title: The impact of severe distal left main disease on target lesion revascularization in patients with trifurcating coronary artery disease receiving the paclitaxel drug-eluting stent.
abstract: BACKGROUND
  The presence of severe left main (LM) disease has been shown to adversely influence the outcome of patients undergoing percutaneous treatment of bifurcating LM disease. LM trifurcating coronary artery disease (LMTCAD) is even more complex and challenging to treat. The present article reports on the immediate and midterm outcomes of patients with severe LM disease treated with the paclitaxel drug-eluting stent for LMTCAD.
  
  
  METHODS
  Consecutive patients (n=52) who underwent LM trifurcating stenting with the paclitaxel drug-eluting stent at the Genesis Medical Center (Iowa, USA) over a two-year period were divided into two groups: type A (with severe [50% or greater] LM involvement including trifurcating branches) and type B (with no LM involvement but involving the trifurcating branches). Demographic, clinical, procedural and midterm clinical outcomes were reviewed. Angiograms were analyzed by an operator who was blinded to patient histories. The primary end point of the study was target lesion revascularization (TLR) on follow-up. Descriptive and univariate analyses were performed, and survival curves were plotted to compare the two groups.
  
  
  RESULTS
  Demographic and clinical variables were identical in both groups. Type A lesions required significantly more stents to treat than type B lesions (4.13±1.78 versus 2.33±1.22; P=0.001). The techniques to treat both lesions were considerably different, with more V stenting in type B and more Y stenting in type A. The TLR rate was 64.3% in type A versus 18.2% in type B (P=0.005). On follow-up, one patient with type B disease had sudden death, possibly related to stent thrombosis.
  
  
  CONCLUSIONS
  Severe LM disease has a significant adverse impact on TLR in patients with LMTCAD. Given the high TLR rate, bypass surgery needs to be considered as first-line therapy in patients with type A trifurcating coronary artery disease.
authors.affiliation: Midwest Cardiovascular Research Foundation and the Genesis Medical Center, Davenport, Iowa, USA.
authors.forename: Nicolas W
authors.initials: NW
authors.lastname: Shammas
authors.forename: Gail A
authors.initials: GA
authors.lastname: Shammas
authors.forename: Michael
authors.initials: M
authors.lastname: Jerin