Coronary artery bypass surgery has been the preferred treatment for patients with a blockage in the left main coronary artery, the conduit that supplies blood to about two-thirds of the heart.
However, in recent years this has been challenged by stent placement in this critical artery. Trusting treatment of such a critical vessel to percutaneous coronary intervention (PCI) is anathema to some. To others, it is the reasonable next step, given recent advances in stent technology.
At the 30th Annual Scientific Sessions of the Society for Cardiovascular Angiography and Interventions (SCAI), in Orlando, FL, two renowned experts will debate the role of PCI and coronary artery bypass grafting (CABG) for the treatment of patients with left main coronary artery disease. Representing left main stenting will be Roxanna Mehran, M.D., FSCAI, an associate professor of medicine at Columbia University, and medical director of the Data Coordinating and Analysis Center of the Cardiovascular Research Foundation, both in New York City. Her opponent: cardiothoracic surgeon Michael J. Mack, M.D., director of the Cardiopulmonary Research Science and Technology Institute in Dallas.
According to Dr. Mack, bypass surgery has long been the gold standard for the treatment of patients with disease of the left main coronary artery. In the mid- 1990s a large, respected clinical trial proved that surgery was superior to medical therapy. Later, bare metal stents failed to gain footing as an alternative to surgery after several studies showed unacceptable rates of death and repeat procedures.
Drug-eluting stents (DES) have markedly changed the landscape, said Dr. Mehran. This breakthrough technology once again raises the possibility that catheter techniques can safely and effectively treat left main disease. "We now have devices that have the ability to deal with much more complex disease that would previously have been treated with bypass surgery," she said. "It is time to start making comparisons of CABG and DES for disease involving the left main coronary artery."
Available data on drug-eluting stents, although better than for bare metal stents, is too little, too soon, Dr. Mack said. "Evidence from a few small studies that are underpowered for either death or heart attack does not warrant use of PCI, especially in view of concerns about late stent thrombosis, which is particularly worrisome in left main stenting," he said.