1. 无保护左主干分叉病变介入治疗策略 The Principles & Strategies for Treatment of Unprotected LM Bifurcation Lesions
Lianglong Chen MD PhD FACC
Dept. of Cardiology, Union Hospital, Fujian Medical University

2. CONTENTS & FOCI
Special issues associated with LMD & special considerations
Different strategies and techniques for the Intervention of UPLMD
Comparison of PCI versus CABG for the treatment of UPLMD
Current guidelines and recommendations for the treatment of UPLMD

3. Why left main lesion is particular?
LM is responsible for 75% myocardial blood supplying
LM is anatomically big with 2 bifurcation & larger angulations
LM is rich in elastic tissue
Plaque is usually located in the lateral wall close to the LAD and LCx bifurcation, the carina is frequently free of disease.
Plaque of LMD is more diffuse
Low shear- stress zone
High shear- stress zone
carina

4. Why left main lesion is particular?
Plaque of LMD is more diffuse, 90% LM plaque extended to LAD

5. Special considerations for UPLMD Intervention
Reliable branch protection
Protecting wire
Protecting balloon
Effective lesion preparation
Pre-dilation
Pre-cutting balloon
Pre-rotablation
First & final balloon kissing
DK-crush
DK-culotte
Special imaging
IVUS guiding procedure
FFR guiding procedure

6. Culottes: DK-Mini-Culottes

7. FBKI: key determinants of restnosis, thrombusis, MI

8. CONTENTS & FOCI
Special issues associated with LMD & special considerations
Different strategies and techniques for the Intervention of UPLMD
Comparison of PCI versus CABG for the treatment of UPLMD
Current guidelines and recommendations for the treatment of UPLMD

9. Different strategies for the Intervention of UPLMD
Simple vs complex
Mono-stent vs dual-stents

10. MACE and TLR in Bifurcation Studies
CACTUS
BBC ONE
BBK
Nordic
P=0.009

11. Double vs. Single Stenting Meta-Analysis N=1642 pts
2 stents stent
2 stents stent
Katritsis DG et al. Circ Cardiovasc Intervent. 2009;2:

12. Double vs. Single Stenting Meta-Analysis N=1642 pts
2 stents stent
2 stents stent
Katritsis DG et al. Circ Cardiovasc Intervent. 2009;2:

13. Shao-Liang Chen EuroIntervention 2012;8:803-814
Five-year clinical follow-up of unprotected left main bifurcation lesion stenting: one-stent versus two-stent techniques versus double-kissing crush technique
To compare the long-term (five-year) safety and efficacy between the one-stent, two-stent and double-kissing (DK) crush strategies, utilising drug-eluting stents, for unprotected left main coronary artery (ULMCA) bifurcation lesions
Shao-Liang Chen EuroIntervention 2012;8:

14. MACE-free survival rates at 5-year follow-up

15. Survival rates free from cardiac death, MI, and TVR at 5-year follow-up

16. Current consensus or guideline recommendation
Simple strategies!

17. UPLMD: Cases

18. The optimal Path for BL Treatment

19. Different techniques for the Intervention of UPLMD
Superiority of
one dual-stenting technique over the others ?

20. Nordic II: Rate of Restenosis (≥50% diameter stenosis by QCA) at 8M
In-segment
In-stent

21. Nordic II: Major Adverse Cardiac Events at 6 Months Follow-up Cumulated MACE rate (cardiac death, MI, TVR, stent thrombosis)
Crush 4.3%, Culotte 3.7%
(plog-rank=0.87).
Erglis A et al. Circ Cardiovasc Intervent, 2009; 2:27-34

22. Shao-Liang Chen, et al. J Am Coll Cardiol 2013;61:1482–8
Comparison of Double Kissing Crush Versus Culotte Stenting for Unprotected Distal Left Main Bifurcation Lesions Results From a Multicenter, Randomized, Prospective DKCRUSH-III Study
Shao-Liang Chen, et al. J Am Coll Cardiol 2013;61:1482–8

23. DK-crush vs classic culotte
TLR
TVR
MACE

24. Conclusions
Classic culotte stenting for UPLMCA bifurcation lesions was associated with significantly increased MACEs, mainly due to the increased TVR.

25. Shao-Liang Chen EuroIntervention 2012;8:803-814
Five-year clinical follow-up of unprotected left main bifurcation lesion stenting: one-stent versus two-stent techniques versus double-kissing crush technique
To compare the long-term (five-year) safety and efficacy between the one-stent, two-stent and double-kissing (DK) crush strategies, utilising drug-eluting stents, for unprotected left main coronary artery (ULMCA) bifurcation lesions
Shao-Liang Chen EuroIntervention 2012;8:

26. Survival rates free from MACE, TLR, and TVR at 5 years between DK crush and other two-stent techniques
MACE
TLR
TVR

27. Major limitation of classic culotte：CUEB
D4.0
D2.5

28. Culottes: DK-Mini-Culottes

29. DK-Mini-Culottes: no CUEB

30. Long-term results at F/U
61 pts
Lesion characteristics
with 85%TBL, 25% UPLM.
Branch diameter difference 0.450.24.
DK-Mini-Culottes
Immediate technical success 100%
FKBI 100%
Acute IST 0.0%
F/U 11.31.5 M
Binary re-stenosis
Main branch 6.6%
Side branch 16.4%
MACE
Death 0.0%
MI 0.0%
TLR 3.2%
Late IST 0.0%

