Coronary Artery Bypass Grafting Versus Stenting for Unprotected Left Main Coronary Artery Disease
2008; Lippincott Williams & Wilkins; Volume: 118; Issue: 23 Linguagem: Inglês
10.1161/circulationaha.108.820324
ISSN1524-4539
Autores Tópico(s)Cardiac Valve Diseases and Treatments
ResumoHomeCirculationVol. 118, No. 23Coronary Artery Bypass Grafting Versus Stenting for Unprotected Left Main Coronary Artery Disease Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBCoronary Artery Bypass Grafting Versus Stenting for Unprotected Left Main Coronary Artery DiseaseWhere Lies the Body of Proof? Richard J. Shemin, MD Richard J. SheminRichard J. Shemin From the Professor and Chief, Division of Cardiothoracic Surgery, David Geffen School of Medicine, Executive Vice Chairman, Department of Surgery, Robert and Kelly Day Chair of Cardiothoracic Surgery, Codirector, UCLA Cardiovascular Center, UCLA Ronald Reagan Medical Center, Los Angeles, Calif. Originally published2 Dec 2008https://doi.org/10.1161/CIRCULATIONAHA.108.820324Circulation. 2008;118:2326–2329The standard of care for left main coronary artery disease is coronary bypass surgery (CABG). The efficacy and survival advantage of CABG have resulted in CABG being established practice since the 1970s.1–3 Further improvements in late survival have been achieved with arterial grafting, which is practiced routinely even in patients more than 80 years of age.4–6Article p 2374Technical advances in percutaneous coronary interventions (PCIs) and stent technology have emboldened the interventional cardiology community to test the feasibility of and document the procedural results for stenting the left main coronary artery.7–14 Surgical approaches have a distinct advantage in that they can ignore the complexity and location of the left main coronary lesion, because bypass grafts are placed distally to the left anterior descending and circumflex coronary arteries. In addition, complete revascularization is easily accomplished.The feasibility and success of PCI require an evaluation of lesion complexity. The probability of procedural success requires a consideration of whether the obstructing plaque involves the ostium of the coronary artery, the body of the left main, or the length of the left main and whether disease involves the bifurcation with or without extension into the left anterior descending or circumflex coronary arteries. Ostial or body obstructions in a long left main vessel are more desirable to stent than bifurcation or trifurcation lesions.15–18 An additional consideration is the possibility of sudden stent thrombosis early or late after the use of drug-eluting stents (DES) or bare-metal stents. Such events in the left main coronary artery would have catastrophic consequences that most likely would result in sudden death.19–23 Current recommendations for DES are to continue dual-antiplatelet therapy for prolonged periods of time (>6 months or indefinitely), because stent healing with endothelium is incomplete. This protocol may be particularly risky in elderly patients. The therapy is costly, and serious consequences can ensue if unrelated medical problems require discontinuation of the platelet therapy.24,25 CABG procedures avoid not only the technical factors of the obstructing lesion but require only low-dose aspirin therapy.Survival advantages of stent therapy for coronary artery disease over medical therapy have not been a consistent result in clinical trials. Most trials of PCI have used a composite end point (major adverse cardiac events) as the primary end point. These trials have limited follow-up, usually no more than 2 years.26–31 The use of major adverse cardiac events as an end point, the small number of patients, and the limited duration of follow-up have biased the randomized trials that compare PCI and CABG. The randomized clinical trial screens large numbers of patients to randomize a small subset of eligible patients. There is no bias regarding assigned treatment. There is bias to entry into the trial, which is a major limitation after the trial is over and the physician needs to extrapolate the data to clinical practice. In addition, intention-to-treat analysis and crossovers make the results misleading. A short duration of follow-up adversely affects CABG when an end point of major adverse cardiac events is used; 5 years of follow-up is necessary in PCI versus CABG trials.Results from real-world therapy can be found in the analysis of large observational databases. In spite of bias to treatment, there is no bias to entry into the data set. Several published large observational studies have used the Duke, Society of Thoracic Surgeons, New York State, and Northern New England databases. These studies have consistently shown a survival advantage for CABG over PCI.32–36The results of the SYNTAX (Synergy between PCI with TAXUS drug-eluting stent and cardiac surgery) Trial, reported at the European Society of Cardiology Congress 2008 in Munich, Germany, showed that DES placement was inferior to CABG surgery as a treatment option for patients with multivessel and left main coronary disease. The SYNTAX study randomized 1800 patients with 3-vessel and left main disease to PCI with DES versus CABG. The study found that at the 1-year end point, PCI was inferior to CABG for major adverse cardiovascular or cerebrovascular events (death, heart attack, stroke, or repeat revascularization; 17.8% versus 12.1%).The SYNTAX trial also provided supportive data regarding the survival benefit of CABG relative to stenting. The study results showed that CABG had a strong trend toward better survival at 1 year, with a 23% relative mortality benefit, consistent with other studies of DES versus CABG. For example, a larger study of DES versus CABG from New York State data presented by Hannan et al34 showed a significant mortality benefit of CABG versus DES at 18 months, with a 21% relative mortality benefit in 3-vessel disease and a 35% relative mortality benefit in 2-vessel disease.It should no longer be considered that there is equipoise for PCI and CABG for this complex, higher-risk group of patients. In previous trials, trial design and eligibility criteria prevented high-risk patients who would benefit most from CABG from participating; therefore, no definitive conclusion could be made for the effectiveness of CABG.With these new results, it is critical that before stenting is performed, clinicians provide patients with full and complete disclosure of the risks and benefits of both DES and bare-metal stents, including the possibilities of decreased survival, risk of stent thrombosis, and increased reintervention. In left main disease, stent thrombosis causes sudden complete closure of a major coronary vessel, and 40% of stent thromboses are fatal. Coronary artery graft closure may cause angina, but rarely does it cause myocardial infarction or muscle loss, because the native vessel is still open with graft failure.36,37The use of major adverse cardiac events as the primary end point allows fewer patients to be randomized to adequately power the study. In addition, it reduces the cost for performing the trial. Inappropriate subset analyses are often performed; however, the subset findings are often reported as factual. This was the case in the SYNTAX trial, in which the primary end point was negative. Underpowered subset analyses were performed and are often quoted as the trial result. These analyses should only be hypothesis generating for future studies, not