Elective Ostial Left Main Stenting: A Tailored Approach
Elective left main (LM) stenting is increasingly performed as a valuable alternative to coronary artery bypass grafting. Nevertheless, clinical data are limited to registries, and randomized trials have not been published. Intravascular ultrasound (IVUS) has been recognized as an accurate tool for assessing optimal stent deployment. We hereby report the usefulness of IVUS in defining the interventional strategy in four consecutive patients presenting with severe, symptomatic ostial LM disease, and this in the era of drug-eluting stents. The first two patients were treated by a short drug-eluting stent for a critical LM stenosis as IVUS demonstrated a reference diameter < 3.7 mm. The third patient had a larger reference diameter and was treated with conventional stenting with optimization of the result by IVUS. IVUS was particularly helpful in all patients to confirm accurate stent placement in relation to the LM ostium and bifurcation. In another patient, based on IVUS findings, surgery was preferred. This patient with diabetes as a risk factor presented with comparable angiographic features. IVUS, however, showed diffuse disease without any healthy reference segment in the LM. All stented patients are asymptomatic at 15 ± 7 months follow-up with negative stress testing. The present observation indicates that IVUS is an essential tool for strategic selection and to optimize percutaneous coronary intervention for LM disease.

Currently, percutaneous coronary intervention (PCI) worldwide is characterized by a liberal use of coronary stents. In developed countries, the average stent use is approximately 80%. In the early days of stenting, unacceptable high early stent thrombosis rates were observed. Intravascular ultrasound (IVUS) has played a key role in improving our understanding of stent thrombosis. Routine higher pressure inflation and/or dilation with a larger balloon in order to improve stent expansion were techniques employed as practical solutions. The usefulness of IVUS to reduce restenosis is still a matter of debate – certainly in the era of drug eluting stents. Left main (LM) stenting has become a popular alternative to surgical revascularization. At present, only registry data have been published with in-hospital mortality rates varying between 0% and 12%, and target vessel revascularization rates between 15% and 17.4% at one-year follow-up. Scarce data are available on the role of IVUS in defining an accurate PCI strategy and in optimizing stent deployment in LM disease. The present series reports on the usefulness of IVUS for this indication in four consecutive patients presenting with ostial LM disease.