A Meta-analysis of Ostial and Trunk versus Distal Lesions in Unprotected Left Main Coronary Artery Stenting
Wassef Karrowni
Department of Cardiovascular Medicine, Unity Point Clinic - St. Luke’s Hospital, Cedar Rapids, Iowa, USA
Amandeep S. Dhaliwal *
Division of Cardiology, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
Nader Makki
Division of Cardiology, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
Ankur Vyas
Division of Cardiology, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
Amy Blevins
Division of Cardiology, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
Saadeddine Dughman
Department of Cardiovascular Medicine, Premier Health Specialists-Atrium Medical Center, Middletown, Ohio, USA
Saket Girotra
Division of Cardiology, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
Peter Cram
Division of General Internal Medicine at UHN/Mt Sinai Hospitals and University of Toronto, Toronto, Canada
Phillip A. Horwitz
Division of Cardiology, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
*Author to whom correspondence should be addressed.
Abstract
Aims: To assess outcomes for percutaneous coronary intervention (PCI) in ostial and trunk versus distal unprotected left main coronary artery (LMCA) lesions in the drug-eluted stent (DES) era.
Study Design: A meta-analysis and systematic review.
Methods: With the help of a librarian, we searched Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and the Clinical Trials Registry from 2001 to July 2012. We included studies that enrolled ≥ 50 patients and had ≥6 months of follow-up. Our co-primary endpoints were the incidence of major adverse cardiac events (MACE) and target lesion/vessel revascularization (TLR/TVR). Data was abstracted and analyzed by two independent reviewers and differences were resolved by consensus. We assessed the results for heterogeneity in our analysis by examining the forest plots and then calculating a Q statistic, which we compared with the I2 index. If there was no evidence of statistical heterogeneity and pooling of results was clinically appropriate, a combined estimate was obtained using the fixed-effects model; otherwise the random-effects model was used.
Results: We identified 11studies involving 3,718 patients. Mean duration of follow-up was 29 months (range 12-62months). Compared with ostial and trunk stenting, distal LMCA PCI was associated with increased MACE (OR 1.95, 95% CI 1.43-2.66) and TLR/TVR (OR 3.13, 95% CI 1.90-5.16).No significant differences were detected for cardiac death (OR 1.06, 95% CI 0.72-1.58, p=0.58), MI (OR 1.15, 95% CI 0.74-1.77, p=0.80) or stent thrombosis (OR 1.57, 95% CI 0.90-2.77, p=0.41).
Conclusion: Patients with ostial and trunk LMCA lesions treated with DES have better outcomes than patients with distal lesions. Our findings may support unprotected non-distal LMCA stenting as a primary approach in selected patient subsets.
Keywords: Drug eluting stent, left main coronary artery, coronary artery disease, ostiallesion, distal lesion