interpreted as clinically proven fact.A current study of CABG versus PCI in octogenarians in the present issue of Circulation38 suffers from the well-recognized limitations of nonrandomized, retrospective studies. The decision to perform PCI versus CABG is biased by the clinicians, referring doctors, or the patient. In the PCI group, the location, extent, and complexity of the left main lesion will often exclude a patient from treatment, thereby adding procedural bias. As noted previously, lesion complexity rarely affects inclusion into the surgical group. Comorbidities in nonrandomized studies are often increased in the PCI group, as was the case in the present study. Propensity analysis attempts to deal with these differences statistically, but imperfectly. The present study had a complex definition of major adverse cardiac or cerebrovascular events (cardiac death, myocardial infarction, cardiovascular event, or repeat revascularization), with an extremely limited mean follow-up of less than 2 years. Surgery patients will always have a higher procedural morbidity. Most studies have shown that a follow-up of >2 years is necessary to discern the advantages of surgery when major adverse cardiac and cerebrovascular events are used as the primary end point.The most unambiguous end point and perhaps the most important is patient survival. In the present study,38 procedural (30 days) mortality was similar in both groups (CABG 8.3%, PCI 6.7%); however, late mortality (mean follow-up of 23±16 months) was 10.3% for PCI and 4.5% for CABG. The CABG patients were more likely to have revascularization (87% versus 57%), less likely to require repeat revascularization (2.3% versus 10.3%), and less likely to experience late myocardial infarctions (2.3% versus 11.3%) and cerebral vascular events (0.8% versus 8.2%). The overall rate of postprocedural major adverse cardiac or cerebrovascular events was 9% for CABG versus 30.9% for PCI.The most useful information from the study by Rodés-Cabau et al38 is found in the results that can be obtained when surgery is not offered because the risk is prohibitive owing to noncardiac risk factors. Interestingly, these authors found the procedural risk prediction euroSCORE (European System for Cardiac Operative Risk Evaluation) overpredicted the observed procedural risk.Therefore, the present study has useful data but does not provide evidence supporting a change from the current recommendation that left main disease requires treatment with a surgical approach.3,39–41 The cardiovascular community requires a study that is multicentered, randomized, and adequately powered to address survival as a primary end point. Such a study is essential to guide therapy for this anatomically critical lesion. The trial must be of adequate duration and contain sufficient subjects to allow adequate power for subset analysis. The results of such a trial will become increasingly relevant as the clinical burden of coronary artery disease and left main lesions increases as the "baby boomers" grow exponentially as a percentage of the US population. Cost analyses must be an important component of these studies, because healthcare budgets are further strained by this demographic change and technological advances.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.DisclosuresNone.FootnotesCorrespondence to Richard J. Shemin, MD, David Geffen School of Medicine, Division of Cardiothoracic Surgery, UCLA Ronald Reagan Medical Center, 10833 Le Conte Ave, 62-182 CHS, Los Angeles, CA 90095. E-mail [email protected] References 1 Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW, Davis K, Killip T, Passamani E, Norris R. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomized trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet. 1994; 344: 563–570.CrossrefMedlineGoogle Scholar2 Caracciolo EA, Davis KB, Sopko G, Kaiser GC, Corley SD, Schaff H, Taylor HA, Chaitman BR. Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease: long-term CASS experience. Circulation. 1995; 91: 2335–2344.CrossrefMedlineGoogle Scholar3 Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, Hart JC, Herrmann HC, Hillis DL, Hutter AM Jr, Lytle BW, Marlow RA, Nugent WC, Orszulak TA. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation. 2004; 110: e340–e437.LinkGoogle Scholar4 Jonsson A, Hammar N, Nordquist T, Ivert T. Left main coronary artery stenosis no longer a risk factor for early and late death after coronary artery bypass surgery: an experience covering three decades. Eur J Cardiothorac Surg. 2006; 30: 311–317.CrossrefMedlineGoogle Scholar5 Taggart DP, D'Amico R, Altman DG. Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet. 2001; 358: 870–875.CrossrefMedlineGoogle Scholar6 Taggart DP, Lees B, Gray A, Altman DG, Flather M, Channon K; ART Investigators. Protocol for the Arterial Revascularisation Trial (ART): a randomised trial to compare survival following bilateral versus single internal mammary grafting in coronary revascularisation [ISRCTN46552265]. Trials. 2006; 7: 7.CrossrefMedlineGoogle Scholar7 Keeley EC, Aliabadi D, O'Neill WW, Safian RD. Immediate and long-term results of elective and emergent percutaneous interventions on protected and unprotected severely narrowed left main coronary arteries. Am J Cardiol. 1999; 83: 242–246.CrossrefMedlineGoogle Scholar8 Silvestri M, Barragan P, Sainsous J, Bayet PG, Simeoni JB, Roquebert PO, Macaluso G, Bouvier JS, Comet B. Unprotected left main coronary artery stenting: immediate and medium-term outcomes of 140 elective procedures. J Am Coll Cardiol. 2000; 35: 1543–1550.CrossrefMedlineGoogle Scholar9 Tan WA, Tamai H, Park SJ, Plokker T, Nobuyoshi M, Suzuki T, Colombo A, Macaya C, Holmes DR, Cohen DJ, Whitlow PL, Ellis SG; for the ULTIMA Investigators. Long-term clinical outcomes after unprotected left main trunk percutaneous revascularization in 279 patients. Circulation. 2001; 104: 1609–1614.CrossrefMedlineGoogle Scholar10 Black A, Cortina R, Bossi I, Choussat R, Fajadet J, Marco J. Unprotected left main coronary artery stenting: correlates of midterm survival and impact of patient selection. J Am Coll Cardiol. 2001; 37: 832–838.CrossrefMedlineGoogle Scholar11 Takagi T, Stankovic G, Finci L, Toutouzas K, Chieffo A, Spanos V, Liistro F, Brigouri C, Corvaja N, Albero R, Silvieri G, Paloschi R, Di Mario C, Colombo A. Results and long-term predictors of adverse clinical events after elective percutaneous interventions on unprotected left main coronary artery. Circulation. 2002; 106: 698–702.LinkGoogle Scholar12 Park SJ, Park SW, Hong MK, Lee CW, Jae-Hwan L, Jae-Joong K, Jang YS, Eak-Kyun S, Yoshinore Y, Takashi T, Takeshi K, Masakiyo N. Long-term (three-year) outcomes after stenting of unprotected left main coronary artery stenosis in patients with normal left ventricular function. Am J Cardiol. 2003; 91: 12–16.MedlineGoogle Scholar13 Brueren BR, Ernst JM, Suttorp MJ, Tenberg JM, Rensing BJWM, Maste G, Bale T, Six AJ, Plokker HWM. Long term follow up after elective percutaneous coronary intervention for unprotected non-bifurcational left main stenosis: is it time to change the guidelines? Heart. 2003; 89: 1336–1339.CrossrefMedlineGoogle Scholar14 Kelley MP, Klugherz BD, Hashemi SM, Meneveau NF, Johnston JM, Matthai WH Jr, Banka VS, Herrmann HC, Hirshfeld JW Jr, Kimmel SE, Kolansky DM, Horwitz PA, Schiele F, Bassand JP, Wilensky RL. One-year clinical outcomes of protected and unprotected left main coronary artery stenting. Eur Heart J. 2003; 24: 1554–1559.CrossrefMedlineGoogle Scholar15 Tanabe K, Hoye A, Lemos PA, Aoki J, Arampatzis CA, Saia F, Lee CH, Degertekin M, Fofma SH, Sianos G, McFadden E, Smits PC, van der Giessen WJ, De Feyter P, van Domburg RT, Serruys PW. Restenosis rates following bifurcation stenting with sirolimus-eluting stents for de novo narrowings. Am J Cardiol. 