–70) | 63 (55–71) | 0.2 |
| Male | 58 (69.1) | 44 (71) | 102 (69.9) | 0.8 |
| Cardiovascular risk factors | ||||
| Hypertension | 71 (84.5) | 51 (83.6) | 0.5 | |
| Dyslipidemia | 73 (86.9) | 53 (86.9) | 126 (86.9) | 0.6 |
| Diabetes | 25 (29.8) | 17 (27.9) | 42 (29) | 0.8 |
| Obesity | 21 (25) | 17 (27.4) | 38 (26) | 0.8 |
| Smoking status | ||||
| Active smoker | 25 (30.1) | 18 (29.5) | 43 (29.9) | 0.8 |
| Former smoker | 16 (19.3) | 10 (16.4) | 26 (18.1) | 0.8 |
| Patient history | ||||
| ACS | 32 (38.1) | 26 (42.6) | 58 (40) | 0.6 |
| Unstable angina | 3 (9.4) | 3 (11.5) | 6 (10.3) | |
| NSTEMI | 11 (34.4) | 5 (19.2) | 16 (27.6) | |
| STEMI | 18 (56.2) | 18 (69.3) | 36 (62.1) | 0.4 |
| PCI | 20 (23.8) | 14 (22.6) | 34 (23.3) | 0.5 |
| Atrial fibrillation | 11 (13.1) | 8 (13.1) | 19 (13.1) | 0.6 |
| Stroke/TIA | 10 (11.9) | 5 (8.1) | 15 (10.3) | 0.6 |
| Bleeding | 2 (2.4) | 3 (4.9) | 5 (3.4) | 0.6 |
| COPD | 1 (1.2) | 1 (1.6) | 2 (1.4) | 0.7 |
| PAD | 21 (25) | 4 (6.6) | 25 (17.2) | 0.004 |
| Neoplasm | 9 (10.7) | 0 (0) | 9 (6.2) | 0.01 |
| Clinical presentation | ||||
| Stable angina | 40 (47.6) | 30 (48.4) | 70 (47.9) | |
| Unstable angina | 19 (22.6) | 11 (17.7) | 30 (20.5) | |
| NSTEMI | 9 (10.7) | 7 (11.3) | 16 (11) | |
| STEMI | 10 (11.9) | 8 (12.9) | 18 (12.3) | |
| ACS with cardiogenic shock | 6 (7.2) | 6 (9.7) | 12 (8.2) | 0.9 |
| Atrial fibrillation | 7 (8.6) | 5 (8.1) | 12 (8.4) | 0.6 |
| LBBB | 6 (7.4) | 3 (4.8) | 9 (6.3) | 0.4 |
| RBBB | 7 (8.6) | 4 (6.4) | 11 (7.7) | 0.4 |
| Ventricular tachycardia | 0 (0) | 2 (3.2) | 2 (1.4) | 0.2 |
| LVEF, % (median, IQR) | 50 (35–55) | 50 (38–60) | 50 (35–57.5) | 0.6 |
| LV systolic disfunction | ||||
| None (>=50%) | 42 (50.6) | 32 (52.5) | 74 (51.4) | |
| Mild (40–49%) | 16 (19.3) | 13 (21.3) | 29 (20.1) | |
| Moderate (30–39%) | 15 (18.1) | 10 (16.4) | 25 (17.4) | |
| Severe (<30%) | 10 (12) | 6 (9.8) | 16 (11.1) | 0.9 |
| Diastolic disfunction | 71 (92.2) | 49 (84.4) | 120 (88.9) | 0.2 |
| Regional wall motion abnormality | 58 (71.6) | 38 (62.3) | 96 (67.6) | 0.3 |
| LV aneurysm | 5 (6.1) | 4 (6.6) | 9 (6.3) | 0.6 |
| LV thrombus | 2 (2.4) | 0 (0) | 2 (1.4) | 0.5 |
| LV hypertrophy | 31 (41.3) | 14 (24.6) | 45 (30.1) | 0.06 |
| Dilated cardiomyopathy | 4 (4.8) | 3 (4.9) | 7 (4.9) | 0.6 |
| Mitral regurgitation | ||||
| None/Trivial | 12 (14.5) | 2 (3.3) | 14 (9.8) | |
| Mild | 51 (61.4) | 45 (75) | 96 (67.1) | |
| Moderate | 12 (14.5) | 10 (16.7) | 22 (15.4) | |
| Severe | 8 (9.6) | 3 (5) | 11 (7.7) | 0.09 |
| Aortic regurgitation | ||||
| None/Trivial | 61 (73.5) | 40 (66.7) | 101 (70.6) | |
| Mild | 15 (18.1) | 20 (33.3) | 35 (24.5) | |
| Moderate | 7 (8.4) | 0 (0) | 7 (4.9) | |
| Severe | 0 (0) | 0 (0) | 0 (0) | 0.01 |
| Ascending aorta diameter, mm (median, IQR) | 32 (30–34) | 34 (31–37) | 32 (30–35) | 0.02 |
| Moderate/severe aortic stenosis | 3 (3.6) | 0 (0) | 6 (4.2) | 0.3 |
| Tricuspid regurgitation | 50 (60.2) | 40 (65.6) | 90 (62.5) | 0.6 |
| Pulmonary hypertension | 15 (20) | 4 (7) | 19 (14.4) | 0.04 |
| Blood samples pre-PCI | ||||
| HB, g/dl (median, IQR) | 13.4 (12.2–14.4) | 13.9 (12.5–15) | 13.5 (12.3–14.7) | 0.1 |
| CK-MB, U/L (median, IQR) | 25 (18–63) | 22 (16–37) | 22 (17–50) | 0.2 |
| Troponin, ng/ml (median, IQR) | 0.24 (0.03–1.3) | 1 (0.07–4.8) | 0.3 (0.03–2.9) | 0.2 |
| Creatinine, mg/dl (median, IQR) | 0.9 (0.8–1.2) | 0.9 (0.8–1.2) | 0.9 (0.8–1.2) | 0.9 |
| Creatinine clearance, ml/min/1.73m2 (median, IQR) | 80 (62–97) | 80 (65–95) | 80 (64–96) | 0.9 |