PERCUTANEOUS coronary intervention (PCI) for unprotected left main coronary artery (ULMCA) disease demonstrates favourable long-term outcomes in a high-volume centre without on-site cardiac surgery, with survival rates of 86.1% at one year and 70% over 5.5 years, though clinical and angiographic success hinges on patient comorbidities and procedural techniques, according to a 20-year Italian registry of 1,000 patients.
ULMCA PCI, increasingly used for older, high-risk populations, lacks robust real-world data on predictors of adverse outcomes. This retrospective analysis included 1,000 patients undergoing de novo ULMCA PCI (2002–2023) at a centre without on-site cardiac surgery, excluding restenosis or prior bypass cases. Primary endpoints were major adverse cardiovascular and cerebrovascular events (MACCE) and target lesion failure (TLF), assessed via angiographic (73.9% follow-up) and clinical (96.6% follow-up) data. Multivariate analyses identified risk factors, and a propensity-matched cohort compared outcomes with versus without elective angiographic follow-up.
MACCE occurred in 30% of patients over a median 5.5-year follow-up, driven by all-cause mortality (70% survival rate). Independent predictors included age >70 (HR 1.8, P<0.001), moderate-severe renal impairment (HR 2.1, P=0.002), multivessel disease (HR 1.5, P=0.01), ejection fraction <40% (HR 2.3, P<0.001), and haemodynamic instability/intubation (HR 3.0, P<0.001). Intravascular imaging reduced MACCE risk by 35% (P=0.004). TLF occurred in 17.2% of angiographic follow-ups, linked to insulin-dependent diabetes (OR 2.2, P=0.01), renal impairment (OR 1.9, P=0.03), and two-stent bifurcation techniques—Culotte (33.3% TLF) and T-protrusion (30%) versus single-stent (12.8%, P<0.001). Elective angiographic follow-up improved survival (HR 0.6, P=0.02) in matched cohorts.
These findings support ULMCA PCI feasibility in high-risk settings but underscore the need for meticulous patient selection. Clinicians should prioritise intravascular imaging, avoid complex bifurcation stenting where possible, and implement protocol-driven angiographic surveillance for high-risk subgroups (e.g., renal impairment, diabetes). Future research should standardise follow-up protocols and explore tailored approaches for frail populations to optimise long-term outcomes.
Reference
Franzé A et al. Twenty years of experience in one thousand de‐novo left main coronary angioplasty with angiographic control in a high‐volume centre without on‐site cardiac surgery. Catheterization and Cardiovascular Interventions. 2025;DOI:10.1002/ccd.31488.
