A Meta-analysis of Ostial and Trunk versus Distal Lesions in Unprotected Left Main Coronary Artery Stenting

Aims: To assess outcomes for percutaneous coronary intervention (PCI) in ostial and trunk versus distal unprotected left main coronary artery (LMCA) lesions in the drug-eluted stent (DES) era.

Study Design: A meta-analysis and systematic review.

Methods: With the help of a librarian, we searched Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and the Clinical Trials Registry from 2001 to July 2012. We included studies that enrolled ≥ 50 patients and had ≥6 months of follow-up. Our co-primary endpoints were the incidence of major adverse cardiac events (MACE) and target lesion/vessel revascularization (TLR/TVR). Data was abstracted and analyzed by two independent reviewers and differences were resolved by consensus. We assessed the results for heterogeneity in our analysis by examining the forest plots and then calculating a Q statistic, which we compared with the I2 index. If there was no evidence of statistical heterogeneity and pooling of results was clinically appropriate, a combined estimate was obtained using the fixed-effects model; otherwise the random-effects model was used.

Results: We identified 11studies involving 3,718 patients. Mean duration of follow-up was 29 months (range 12-62months). Compared with ostial and trunk stenting, distal LMCA PCI was associated with increased MACE (OR 1.95, 95% CI 1.43-2.66) and TLR/TVR (OR 3.13, 95% CI 1.90-5.16).No significant differences were detected for cardiac death (OR 1.06, 95% CI 0.72-1.58, p=0.58), MI (OR 1.15, 95% CI 0.74-1.77, p=0.80) or stent thrombosis (OR 1.57, 95% CI 0.90-2.77, p=0.41).

Conclusion: Patients with ostial and trunk LMCA lesions treated with DES have better outcomes than patients with distal lesions. Our findings may support unprotected non-distal LMCA stenting as a primary approach in selected patient subsets.