The treatment of proximal left anterior descending (P-LAD) coronary artery lesions using new-generation drug-eluting stents (DES) was not found to be associated with higher rates of adverse clinical events at 2 years, according to study results published in JACC: Cardiovascular Interventions.
In current guidelines on myocardial revascularization, P-LAD lesions are addressed separately from lesions in other vessels. A greater part of the myocardium receives its blood supply from the P-LAD vs other vessels. The risk for adverse events is therefore greater when percutaneous coronary intervention (PCI) is chosen for revascularization of P-LAD is chosen vs bypass surgery, and if the interventions fails. There is little information on the treatment of P-LAD vs other coronary vessel segments using thin strut new-generation DES, and extended outcomes have not been examined in randomized controlled studies.
In this study, 6037 Dutch adult patients with no history of left main stem involvement or bypass surgery were enrolled in a patient-level pooled analysis of the TWENTE I, II and III randomized trials (ClinicialTrials.gov identifiers: NCT01066650, NCT01331707 and NCT01674803, respectively). Participants who underwent P-LAD DES implantation (n=1607; 26.6%; mean age, 63.8±10.8 years; 25.3% women) were compared with those who underwent DES implantation in non-P-LAD segments (n=4430; 73.4]; mean age, 63.3±10.7 years; 29.0% women). The same thin strut new-generation DES was used on all study participants who were followed for 2 years.
The study’s 2 primary outcomes were a patient-oriented composite endpoint (any myocardial infarction [MI], any repeat revascularization, or any death), and a device-oriented composite endpoint (target vessel MI, target lesion revascularization, or cardiac mortality).
At baseline, patients with P-LAD lesions had greater total stent lengths and more treatments of multiple vessels. At 2 years, 99.3% of the participants were available for follow-up.
The patient-oriented composite was comparable in participants with a P-LAD or a non-P-LAD (11.4% vs 11.6%, respectively; hazard ratio [HR], 0.99; 95% CI, 0.83-1.17; P =.87). The device-oriented composite had a higher rate in patients with a P-LAD vs non-P-LAD (7.6% vs 6.0%, respectively; HR, 1.29; 95% CI, 1.04-1.60; P =.020), which was due to a higher rate of target vessel MI (4.1% vs 2.6%, respectively; P =.002).
After adjusting for variables that included previous and acute MI at presentation, sex, and the number of implanted stents, the association between P-LAD treatment with DES and greater rates at 2 years of target lesion failure was no longer present (adjusted HR, 1.11; 95% CI, 0.89-1.38; P =.34).
Study limitations include the inability to rule out long-term clinical differences, a lack of data on the presence of angina, heart failure symptoms or left ventricular function, and the lack of a bypass surgery control group.
“Based on the results of our present analysis, one may question whether P-LAD lesions deserve a dedicated section in future revascularization guidelines,” noted the authors.
Funding and Conflicts of Interest Disclosures:
CvB reports that the research department of Thoraxcentrum Twente has received research grants provided by Abbott Vascular, Santa Clara, CA; Biotronik, Bülach, Switzerland; Boston Scientific, Natick, MA; and Medtronic, Santa Rosa, CA. Other authors indicated no potential conflicts of interest.
Roguin A, Buiten RA, Doggen CJ, et al. Proximal LAD treated with thin-strut new-generation drug-eluting stents: a patient-level pooled analysis of TWENTE I-III. JACC Cardiovasc Interv. March 2020. doi:10.1016/j.jcin.2019.11.018