2004; 94: 115–118.CrossrefMedlineGoogle Scholar16 Lemos PA, Hoye A, Goedhart D, Arampatzis CA, Saia F, van der Giessen WJ, McFadden E, Sianos G, Smits PC, Hofma SH, de Feyter PJ, van Domburg RT, Serruys PW. Clinical, angiographic, and procedural predictors of angiographic restenosis after sirolimus-eluting stent implantation in complex patients: an evaluation from the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) study. Circulation. 2004; 109: 1366–1370.LinkGoogle Scholar17 Hoye A, Iakovou I, Ge L, van Mieghem CA, Ong AT, Cosgrave J, Sangiorgi GM, Airoldi F, Montorfano M, Michev I, Chieffo A, Carlino M, Corvaja N, Aoki J, Rodriguez Granillo GA, Valgimigli M, Sianos G, van der Giessen WH, de Feyter PJ, van Domborg RT, Serruys PW, Colombo A. Long-term outcomes after stenting of bifurcation lesions with the "crush" technique: predictors of an adverse outcome. J Am Coll Cardiol. 2006; 47: 1949–1958.CrossrefMedlineGoogle Scholar18 Valgimigli M, Malagutti P, Rodriguez-Granillo GA, Garcia-Garcia HM, Polad J, Tsuchida K, Regar E, Van der Giessen WJ, de Jaegere P, De Feyter P, Serruys PW. Distal left main coronary disease is a major predictor of outcome in patients undergoing percutaneous intervention in the drug-eluting stent era: an integrated clinical and angiographic analysis based on the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) and Taxus-Stent Evaluated At Rotterdam Cardiology Hospital (T-SEARCH) registries. J Am Coll Cardiol. 2006; 47: 1530–1537.CrossrefMedlineGoogle Scholar19 Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G, Airoldi F, Chieffo A, Montorfano M, Carlino M, Michev I, Corvaja N, Briguori C, Gerkens U, Grube E, Colombo A. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA. 2005; 293: 2126–2130.CrossrefMedlineGoogle Scholar20 Camenzind E, Gabriel Steg P, Wijns W. Stent thrombosis late after implantation of first-generation drug-eluting stents. a cause for concern. Circulation. 2007; 115: 1440–1455.LinkGoogle Scholar21 Lagerqvist B, James SK, Stenestrand U, Lindback J, Nilsson T, Wallentin L; for the SCAAR Study Group. Long-term outcomes with Drug-Eluting Stents versus Bare-Metal Stents in Sweden. N Engl J Med. 2007; 356: 1009–1019.CrossrefMedlineGoogle Scholar22 Pfisterer M, Brunner-La Rocca HP, Buser PT, Rickenbacher P, Hunziker P, Mueller C, Jeger R, Bader F, Osswald S, Kaiser C; BASKET-LATE Investigators. Late clinical events after clopidogrel discontinuation may limit the benefit of drug-eluting stents: an observational study of drug-eluting versus bare-metal stents. J Am Coll Cardiol. 2006; 48: 2584–2591.CrossrefMedlineGoogle Scholar23 Farb A, Boam MS. Stent thrombosis redux: the FDA perspective. N Engl J Med. 2007; 356: 984–987.CrossrefMedlineGoogle Scholar24 Joner M, Finn AV, Farb A, Mont EK, Kolodgie FD, Ladich E, Kutys R, Skorija K, Gold HK, Virmani R. Pathology of drug-eluting stents in humans: delayed healing and late thrombotic risk. J Am Coll Cardiol. 2006; 48: 193–202.CrossrefMedlineGoogle Scholar25 Grines CL, Bonow RO, Casey DE Jr, Gardner TJ, Lockhart PB, Moliterno DJ, O'Gara P, Whitlow P; American Heart Association; American College of Cardiology; Society for Cardiovascular Angiography and Interventions; American College of Surgeons; American Dental Association; American College of Physicians. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. J Am Coll Cardiol. 2007; 49: 734–739.CrossrefMedlineGoogle Scholar26 Babapulle MN, Joseph L, Belisle P, Brophy JM, Eisenberg MJ. A hierarchical Bayesian meta-analysis of randomised clinical trials of drug-eluting stents. Lancet. 2004; 364: 583–591.CrossrefMedlineGoogle Scholar27 Hill RA, Dundar Y, Bakhai A, Dickson R, Walley T. Drug-eluting stents: an early systematic review to inform policy. Eur Heart J. 2004; 25: 902–919.CrossrefMedlineGoogle Scholar28 Nordmann AJ, Briel M, Bucher HC. Mortality in randomized controlled trials comparing drug-eluting vs. bare metal stents in coronary artery disease: a meta-analysis. Eur Heart J. 2006; 27: 2784–2814.CrossrefMedlineGoogle Scholar29 Hill R, Bagust A, Bakhai A, Dickson R, Dundar Y, Haycox A, Mujica Mota R, Reaney A, Roberts D, Williamson P, Walley T. Coronary artery stents: a rapid systematic review and economic evaluation. Health Technol Assess. 2004; 8: 1–242.MedlineGoogle Scholar30 Kaiser C, Brunner-La Rocca HP, Buser PT, Bonetti PO, Osswald S, Linka A, Bernheim A, Zutter A, Zellweger M, Grize L, Pfisterer ME; BASKET Investigators. Incremental cost-effectiveness of drug-eluting stents compared with a third-generation bare-metal stent in a real-world setting: randomised Basel Stent Kosten Effektivitats Trial (BASKET). Lancet. 2005; 366: 921–929.CrossrefMedlineGoogle Scholar31 Tung R, Kaul S, Diamond GA, Shah PK. Narrative review: drug-eluting stents for the management of restenosis: a critical appraisal of the evidence. Ann Intern Med. 2006; 144: 913–919.CrossrefMedlineGoogle Scholar32 Hoffman SN, TenBrook JA, Wolf MP, Pauker SG, Salem DN, Wong JB. A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes. J Am Coll Cardiol. 2003; 41: 1293–1304.CrossrefMedlineGoogle Scholar33 Brener SJ, Lytle BW, Casserly IP, Schneider JP, Topol EJ, Lauer MS. Propensity analysis of long-term survival after surgical or percutaneous revascularization in patients with multivessel coronary artery disease and high-risk features. Circulation. 2004; 109: 2290–2295.LinkGoogle Scholar34 Hannan EL, Racz MJ, Walford G, Jones RH, Ryan TJ, Bennett E, Culliford AT, Isom OW, Gold JP, Rose EA. Long-term outcomes of coronary-artery bypass grafting versus stent implantation. N Engl J Med. 2005; 352: 2174–2183.CrossrefMedlineGoogle Scholar35 Malenka DJ, Leavitt BJ, Hearne MJ, Robb JF, Barbeau YR, Ryan TJ, Helm RE, Kellett MA, Dauerman HL, Dacey LJ, Silver MT, VerLee PN, Weldner PW, Hettleman BD, Olmstead EM, Piper WD, O'Conner GT; Northern New England Cardiovascular Disease Study Group. Comparing long-term survival of patients with multivessel coronary disease after CABG or PCI: analysis of BARI-like patients in northern New England. Circulation. 2005; 112 (suppl): I-371–I-376.LinkGoogle Scholar36 Smith PK, Califf RM, Tuttle RH, Shaw LK, Lee KL, Delong ER, Lilly RE, Sketch MH Jr, Peterson ED, Jones RH. Selection of surgical or percutaneous coronary intervention provides differential longevity benefit. Ann Thorac Surg. 2006; 82: 1420–1428.CrossrefMedlineGoogle Scholar37 Taggart DP, D'Amico R, Altman DG. Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet. 2001; 358: 870–875.CrossrefMedlineGoogle Scholar38 Rodés-Cabau J, DeBlois J, Bertrand OF, Mohammadi S, Courtis J, Larose E, Dagenais F, Déry JP, Mathieu P, Rousseau M, Barbeau G, Baillot R, Gleeton O, Perron J, Nguyen CM, Roy L, Doyle D, De Larochellière R, Bogaty P, Voisine P. Nonrandomized comparison of coronary artery bypass surgery and percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease in octogenarians. Circulation. 2008; 118: 2374–2381.LinkGoogle Scholar39 Smith SC Jr, Dove JT, Jacobs AK, Kennedy JW, Kereiakes D, Kern MJ, Kuntz RE, Popma JJ, Schaff HV, Williams DO, Gibbons RJ, Alpert JP, Eagle KA, Faxon DP, Fuster V, Gardner TJ, Gregoratos G, Russell RO; American Heart Association Task Force on Practice Guidelines, Committee to Revise the 1993 Guidelines for Percutaneous Transluminal Coronary Angioplasty. ACC/AHA guidelines of percutaneous coronary interventions (revision of the 1993 PTCA guidelines): executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1993 Guidelines for Percutaneous Transluminal Coronary Angioplasty). J Am Coll Cardiol. 2001; 37: 2215–2239.CrossrefMedlineGoogle Scholar40 Smith SC Jr, Feldman TE, Hirshfeld JW Jr, Jacobs Kern MJ, King SB III, Morrison DA, O'Neill WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Reigel B; American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Circulation. 2006; 113: 156–175.LinkGoogle Scholar41 Taggart DP, Kaul S, Boden WE, Ferfuson TB Jr, Guyton RA, Mack MJ, Sergeant PT, Shemin RJ, Smith PK, Yusuf S. Revascularization of the unprotected left main stem coronary artery stenosis stenting of surgery. J Am Coll Cardiol. 2008; 51: 885–892.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By O'Connor R, Cahill P and McGuinness G (2020) Cardiovascular tissue engineering Biomaterials for Organ and Tissue Regeneration, 10.1016/B978-0-08-102906-0.00011-8, (249-272), . Higami H, Toyofuku M, Morimoto T, Ohya M, Fuku Y, Yamaji K, Muranishi H, Yamaji Y, Nishida K, Furukawa D, Tada T, Ko E, Ando K, Sakamoto H, Tamura T, Kawai K, Kadota K and Kimura T (2018) Acute Coronary Syndrome With Unprotected Left Main Coronary Artery Culprit ― An Observation From the AOI-LMCA Registry ―, Circulation Journal, 10.1253/circj.CJ-18-0896, 83:1, (198-208), Online publication date: 25-Dec-2018. La A and Tranquillo R (2018) Shear Conditioning of Adipose Stem Cells for Reduced Platelet Binding to Engineered Vascular Grafts, Tissue Engineering Part A, 10.1089/ten.tea.2017.0475, 24:15-16, (1242-1250), Online publication date: 1-Aug-2018. Yıldız A, Yıldız C, Bağırtan B and Karakurt A (2016) Prognostic value of anatomical SYNTAX score in patients with acute ST elevation myocardial infarction undergoing percutaneous coronary intervention for unprotected left main coronary artery, International Journal of the Cardiovascular Academy, 10.1016/j.ijcac.2016.05.002, 2:2, (98-102), Online publication date: 1-Jun-2016. Sim D, Ahn Y, Jeong M, Kim Y, Chae S, Hong T, Seong I, Chae J, Kim C, Cho M and Seung K (2013) Clinical Outcome of Unprotected Left Main Coronary Artery Disease in Patients With Acute Myocardial Infarction, International Heart Journal, 10.1536/ihj.54.185, 54:4, (185-191), . Suzuki T, Asai T, Matsubayashi K, Kambara A, Hiramatsu N, Kinoshita T and Nishimura O (2010) Left Main Coronary Artery Disease Does Not Affect the Outcome of Off-Pump Coronary Artery Bypass Grafting, The Annals of Thoracic Surgery, 10.1016/j.athoracsur.2010.06.023, 90:5, (1501-1506), Online publication date: 1-Nov-2010. Adams D, Anyanwu A, Chikwe J and Filsoufi F (2009) The Year in Cardiovascular Surgery, Journal of the American College of Cardiology, 10.1016/j.jacc.2009.02.061, 53:25, (2389-2403), Online publication date: 1-Jun-2009. Morrison D (2009) PCI for critically ill STEMI patients with complex anatomy: Another (Nonrandomized) "Brick in the Wall", Catheterization and Cardiovascular Interventions, 10.1002/ccd.21991, 73:3, (308-309), Online publication date: 15-Feb-2009. Montalescot G, Brieger D, Eagle K, Anderson F, FitzGerald G, Lee M, Steg P, Avezum A, Goodman S and Gore J (2009) Unprotected left main revascularization in patients with acute coronary syndromes, European Heart Journal, 10.1093/eurheartj/ehp353, 30:19, (2308-2317), Online publication date: 1-Oct-2009. December 2, 2008Vol 118, Issue 23 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.108.820324PMID: 19047591 Originally publishedDecember 2, 2008 Keywordscoronary artery bypass graftingEditorialsstentsPDF download Advertisement
Referência(s)