Welcome to the 8th
European Bifurcation Club
12-13 October 2012 - Barcelona
Long-term Clinical Outcome of Crossover
Technique from Unprotected Left Main
Coronary Artery to the Left Circumflex
Coronary Artery
Alaide Chieffo, MD
Interventional Cardiology Unit
San Raffaele Scientific Institute
Milan, Italy
Stenting from LMCA to the CX
•  PCI of distal LMCA is usually performed by cross over
stenting from LMCA to the LAD.
•  However, in certain rare situations, single-stent
crossover technique from LMCA to the LCx is
performed.
LAD
LMCA
LCx
•  There is scarcity of data on the outcome with this
strategy.
Patient Population: Milan Tokyo ULMCA Registry A total of 1060 pts were treated with DES for ULMCA (de novo
lesion) between April 2002 and April 2011 in 3 high volume centers.
• San Raffaele Scientific Institute/EMO-GVM Centro Cuore Columbus,
Milan, Italy New-Tokyo Hospital, Chiba, Japan
AMI: n=40
Provisional→2 stent (LCx+LAD):
n=2
Ostial/body LMCA lesion: n=98
Systematic 2-stent strategy :
n=300
Provisional→2 stent (LAD+LCx):
n=39
Single-stenting for distal LMCA:
n=584
Single-stenting crossover from
LMCA to the LCx: n=31
Single-stenting crossover from
LMCA to the LAD: n=553
The decision to perform this technique was taken in
the following situations…
1) Non-involvement of the LAD-ostium (Medina 1.0.1/0.0.1): n=19 (61%)
LMCA
LCx
LAD
LAD
LMCA
LCx
The decision to perform this technique was taken
in the following situations…
2) When LCx was considered as the main branch (because of
relatively large caliber vessel and/or subtending greater
degree of myocardium as compared to the LAD):
n=9 (29%)
3) untreated or unsuccessful revascularization of CTO in
LAD: n=3 (10%)
Baseline Clinical Characteristics
LMCA-LCx, n=31 (%) LMCA-LAD, n=553 (%)
P value
Age (years)
67.9±9.0
69.0±9.7
0.537
Male gender
25 (81)
439 (79)
0.866
Previous MI
14 (45)
210 (38)
0.423
3 (10)
29 (5)
0.291
Previous PCI
21 (68)
330 (60)
0.372
Diabetes mellitus
18 (58)
233 (42)
0.081
Insulin
4 (13)
49 (9)
0.446
Hypertension
23 (74)
434 (79)
0.573
Dyslipidemia
21 (68)
366 (66)
0.858
Current smoker
9 (29)
120 (22)
0.338
Family history of CAD
6 (19)
61 (11)
0.157
16 (52)
242 (44)
0.321
Dialysis
2 (6)
32 (6)
0.878
Peripheral artery disease
1 (3)
89 (16)
0.053
52.7±12.1
56.7±10.2
0.040
1 (3)
13 (2)
0.757
4.1±2.1
4.2±2.6
0.833
Previous stroke
CKD (e-GFR<60ml/min/1.73m2)
LVEF (%)
COPD
Standard EuroSCORE
Clinical presentation
Stable angina/silent ischemia
Unstable angina
0.772
27 (87)
491 (89)
4 (13)
62 (11)
Angiographic and Procedural Characteristics
LMCA-LCx, n=31
(%) Triple vessel disease
7 (21)
Bifurcation type, Medina classification
101, 001
19 (61)
111
7 (23)
110, 011, 100, 010
5 (16)
SYNTAX score
26.0±10.6
IABP
5 (16)
IVUS
19 (61)
Rotational atherectomy
2 (6)
DES type
First generation DES
22 (71) Second generation DES
9 (29)
FKBI
28 (90)
Number of stents at LMCA
1.10±0.30
Total stent length at LMCA
23.8±8.2
(mm)
Stent diameter at LMCA (mm)
3.39±0.25
LMCA-LAD, n=553
(%) 251 (45)
26 (5)
211 (38)
316 (57)
26.9±10.4
46 (8)
384 (69)
45 (8)
P value 0.013
<0.001
0.641
0.134
0.340
0.737
0.422 427 (77)
126 (23)
410 (74)
1.03±0.17
0.043
0.235
22.9±0.77
0.546
3.42±0.24
0.392
MACE at 37.8 month Fup
LMCA-LCx, n=31
MACE
Cardiac
death
LMCA-LAD, n=553
11 events in 8 pts 144 events in 114 pts
0.489
3 (10%)
34 (6%)
0.433
MI
1 (3%)
29 (5%)
0.620
TLR
7 (23%)
72 (14%)
0.130
TVR
12 (39%)
168 (30%)
0.567
Definite
1 (3%)
4 (1%)
0.142
Probable
0 (0%)
7 (1%)
0.529
Possible
2 (6%)
17 (3%)
0.302
Stent
thrombosis
MACE at 3-years
Major adverse cardiac e vents (%)
40
Log-­‐rank p= 0.578
LMCA-­‐LCx
LMCA-­‐LAD
30
24.1%
20
20.0%
10
0
0
1
2
3
Follow-­‐up (years)
No. at risk
