title: Clinical and procedural predictors of suboptimal outcome after the treatment of drug-eluting stent restenosis in the unprotected distal left main stem: the Milan and New-Tokyo (MITO) registry.
abstract: BACKGROUND
  Few data are available regarding the optimal revascularization strategy for unprotected distal left main coronary artery (UDLM) in-stent restenosis (ISR).
  
  
  RESULTS
  Between April 2002 and December 2008, UDLM-ISR following drug-eluting stent (DES) implantation occurred in 92 of 474 patients (19.4%). Of these, 8 (8.7%) who underwent a coronary artery bypass graft (CABG) were excluded, and the remaining 84 (91.3%) who underwent percutaneous coronary intervention (PCI) (43 plain old balloon angioplasty [POBA] and 41 DES) were analyzed to assess the feasibility of PCI for UDLM-ISR. The overall cardiac death, myocardial infarction (MI), and major adverse cardiac events during the follow-up period (median, 24 months) occurred in 4, 2, and 31 patients, respectively. Repeat target lesion revascularization (TLR) occurred in 28 patients. The incidence of repeat TLR was higher following PCI with POBA than with DES (hazard ratio [HR], 2.79; 95% CI, 1.23-6.34; P=0.014). On Cox regression analysis, the independent predictors of repeat TLR were treatment with POBA (HR, 3.29; 95% CI, 1.41-7.69; P=0.006) and EuroSCORE (European System for Cardiac Operative Risk Evaluation) >6 (HR, 2.53; 95% CI, 1.02-6.28; P=0.045). More complex lesions requiring a 2-stent strategy were associated with a higher occurrence of TLR for restenosis of the left circumflex coronary artery ostium (LCX-ISR) (HR, 2.51; 95% CI, 1.59-3.97; P=0.001) as well as repeat TLR for recurrent LCX-ISR (HR, 4.32; 95% CI, 0.97-19.20; P=0.05) compared to a 1-stent strategy. No cardiac death at 2 years occurred in patients with LCX-ISR.
  
  
  CONCLUSIONS
  UDLM restenosis is better treated with DES than with POBA. The rate of recurrent ISR following repeat PCI was high, whereas the rates of MI and death were relatively low. Complex lesions requiring a 2-stent strategy had a higher recurrence rate at the ostial LCX but without an associated increased risk of MI and death.
authors.affiliation: Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Kensuke
authors.initials: K
authors.lastname: Takagi
authors.forename: Alfonso
authors.initials: A
authors.lastname: Ielasi
authors.forename: Joanne
authors.initials: J
authors.lastname: Shannon
authors.forename: Azeem
authors.initials: A
authors.lastname: Latib
authors.forename: Cosmo
authors.initials: C
authors.lastname: Godino
authors.forename: Giedrius
authors.initials: G
authors.lastname: Davidavicius
authors.forename: Marco
authors.initials: M
authors.lastname: Mussardo
authors.forename: Santo
authors.initials: S
authors.lastname: Ferrarello
authors.forename: Filippo
authors.initials: F
authors.lastname: Figini
authors.forename: Mauro
authors.initials: M
authors.lastname: Carlino
authors.forename: Matteo
authors.initials: M
authors.lastname: Montorfano
authors.forename: Alaide
authors.initials: A
authors.lastname: Chieffo
authors.forename: Sunao
authors.initials: S
authors.lastname: Nakamura
authors.forename: Antonio
authors.initials: A
authors.lastname: Colombo
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000379:methods / Q000401:mortality*; D003324:Coronary Artery Disease / Q000401:mortality* / Q000628:therapy*; D023903:Coronary Restenosis / Q000401:mortality* / Q000517:prevention & control; D003331:Coronary Vessels; D054855:Drug-Eluting Stents / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007558:Italy / Q000453:epidemiology; D007564:Japan / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012042:Registries / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome