title: Intravascular ultrasound-guided directional coronary atherectomy for unprotected left main coronary stenoses with distal bifurcation involvement.
abstract: Stent implantation in unprotected left main coronary artery (LMCA) bifurcation lesions may improve procedural and late clinical outcomes. However, concerns regarding stent-related complications, such as stent jail, subacute thrombosis, and in-stent restenosis remain. Optimal debulking by directional coronary atherectomy (DCA) with intravascular ultrasound (IVUS) guidance may be effective in this complex lesion subset, but this strategy has not yet been established. Our objective was to evaluate the safety and efficacy of IVUS-guided DCA for unprotected LMCA stenoses with distal bifurcation involvement. A total of 67 consecutive patients were included in this study and procedural success was achieved in all cases. Two cardiac deaths (2.9%) were noted and 3 patients (4.5%) underwent repeat angioplasty during hospitalization. There was no Q-wave myocardial infarction or emergency bypass surgery. Non-Q-wave myocardial infarction (creatine kinase-MB >3 times normal) occurred in 13.4% of patients. Stent implantation was necessary in 17 cases (25.4%) to achieve an optimal result. IVUS showed an improved lumen cross-sectional area and a low plaque burden in the LMCA after intervention. All-cause mortality, angiographic restenosis, and the target lesion revascularization rates at 6 months were 7.4%, 23.8%, and 20.0%, respectively. With IVUS guidance, aggressive DCA can be performed safely in unprotected LMCA bifurcation lesions, and optimal angiographic and IVUS results can be achieved with low residual plaque burden, which leads to a low restenosis rate. Optimal lesion debulking by DCA does not necessarily need adjunctive stenting in this specific anatomic subset.
authors.affiliation: Department of Cardiology, Shiga Medical Center for Adults, Moriyama, Japan.
authors.forename: Fang-Bin
authors.initials: FB
authors.lastname: Hu
authors.forename: Hideo
authors.initials: H
authors.lastname: Tamai
authors.forename: Kunihiko
authors.initials: K
authors.lastname: Kosuga
authors.forename: Eisho
authors.initials: E
authors.lastname: Kyo
authors.forename: Tatsuhiko
authors.initials: T
authors.lastname: Hata
authors.forename: Masaharu
authors.initials: M
authors.lastname: Okada
authors.forename: Takuji
authors.initials: T
authors.lastname: Nakamura
authors.forename: Shinya
authors.initials: S
authors.lastname: Fujita
authors.forename: Takafumi
authors.initials: T
authors.lastname: Tsuji
authors.forename: Shinsaku
authors.initials: S
authors.lastname: Takeda
authors.forename: Seiichio
authors.initials: S
authors.lastname: Motohara
authors.forename: Hiromu
authors.initials: H
authors.lastname: Uehata
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017225:Atherectomy, Coronary / Q000379:methods*; D001803:Blood Transfusion / Q000706:statistics & numerical data; D002304:Cardiac Pacing, Artificial / Q000706:statistics & numerical data; D023903:Coronary Restenosis / Q000453:epidemiology / Q000209:etiology; D023921:Coronary Stenosis / Q000601:surgery*; D003331:Coronary Vessels / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery*; D048909:Diabetes Complications; D005260:Female; D006801:Humans; D007423:Intra-Aortic Balloon Pumping / Q000706:statistics & numerical data; D008297:Male; D009203:Myocardial Infarction / Q000209:etiology; D012086:Reoperation; D012307:Risk Factors; D015607:Stents; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional