Outcomes among patients undergoing distal left main percutaneous coronary intervention: Technique analysis from the EXCEL trial

David E. Kandzari, Anthony H. Gershlick, Patrick W. Serruys, Martin B. Leon, Marie Claude Morice, Charles A. Simonton, Nicholas J. Lembo, Adrian P. Banning, Béla Merkely, J. Van Boven, Imre Ungi, Arie Pieter Kappetein, Joseph F. Sabik, Philippe Généreux, Ovidiu Dressler, Gregg W. Stone

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

BACKGROUND: Distal left main (LM) coronary artery bifurcation disease increases percutaneous coronary intervention (PCI) procedural complexity and is associated with worse outcomes than isolated ostial/shaft disease. The optimal treatment strategy for distal LM disease is undetermined. We sought to determine whether outcomes after PCI of LM distal bifurcation lesions are influenced by treatment with a provisional 1-stent versus planned 2-stent technique, and if so, whether such differences are conditioned by the complexity of the LM bifurcation lesion. METHODS AND RESULTS: The clinical and angiographic characteristics, procedural methods and outcomes, and clinical events through 3-year follow-up were compared in patients undergoing distal LM PCI with a 1-stent provisional versus planned 2-stent technique in the EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization). Among 529 patients undergoing planned distal LM PCI, 344 (65.0%) and 185 (35.0%) were treated with intended 1-stent provisional and planned 2-stent techniques, respectively. The primary composite end point rate of death, myocardial infarction, or stroke at 3 years was significantly lower in patients treated with the provisional 1-stent versus planned 2-stent method (14.1% versus 20.7%; adjusted hazard ratio, 0.55; 95% CI, 0.35-0.88; P=0.01), driven by differences in cardiovascular death (3.3% versus 8.3%, P=0.01) and myocardial infarction (7.7% versus 12.8%, P=0.06). The 3-year rate of ischemia-driven revascularization of the LM complex was also lower in the provisional group (7.2% versus 16.3%, P=0.001). In 342 patients with distal LM bifurcation disease that did not involve both major side branch vessels, the 3-year primary end point was lower with a provisional 1-stent versus planned 2-stent technique (13.8% versus 23.3%, P=0.04), whereas no significant difference was present in 182 patients with distal LM bifurcation disease that did involve both side branch vessels (14.3% versus 19.2%, P=0.36). CONCLUSIONS: Among patients with distal LM bifurcation disease in the EXCEL trial randomized to PCI, 3-year adverse outcomes were worse with planned 2-stent treatment compared with a provisional 1-stent approach, a difference that was confined to patients without major involvement of both LM side branch vessels. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01205776.

Original languageEnglish (US)
Article numbere007007
JournalCirculation: Cardiovascular Interventions
Volume11
Issue number10
DOIs
StatePublished - Jan 1 2018

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Percutaneous Coronary Intervention
Stents
Myocardial Infarction
Coronary Artery Bypass
Coronary Artery Disease
Therapeutics
Ischemia
Stroke
Clinical Trials

All Science Journal Classification (ASJC) codes

  • Cardiology and Cardiovascular Medicine

Cite this

Kandzari, David E. ; Gershlick, Anthony H. ; Serruys, Patrick W. ; Leon, Martin B. ; Morice, Marie Claude ; Simonton, Charles A. ; Lembo, Nicholas J. ; Banning, Adrian P. ; Merkely, Béla ; Van Boven, J. ; Ungi, Imre ; Kappetein, Arie Pieter ; Sabik, Joseph F. ; Généreux, Philippe ; Dressler, Ovidiu ; Stone, Gregg W. / Outcomes among patients undergoing distal left main percutaneous coronary intervention : Technique analysis from the EXCEL trial. In: Circulation: Cardiovascular Interventions. 2018 ; Vol. 11, No. 10.
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title = "Outcomes among patients undergoing distal left main percutaneous coronary intervention: Technique analysis from the EXCEL trial",
abstract = "BACKGROUND: Distal left main (LM) coronary artery bifurcation disease increases percutaneous coronary intervention (PCI) procedural complexity and is associated with worse outcomes than isolated ostial/shaft disease. The optimal treatment strategy for distal LM disease is undetermined. We sought to determine whether outcomes after PCI of LM distal bifurcation lesions are influenced by treatment with a provisional 1-stent versus planned 2-stent technique, and if so, whether such differences are conditioned by the complexity of the LM bifurcation lesion. METHODS AND RESULTS: The clinical and angiographic characteristics, procedural methods and outcomes, and clinical events through 3-year follow-up were compared in patients undergoing distal LM PCI with a 1-stent provisional versus planned 2-stent technique in the EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization). Among 529 patients undergoing planned distal LM PCI, 344 (65.0{\%}) and 185 (35.0{\%}) were treated with intended 1-stent provisional and planned 2-stent techniques, respectively. The primary composite end point rate of death, myocardial infarction, or stroke at 3 years was significantly lower in patients treated with the provisional 1-stent versus planned 2-stent method (14.1{\%} versus 20.7{\%}; adjusted hazard ratio, 0.55; 95{\%} CI, 0.35-0.88; P=0.01), driven by differences in cardiovascular death (3.3{\%} versus 8.3{\%}, P=0.01) and myocardial infarction (7.7{\%} versus 12.8{\%}, P=0.06). The 3-year rate of ischemia-driven revascularization of the LM complex was also lower in the provisional group (7.2{\%} versus 16.3{\%}, P=0.001). In 342 patients with distal LM bifurcation disease that did not involve both major side branch vessels, the 3-year primary end point was lower with a provisional 1-stent versus planned 2-stent technique (13.8{\%} versus 23.3{\%}, P=0.04), whereas no significant difference was present in 182 patients with distal LM bifurcation disease that did involve both side branch vessels (14.3{\%} versus 19.2{\%}, P=0.36). CONCLUSIONS: Among patients with distal LM bifurcation disease in the EXCEL trial randomized to PCI, 3-year adverse outcomes were worse with planned 2-stent treatment compared with a provisional 1-stent approach, a difference that was confined to patients without major involvement of both LM side branch vessels. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01205776.",
author = "Kandzari, {David E.} and Gershlick, {Anthony H.} and Serruys, {Patrick W.} and Leon, {Martin B.} and Morice, {Marie Claude} and Simonton, {Charles A.} and Lembo, {Nicholas J.} and Banning, {Adrian P.} and B{\'e}la Merkely and {Van Boven}, J. and Imre Ungi and Kappetein, {Arie Pieter} and Sabik, {Joseph F.} and Philippe G{\'e}n{\'e}reux and Ovidiu Dressler and Stone, {Gregg W.}",
year = "2018",
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doi = "10.1161/CIRCINTERVENTIONS.118.007007",
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Kandzari, DE, Gershlick, AH, Serruys, PW, Leon, MB, Morice, MC, Simonton, CA, Lembo, NJ, Banning, AP, Merkely, B, Van Boven, J, Ungi, I, Kappetein, AP, Sabik, JF, Généreux, P, Dressler, O & Stone, GW 2018, 'Outcomes among patients undergoing distal left main percutaneous coronary intervention: Technique analysis from the EXCEL trial', Circulation: Cardiovascular Interventions, vol. 11, no. 10, e007007. https://doi.org/10.1161/CIRCINTERVENTIONS.118.007007

Outcomes among patients undergoing distal left main percutaneous coronary intervention : Technique analysis from the EXCEL trial. / Kandzari, David E.; Gershlick, Anthony H.; Serruys, Patrick W.; Leon, Martin B.; Morice, Marie Claude; Simonton, Charles A.; Lembo, Nicholas J.; Banning, Adrian P.; Merkely, Béla; Van Boven, J.; Ungi, Imre; Kappetein, Arie Pieter; Sabik, Joseph F.; Généreux, Philippe; Dressler, Ovidiu; Stone, Gregg W.

In: Circulation: Cardiovascular Interventions, Vol. 11, No. 10, e007007, 01.01.2018.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Outcomes among patients undergoing distal left main percutaneous coronary intervention

T2 - Technique analysis from the EXCEL trial

AU - Kandzari, David E.

AU - Gershlick, Anthony H.

AU - Serruys, Patrick W.

AU - Leon, Martin B.

AU - Morice, Marie Claude

AU - Simonton, Charles A.

AU - Lembo, Nicholas J.

AU - Banning, Adrian P.

AU - Merkely, Béla

AU - Van Boven, J.

AU - Ungi, Imre

AU - Kappetein, Arie Pieter

AU - Sabik, Joseph F.

AU - Généreux, Philippe

AU - Dressler, Ovidiu

AU - Stone, Gregg W.

PY - 2018/1/1

Y1 - 2018/1/1

N2 - BACKGROUND: Distal left main (LM) coronary artery bifurcation disease increases percutaneous coronary intervention (PCI) procedural complexity and is associated with worse outcomes than isolated ostial/shaft disease. The optimal treatment strategy for distal LM disease is undetermined. We sought to determine whether outcomes after PCI of LM distal bifurcation lesions are influenced by treatment with a provisional 1-stent versus planned 2-stent technique, and if so, whether such differences are conditioned by the complexity of the LM bifurcation lesion. METHODS AND RESULTS: The clinical and angiographic characteristics, procedural methods and outcomes, and clinical events through 3-year follow-up were compared in patients undergoing distal LM PCI with a 1-stent provisional versus planned 2-stent technique in the EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization). Among 529 patients undergoing planned distal LM PCI, 344 (65.0%) and 185 (35.0%) were treated with intended 1-stent provisional and planned 2-stent techniques, respectively. The primary composite end point rate of death, myocardial infarction, or stroke at 3 years was significantly lower in patients treated with the provisional 1-stent versus planned 2-stent method (14.1% versus 20.7%; adjusted hazard ratio, 0.55; 95% CI, 0.35-0.88; P=0.01), driven by differences in cardiovascular death (3.3% versus 8.3%, P=0.01) and myocardial infarction (7.7% versus 12.8%, P=0.06). The 3-year rate of ischemia-driven revascularization of the LM complex was also lower in the provisional group (7.2% versus 16.3%, P=0.001). In 342 patients with distal LM bifurcation disease that did not involve both major side branch vessels, the 3-year primary end point was lower with a provisional 1-stent versus planned 2-stent technique (13.8% versus 23.3%, P=0.04), whereas no significant difference was present in 182 patients with distal LM bifurcation disease that did involve both side branch vessels (14.3% versus 19.2%, P=0.36). CONCLUSIONS: Among patients with distal LM bifurcation disease in the EXCEL trial randomized to PCI, 3-year adverse outcomes were worse with planned 2-stent treatment compared with a provisional 1-stent approach, a difference that was confined to patients without major involvement of both LM side branch vessels. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01205776.

AB - BACKGROUND: Distal left main (LM) coronary artery bifurcation disease increases percutaneous coronary intervention (PCI) procedural complexity and is associated with worse outcomes than isolated ostial/shaft disease. The optimal treatment strategy for distal LM disease is undetermined. We sought to determine whether outcomes after PCI of LM distal bifurcation lesions are influenced by treatment with a provisional 1-stent versus planned 2-stent technique, and if so, whether such differences are conditioned by the complexity of the LM bifurcation lesion. METHODS AND RESULTS: The clinical and angiographic characteristics, procedural methods and outcomes, and clinical events through 3-year follow-up were compared in patients undergoing distal LM PCI with a 1-stent provisional versus planned 2-stent technique in the EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization). Among 529 patients undergoing planned distal LM PCI, 344 (65.0%) and 185 (35.0%) were treated with intended 1-stent provisional and planned 2-stent techniques, respectively. The primary composite end point rate of death, myocardial infarction, or stroke at 3 years was significantly lower in patients treated with the provisional 1-stent versus planned 2-stent method (14.1% versus 20.7%; adjusted hazard ratio, 0.55; 95% CI, 0.35-0.88; P=0.01), driven by differences in cardiovascular death (3.3% versus 8.3%, P=0.01) and myocardial infarction (7.7% versus 12.8%, P=0.06). The 3-year rate of ischemia-driven revascularization of the LM complex was also lower in the provisional group (7.2% versus 16.3%, P=0.001). In 342 patients with distal LM bifurcation disease that did not involve both major side branch vessels, the 3-year primary end point was lower with a provisional 1-stent versus planned 2-stent technique (13.8% versus 23.3%, P=0.04), whereas no significant difference was present in 182 patients with distal LM bifurcation disease that did involve both side branch vessels (14.3% versus 19.2%, P=0.36). CONCLUSIONS: Among patients with distal LM bifurcation disease in the EXCEL trial randomized to PCI, 3-year adverse outcomes were worse with planned 2-stent treatment compared with a provisional 1-stent approach, a difference that was confined to patients without major involvement of both LM side branch vessels. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01205776.

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