31. Different techniques for the Intervention of UPLMD
Superiority of
one dual-stenting technique over the others
???

32. CONTENTS & FOCI
Special issues associated with LMD & special considerations
Different strategies and techniques for the Intervention of UPLMD
Comparison of PCI versus CABG for the treatment of UPLMD
Current guidelines and recommendations for the treatment of UPLMD

33. MACCE to 5 Years by SYNTAX Score Tercile Low Scores (0-22)

34. MACCE to 5 Years by SYNTAX Score Tercile Intermediate Scores (33)

35. Patient Characteristics
CABG N=897
PCI N=903
CABG
Registry
N=644
PCI
Registry
N=192
P value
Age* (y)
Male, %
Diabetes*†, %
Additive euroSCORE*
Total Parsonnet score*
65.0±9.8
78.9
24.6
3.8±2.7
8.4±6.8
65.2±9.7
76.4
25.6
3.8±2.6
8.5±7.0
0.55
0.20
0.64
0.78
0.76
65.7±9.4
80.7
26.4
3.9±2.7
9.0±7.1
71.2±10.4
70.3
30.2
5.8±3.1
14.4±9.5
Total SYNTAX Score
29.1±11.4
28.4±11.5
0.19
37.8± ±12.3
Mean # of lesions
3VD only, %
Left main, any, %
Total occlusion, %
Complete revasc, %
4.4±1.8
66.3
33.7
22.2
63.2
4.3±1.8
65.4
34.6
24.2
56.7
0.44
0.70
0.33
0.005
4.6±1.7
59.7
40.3
56.4
74.7
4.5±1.8
66.7
33.3
36.5

36. MACCE to 5 Years by SYNTAX Score Tercile Low Scores (0-22)
CABG (N=275)
TAXUS (N=299)
CABG
10.1%
PCI
8.9%
P value
0.64
Overall
Death 50
Cumulative Even Rate(%)
CVA MI
Death,
CVA or
4.0%
4.2%
14.9%
1.8%
7.8%
16.1%
0.11
0.81
32.1%
28.6%
P=0.43 25
Months Since Allocation
Revasc.
16.9%
23.0%
0.06
Cumulative KM Event Rate ± 1.5 SE; log-rank P value
Core lab-reported Data; ITT population

37. MACCE to 5 Years by SYNTAX Score Tercile Intermediate Scores (23-32)
CABG (N=300)
TAXUS (N=310)
P=0.008
CABG
12.7%
3.6%
PCI
13.8%
2.0%
P value
0.68
0.25
Overall
36.0%
Death
CVA 50
Cumulative Even Rate(%) MI
Death,
CVA or
3.6%
18.0%
11.2%
20.7%
<0.001
0.42 25
25.8%
Months Since Allocation
Revasc.
12.7%
24.1%
<0.001
Cumulative KM Event Rate ± 1.5 SE; log-rank P value
Core lab-reported Data; ITT population

38. MACCE to 5 Years by SYNTAX Score Tercile Intermediate Scores (33)
CABG (N=315)
TAXUS (N=290)
P<0.001
CABG
11.4%
PCI
19.2%
P value
0.005
Overall
Death 50
Cumulative Even Rate(%)
CVA MI
3.7%
3.9%
3.5%
10.1%
0.80
0.004
44.0% 25
26.8%
Death,
CVA or MI
17.1%
26.1%
0.007
Months Since Allocation
Revasc.
12.1%
30.9%
<0.001
Cumulative KM Event Rate ± 1.5 SE; log-rank P value
Core lab-reported Data; ITT population

39. SYNTAX UPLMD subgroup analysis at 3 years
The UPLMD subgroup (N=705);
despite higher TVR for the PCI group at 3 yrs (20.0% PCI vs 11.7% CABG; P=0.004) and lower stroke in the PCI group (1.2% PCI vs 4.0% CABG; P=0.02);
Death (7.3% PCI vs 8.4% CABG; P=0.64), MI (6.9% PCI vs 4.1% CABG; P=0.14), and the composite end point of death/MI/stroke (13.0% PCI vs 14.3% CABG; P=0.60) remained similar between groups.
These results are consistent reporting similar safety outcomes between PCI and CABG but a higher rate of TVR with PCI.

40. Rev Bras Cir Cardiovasc 2013;28(1):83-92
Five-year outcomes following PCI with DES versus CABG for unprotected LM coronary lesions: meta-analysis and meta-regression of 2914 patients
To compare the safety and efficacy at long-term follow-up of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease
Rev Bras Cir Cardiovasc 2013;28(1):83-92

41. Odds ratio and conclusions plot of endpoints associated with CABG versus DES
死亡、MI、中风 死亡
MACE
TVR

42. Conclusion
CABG surgery remains the best option of treatment for patients with ULMCA disease, with less need of TVR and MACCE rates at long-term follow-up

43. FREEDOM Design

44. Primary Outcome-Death/Stroke/MI

45. Outcomes
全因死亡 MI 中风
TVR

46. Primary Outcome-Death/Stroke/MI

47. Conclusion
For patients with UPLMD complicating DM, CABG surgery is the only best option of treatment with no more requirement of Syntax score

48. CONTENTS & FOCI
Special issues associated with LMD & special considerations
Different strategies and techniques for the Intervention of UPLMD
Comparison of PCI versus CABG for the treatment of UPLMD
Current guidelines and recommendations for the treatment of UPLMD

49. 2011 ACCF/AHA/SCAI Guideline for PCI: recommendations

50. Thanks!