Long-Term Outcomes of Stenting the Proximal Left Anterior Descending Artery in the PROTECT Trial.
This study sought to compare the outcomes of patients undergoing drug-eluting stent implantation according to lesion location within or outside the proximal left anterior descending (LAD) artery.



Proximal LAD artery involvement is considered uniquely in revascularization guidelines. The impact of LAD lesion location on long-term outcomes after revascularization is poorly understood in context of current percutaneous coronary intervention and medical therapy.



Among 8,709 patients enrolled in PROTECT (Patient Related Outcomes with Endeavor Versus Cypher Stenting Trial), a multicenter percutaneous coronary intervention trial, we compared the outcomes of 2,534 patients (29.1%) (3,871 lesions [31.5%]) with stents implanted in the proximal LAD to 6,172 patients (70.9%) (8,419 lesions [68.5%]) with stents implanted outside the proximal LAD.



At the 4-year follow-up, death rates were the same (5.8% vs. 5.8%; p > 0.999), but more myocardial infarctions occurred in the proximal LAD group (6.2% vs. 4.9%; p = 0.015). The rate of clinically driven target vessel failure (TVF) (14.8% vs. 13.5%; p = 0.109), major adverse cardiac event(s) (MACE) (15.0% vs. 13.7%; hazard ratio: 1.1; 95% confidence interval: 0.97 to 1.31; p = 0.139), and stent thrombosis (2.1% vs. 2.0%; p = 0.800) were similar. Drug-eluting stent type had no interaction with MACE or TVF. In multivariate analysis, the proximal LAD was a predictor of myocardial infarction (p = 0.038) but not of TVF (p = 0.149) or MACE (p = 0.069).



In this study of contemporary percutaneous coronary intervention, proximal LAD location was associated with higher rates of myocardial infarction during the long-term follow-up, but there were no differences in stent thrombosis, death, TVF, or overall MACE. This finding may suggest that, in the drug-eluting stent era, proximal LAD no longer confers a different prognosis than other lesion sites. (Randomized Study Comparing Endeavor With Cypher Stents [PROTECT]; NCT00476957).
Rambam Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel. Electronic address: aroguin@technion.ac.il.
Ariel
A
Roguin
Institut Lorrain du Coeur et des Vaisseaux, Vandoeuvre-les-Nancy, France; Université de Lorraine, Nancy, France.
Edoardo
E
Camenzind
Rambam Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel.
Arthur
A
Kerner
Rambam Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel.
Rafael
R
Beyar
Erasmus Medical Center, Rotterdam, the Netherlands.
Eric
E
Boersma
Harvard Medical School, and Brigham and Women's Hospital, Boston, Massachusetts.
Laura
L
Mauri
Département Hospitalo-Universitaire FIRE, Paris, France; Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France; Assistance Publique - Hôpitaux de Paris, Hôpital Bichat, Paris, France; NHLI Imperial College, ICMS, Royal Brompton Hospital, London, United Kingdom.
Ph Gabriel
PG
Steg
Cardiovascular Research Center, OLV Hospital, Aalst, Belgium.
William
W
Wijns
D000368:Aged; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D003328:Coronary Thrombosis / Q000209:etiology; D004359:Drug Therapy, Combination; D054855:Drug-Eluting Stents; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000209:etiology; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
D010975:Platelet Aggregation Inhibitors
angioplasty; coronary artery disease; decision making; guidelines; left anterior descending artery; stent