Stenting the unprotected left main coronary artery without invasive imaging techniques

doi:10.21203/rs.3.rs-2131803/v1

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Stenting the unprotected left main coronary artery without invasive imaging techniques

https://doi.org/10.21203/rs.3.rs-2131803/v1

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Background

New imaging modalities such as IVUS had improved results of stenting of the unprotected left main coronary artery (UPLM). The results of stenting UPLM without these new modalities but with meticulous care need to be studied more.

Methods

We analyzed data from 120 patients with UPLMD of > 50% subjected to stenting. All were stented by drug-eluting stents and followed for six months.

Results

92 patients (77.3%) presented with ACS, of which 65 patients (54.6%) had no Previous Intervention, and 27 patients (22.7%) had a previous PCI. Left ventricular ejection fraction significantly correlates with complication, at 6 months follow up; all 16 patients with reported complications (100%) had baseline LVEF of < 40% (P-value = 0.023). Syntax score: 11 patients (55%) with a high score of more than 32 had adverse events, P = 0.004. Residual syntax shows a less significant correlation with a mean value of 7.3 in the complication group versus 4.9 in the other group (P = 0.016). Final kissing balloon inflation shows no statistically significant difference.

Conclusions

PCI in UPLM is a safe, feasible option with a high technical success rate and acceptable outcome at follow-up even without the utilization of IVUS

Left main coronary artery stenosis

drug-eluted stents

SYNTAX score

IVUS

PCI

Clinical trials demonstrated a higher rate of reintervention after coronary percutaneous intervention (PCI) compared with coronary artery bypass grafting (CABG). PCI had a lower incidence of cerebrovascular events. ^(1–21)

Current guidelines recommend CABG as class I for most patients with LM ^{(3, 4)}. New features in stent technology, revascularization techniques, and antithrombotic medications make PCI safer.

Detailed examination of the anatomic size of LM lesions is achieved using intravascular ultrasound (IVUS) ⁽²²⁾.

Aim of the work: The study was designed to evaluate the short and mid-term clinical outcomes of elective, unprotected left main coronary artery stenting in multiple local centers.

This prospective and retrospective study was performed in multiple local centers. The local ethics committee approved the study, and the patients signed informed consent.

In the last five years, one hundred twenty patients with left main disease > 50% were subjected to stenting with drug-eluted stents.

All patients were subjected to detailed history taking with particular emphasis on acute coronary syndrome, angina duration, class, previous coronary interventions, and medications. In addition, 12 lead ECGs were revised with an evaluation of ST/T changes and any old infarction. An echocardiographic examination was done on all patients following the recommendations of the American Society of Cardiology [23]. Ejection fraction, LV diameters, and wall motion were recorded. Laboratory testing included kidney function, lipid profile, and blood sugar.

Risk assessment was calculated for every patient, including Euro SCORE and Syntax score.

Medications: All patients received clopidogrel and aspirin before the planned procedure. Anticoagulation with unfractionated heparin in a dose of 10000 IU was given at the beginning of the PCI. Post PCI, all patients received B blockers, ACE inhibitors, statins, and dual antiplatelets in the guidelines recommended doses.

PCI technique: A steerable guidewire was advanced in LAD, followed by PCI with pre-dilatation or direct stenting according to the operator's discretion. One or two stent strategy was utilized according to the situation of the lesions.

Study outcomes

1. Procedural outcomes:

a. Thrombolysis in Myocardial Infarction (TIMI) flow grade was graded Grade 0, absence of antegrade flow beyond the point of occlusion; Grade1, partial penetration of contrast agent beyond the obstruction but incomplete distal filling; Grade 2, patency with opacification of the entire distal vessel but with delayed filling or washout of contrast agent; and Grade 3, normal flow.

b. We defined the procedural success rate as residual stenosis of less than 20% and establishment of Thrombolysis in Myocardial Infarction (TIMI)-3 flow. Without major periprocedural adverse events (Death, myocardial infarction, emergency revascularization).

2. In-hospital outcomes

A. Death. B. Myocardial infarction. C. Cerebrovascular stroke. D. Re-intervention: Target Vessel Revascularization (TVR), Target Lesion Revascularization (TLR), and Non-Target Vessel Revascularization (Non- TVR). E. Heart Failure.

