Coronary artery diseaseEffect of Intravascular Ultrasound Findings on Long-Term Repeat Revascularization in Patients Undergoing Drug-Eluting Stent Implantation for Severe Unprotected Left Main Bifurcation Narrowing
Section snippets
Methods
From February 2003 to November 2007, 509 patients with unprotected LM disease (angiographic diameter stenosis >50%) underwent percutaneous coronary intervention with drug-eluting stent implantation at the Asan Medical Center (Seoul, Korea). Of these 509 patients, 168 with distal LM bifurcation lesions underwent preprocedural IVUS obtained by pullback from the left anterior descending artery (LAD) to the LM (LAD pullback). All patients had immediate post-stenting LAD pullback images available.
Results
The baseline clinical and procedural characteristics in 168 LM bifurcations are listed in Table 1. The most common types, using the Medina classification, were (1,1,1) in 71 (45%), (1,1,0) in 48 (30%), (0,1,0) in 16 (10%), and (1,0,0) in 10 (6%).
A comparison of the angiographic data and IVUS-defined stenoses is listed in Table 2. In both the distal LM and the LAD ostium, the sensitivity of an angiographically defined diameter stenosis >50% to predict for IVUS stenosis was high (97% in the
Discussion
The results of the present analysis have highlighted the importance of the POC in understanding distal LM disease and predicting the acute procedural results and long-term clinical events after drug-eluting stent implantation for unprotected distal LM bifurcation lesions. The POC is a confluent zone of the LAD and left circumflex artery just proximal to the carina and the distal LM above the carina. First, the preprocedural MLA and the post-stenting minimum stent area within the LM were mainly
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2018, American Heart JournalCitation Excerpt :Underexpansion of stented segments is associated with in-stent restenosis34,35 and is a frequent finding after otherwise apparent successful angiographic-guided stent implantation.36,37 Kang et al (2011) showed that segmental cutoff values for minimal luminal area in the distal left main bifurcation predicted TLR.38 These values may become the standard of care but are only used sporadically, and the assessment of the circumflex (Cx) ostium has so far required direct interrogation by the IVUS catheter for valid assessment.39
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2012, International Journal of CardiologyCitation Excerpt :In a study by Kang et al., the IVUS-assessed preprocedural minimal lumen area within the confluent zone of the LAD and the LCX arteries (polygon of confluence) has been shown to significantly predict the post-stent minimum stent area within the distal portion of the LM artery above the LAD carina and the occurrence of cardiac events at 3 years of follow-up (adjusted HR 0.83, 95% CI 0.71 to 0.97, P = 0.02). This measure could be a useful surrogate reflecting the overall severity of LM bifurcation disease and the ability to obtain an optimal stent expansion at the end of the procedure [33]. The specific distribution pattern of the atherosclerotic plaque, which embraces a broad spectrum of localizations in the different segments composing the bifurcation, might be another important factor in interventional decision-making.
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2012, JACC: Cardiovascular InterventionsCitation Excerpt :As such, the underlying mechanism for the observed reductions in mortality in this study remains elusive. More recent data from Kang et al. (66) have shed some further light on the importance of evaluating the IVUS-derived MLA within the region of the distal LMCA segment and origin of both daughter branches (termed “polygon of confluence,” or POC) with IVUS before and after PCI. In the 168 patients with ULMCA segment bifurcation lesions undergoing PCI with 42 months of follow-up, the pre-PCI polygon of confluence MLA (a surrogate of the burden of distal LMCA disease) was an important predictor of the subsequent post-PCI minimal stent area that was achieved, which was also an important predictor of clinical events during follow-up.