Twenty Years of Experience in One Thousand De-Novo Left Main Coronary Angioplasty With Angiographic Control in a High-Volume Centre Without On-Site Cardiac Surgery

Abstract

Introduction

Given the widespread use of percutaneous coronary intervention (PCI) for the treatment of unprotected left main coronary artery (ULMCA) disease, real-world data are needed to understand the current practice and identify pitfalls and potential benefits, especially for an older and frail population.

Methods

We conducted a retrospective analysis including all patients, namely 1000, who underwent PCI on ULMCA for de-novo lesions, at our high-volume Italian center without on-site cardiac surgery, from 2002 to April 2023. Cases of restenosis, stent thrombosis, and coronary artery bypass grafting (CABG) were excluded.

The primary clinical endpoint is major adverse cardiovascular and cerebrovascular event (MACCE), a composite endpoint including all-cause mortality, unplanned revascularization, myocardial infarction and stroke. Secondary clinical endpoints included the individual components of MACCE.

Angiographic follow-up data, derived from both elective and clinical-driven procedures, were extensively available. The primary angiographic endpoint is target lesion failure (TLF), defined as significant restenosis or stent thrombosis of the LMCA. We performed a dedicated analysis comparing patients with a protocol-driven elective angiographic follow-up to those without, to evaluate the potential impact of this strategy on clinical outcomes.

Results

Our registry encompasses a real-world frail and compromised population, with most patients (75%) presenting with acute coronary syndrome. Angiographic follow-up data were available for 739 patients (73.9%), of whom 612 (82.8%) demonstrated good results of the previous PCI and 127 patients (17.2%) experienced TLF. Multivariate analysis identified insulin-dependent diabetes, moderate to severe renal impairment, and a two-stents bifurcation technique as independent predictors of TLF. Among bifurcation techniques, the highest restenosis rates were observed in the Culotte technique (33.3%), followed by T and protrusion (30%) and Minicrush (28.2%), while the single stent approach was associated with the lowest rate of TLF (12.8%, p = < 0.001).

Clinical follow-up data were available for 966 patients, with a survival rate of 95% at 7 days, 86.1% at 1 year, and 70% at an average follow-up of 2033 days. Multivariate analysis identified age over 70 years, moderate to severe renal impairment, multivessel disease, ejection fraction lower than 40%, hemodynamic instability (HDI) and endotracheal intubation (ETI) as independent predictors of MACCE and all-cause mortality while intravascular imaging was found to be protective for both.

A propensity score matched analysis comparing two homogenous cohorts of 131 patients with and without elective angiographic follow-up demonstrated a significant survival advantage in the elective follow-up group, highlighting the potential benefits of this strategy.

Conclusions

In the real world setting clinical outcomes of PCI for unprotected LMCA disease are good and mainly affected by age, renal impairment, lower ejection fraction, multivessel disease and by the severity of the clinical presentation (namely HDI and ETI), while intravascular imaging was found to be protective. Notably, insulin-dependent diabetes and two-stent technique are independent predictors of TLF but not of mortality, while renal impairment has a negative impact on both. An elective angiographic follow-up could provide a survival benefit in this setting.