Left main stem atherosclerotic disease which supplies the vast portion of the left ventricle myocardium is associated with significant morbidity and mortality. Coronary artery bypass surgery has been the definitive treatment choice. However, advancements in percutaneous coronary intervention (such as drug-eluting stents and techniques, risk stratification, and intravascular ultrasound) have increased the viability of this treatment option.

Treatment Left Main Disease

Left Main Treatment Advances

The fundamental balance between coronary artery bypass surgery and PCI, is the tradeoff of risk of need for revascularization and embolic stroke. Intravascular ultrasound and technique have allow the more precise placement of stents and lower the incidence of acute complications. The development of DES stents and second generation antiplatelet medications and reduced the incidence of in stent restenosis. Surgical advancements reduced the risk of stroke including the expanding use of off-pump CAB, better vein graft patency, and widespread use of LIMA. This pace of development makes the external applicability of trials difficult to interpret.

Guidelines on Left Main Treatment

Both the American and European societal guidelines have endorsed PCI in patients with less-complex coronary disease while CABG still maintains a class I recommendation across all groups. The data to firmly establish the role of percutaneous treatment are currently lacking and the two on-going EXCEL and NOBLE trials will hopefully take us a step further in clarifying the role of PCI in the treatment of LMS disease.


Key References on Left Main Disease Treatment

  1. Yusuf S, Zucker D, Peduzzi P, et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 1994;344:563–70.
  2. Tan WA, Tamai H, Park SJ, et al. Long-term clinical outcomes after unprotected left main trunk percutaneous revascularization in 279 patients. (ULTIMA) Circulation 2001;104:1609–14.
  3. Biondi-Zoccai GG, Lotrionte M, Moretti C, et al. A collaborative systematic review and meta-analysis on 1278 patients undergoing percutaneous drug-eluting stenting for unprotected left main coronary artery disease. Am Heart J 2008;155:274–83.
  4. Seung KB, Park DW, Kim YH, et al. Stents versus coronaryartery bypass grafting for left main coronary artery disease. (MAIN-COMPARE) N Engl J Med 2008;358:1781–92.
  5. Buszman PE, Kiesz SR, Bochenek A, et al. Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization. (Le Mans) J Am Coll Cardiol 2008;51:538–45.
  6. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009;360:961–72.
  7. Sianos G, Morel M, Kappetein AP, et al. The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease. Eurointervention 2005;1:219–27.
  8. Park SJ, Kim YH, Park DW, et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease. N Engl J Med 2011;364:1718–27.
  9. Boudriot E, Thiele H, Walther T, et al. Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis. J Am Coll Cardiol 2011;57:538–45.
  10. Athappan G, Patvardhan E, Tuzcu ME, et al. Left main coronary artery stenosis: a meta-analysis of drug-eluting stents versus coronary artery bypass grafting. JACC Cardiovasc Interv 2013;6:1219–30.
  11. Naganuma T, Chieffo A, Meliga E, et al. Long-term clinical outcomes after percutaneous coronary intervention for ostial/mid-shaft lesions versus distal bifurcation lesions in unprotected left main coronary artery: the DELTA Registry (drug-eluting stent for left main coronary artery disease): a multicenter registry evaluating percutaneous coronary intervention versus coronary artery bypass grafting for left main treatment. JACC Cardiovasc Interv 2013;6:1242–9.
  12. Tiroch K, Mehilli J, Byrne RA, et al. Impact of coronary anatomy and stenting technique on long-term outcome after drug-eluting stent implantation for unprotected left main coronary artery disease. JACC Cardiovasc Interv 2014;7:29–36.
  13. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/ SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011;124:e574–651.