LMCA-LCx
31
26
23
15
LMCA-LAD
553
464
356
246
Cardiac death at 3-years
Myocardial infarction (%)
40
Log-­‐rank p=0.749
LMCA-­‐LCx
LMCA-­‐LAD
30
20
10
6.6%
6.2%
0
0
1
2
3
Follow-­‐up (years)
No. at risk
LMCA-LCx
28
26
21
14
LMCA-LAD
553
516
408
287
MIs at 3-years
Target lesion revascularization (%)
40
Log-­‐rank p=0.701
LMCA-­‐LCx
LMCA-­‐LAD
30
20
10
4.6%
0
2.9%
0
1
2
3
Follow-­‐up (years)
No. at risk
LMCA-LCx
31
26
24
17
LMCA-LAD
553
500
400
282
TLR at 3-years
Target lesion revascularization (%)
40
Log-­‐rank p=0.196
LMCA-­‐LCx
LMCA-­‐LAD
30
21.4%
20
10
0
13.1%
0
1
2
3
26
23
15
477
361
248
Follow-­‐up (years)
No. at risk
LMCA-LCx
28
LMCA-LAD 553
3-year incidence of TLR
for ISR in the stent body
Target lesion revascularization (%)
40
Log-­‐rank p=0.006
LMCA-­‐LCx
LMCA-­‐LAD
30
18.2%
20
10
0
5.6%
0
1
2
3
Follow-­‐up (years)
No. at risk
LMCA-LCx
31
27
23
15
LMCA-LAD
553
499
390
273
Angiographic Pattern of ISR in patients with
TLR
LMCA-LCx,
n=6 (%) LMCA-LAD,
n=70 (%) 6 (100)
51 (73)
5 (83)
45(64)
Location of ISR
Bifurcation
Involving LCX-ostium Involving LAD-ostium
FKBI:
5
LMCA only
LAD or LCx
6 (100)
0 (0)
FKBI:
15 (21)
33 16 (23)
0 (0)
3 (4)
Focal pattern
5 (83)
57 (81)
Diffuse pattern
1 (17)
13 (19)
Type of ISR
Detail of cardiac death in LMCA-­‐LCx sten6ng group Gender LVE SYNTA Standard Type Interval Cause
CTO in
Bif. type
and
F
X
EuroSCO of (months
of
mid(Medina) Age
(%) score
RE
DES
)
death
LAD
Male
66
35
Femal
41
e 86
Male
52
30
45.5
24.0
34.0
3
SES
8
SES
6
BE
S
FK
BI
Continuo
us
DAT
46
Sudde
n
death
111
Yes
No
Yes
4
Sudde
n
death
101
No
Ye
s
Yes
9
Sudde
n
death
111
Yes
Ye
s
Yes
•  Major reason of LMCA-LCx stenting: Medina 1.0.1 or
0.0.1
1%
Oviedo C, et al. Circ Cardiovasc Interv
2010
•  LMCA-LCx stenting: 2.9% (n=31/1060) (de novo,
unprotected, DES)
•  Use of 1st generation DES: about 70% in our population
LCx-Ostium
•  TLR rate for ISR in stent body was significantly higher in LMCALCx stenting vs. LMCA-LAD stenting group (3-year follow-up, logrank test p=0.006).
SES 3.5× 33 mm, 34 months later
LMCA
LCx
LMCA
LCx
•  Hinge point >> acute angulation in LCx-ostium
•  Torsion, flexion and rotational forces
•  Stent fatigue and rupture → ISR in LCx-ostium…
LAD-Ostium
•  TAP stenting due to LAD-ostium dissection in provisional single-stent
strategy from LMCA to LCx in 6.1% (n=2/33).
•  FKBI was performed in 90% (n=28/31).
•  LAD-ostium was involved in all patients who underwent TLR (n=6/6).
•  Of the 6, FKBI was performed in 5.
SES 3.5× 23 mm, just after PCI
4-­‐month later
•  LMCA-LCx stenting strategy may cause events due to dissection
during procedure (acute event) or restenosis (chronic event) at
LAD-ostium.
•  LCx-ostium: “Anatomical weakness”
•  LAD-ostium: Risk of flow compromise or restenosis
We should not take this strategy aggressively.
What should we do?
•  Spot stenting for Medina 0.0.1 (non-crossover)?
•  Aggressive use of FFR → negative! → medication?
•  LMCA-’LAD’ crossover (systematic 2-stenting)?
•  New devices: DEB, new generation DES, BVS?
•  CABG?
Conclusions
•  Single-stent crossover technique from
unprotected LMCA to the LCx is associated with
high rates of TLR for ISR in stent body.
•  This strategy may have risks of acute (dissection)
and chronic (restenosis) events at LAD-ostium.
Aknowledgments
Toru Naganuma MD1,2,3, Sandeep Basavarajaiah MD1,2, Kensuke
Takagi MD3, Sunao Nakamura MD3, Antonio Colombo, MD1,2
1Interventional
Cardiology Unit, San Raffaele Scientific Institute,
Milan, Italy
2Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus,
Milan, Italy
3Interventional Cardiology Unit, New Tokyo Hospital, Chiba, Japan
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