3. Thirty days outcomes

a. Death. B. New angina or myocardial infarction. C. Cerebrovascular stroke.

d. Re-intervention: (TVR), (TLR), and (Non- TVR). E. Heart Failure.

a. We recorded six-month outcomes as death, cerebrovascular stroke, re-intervention (TVR), (TLR), and (Non- TVR), New angina, and Heart Failure.

Study endpoints: Primary endpoints are major cardiovascular events at 30 days and six months, defined as death, myocardial infarction, cerebrovascular stroke, and re-intervention: TVR, TLR, and Non-TVR.

All methods were performed following the relevant guidelines and regulations

Statistical analysis of the data

Data were fed to the computer and analyzed using IBM SPSS version 20.0. (Armonk, NY: IBM Corp) Qualitative data were described using numbers and percentages. The Kolmogorov-Smirnov test was used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, standard deviation, and median. The significance of the obtained results was judged at the 5% level. The used tests were: Chi-square test: For categorical variables, to compare different groups. Fisher's Exact or Monte Carlo correction: Correction for chi-square when more than 20% of the cells have an expected count of less than 5. Student t-test: For normally distributed quantitative variables, to compare two studied groups.

This prospective study included 50 patients undergoing elective percutaneous coronary intervention for unprotected left coronary artery disease in Alexandria. In addition, a retrospective arm included 70 patients who had left main stenting in the last five years.

The study included 120 patients, 88 males, and 32 females, with a mean age of 61.

Regarding risk factors, we found that diabetes was the most common risk factor present in 95 patients (79.2%), followed by hypertension in 83 patients (69.2%), 69 patients were current smokers (57.5%), and dyslipidemia in 60 patients (50%).

Regarding clinical presentation, we found that 92 patients (77.3%) presented with ACS, of which 65 patients (54.6%) had no previous intervention, and 27 patients (22.7%) had a prior PCI. One patient with previous CABG, Patients with chronic coronary syndrome, were 27 (22.7%), and none of the chronic coronary syndrome patients had an earlier intervention. As shown in table (1)

Anatomical characteristics:

According to coronary angiography, we determined the following anatomical characteristics:

a) CAD extent, whether non-distal LM disease (ostial and shaft) or a distal bifurcation or trifurcation

b) Left circumflex dominance.

c) Bifurcation angle between LAD, LCX

d) Ostial LCX significant disease as shown in table (2).

PCI characteristics:

We classified the patients according to the following PCI Characteristics:

a. Access either femoral (101 patients) or radial (19 patients).

b. We used Guiding catheters to cannulate LMCA. 6F in 53 patients, 7F in 67.

c. LM stent number.

d. The technique used for stenting (Provisions-Cullotte-SKS-TAP-Minicrush)

e. POT and Final kissing done or not?

f. Diameter and length of the LM stent.

g. Other stents (s) are used to treat other lesions.

h. Total stents number

i. We calculated the residual syntax score (Table 3)

Complications

Procedural, In-hospital, one-month, and six months complications were documented, including access site hematoma, contrast nephropathy, dissection, heart failure, bleeding, TLR, non-TLR, Angina, ACS, stroke, and Death. As shown in (Tables 4–9)

Statistical relation with different complications:

a) Demographic data

The study included 120 patients

There was no statistically significant difference between the procedural and in-hospital complications regarding sex (p-value = 0.46) and age group (p-value = 0.52). Still, at one-month follow-up, 9 out of 12 complications were more than 6o years, and only three were below 50 years (P-value = 0.024); at six months, there were no significant correlations between age, sex, and adverse events.

b) Risk Factors

As regards the risk factors, only the hypertension group showed statistically significant increased complications where 17 out of 20 complications were in hypertensive subjects (85% with P-value = 0.093); this finding was consistent at one-month follow-up where all 12 patients with complications were hypertensive (100%) (P-value = 0.017) and to less extent at six months follow up eight patients out of 16 cases with complications were hypertensive (P-value = 0.087)

Diabetes and presentation (acute vs. CCS) were not significantly correlated with complication rate, P-value = 0.76 for DM and 0.77, the same finding at one month and six months of follow-up.

C) LV function

Left ventricular ejection fraction significantly correlated with procedural and in-hospital complications; with 12 patients out of 20 who had reduced LVEF by Less than 40% (P-value = 0.033); at one-month LVEF was not significantly associated with complications, yet at six months follow up all 16 patients with reported complications (100%) had baseline LVEF of less than 40% (P-value = 0.023)

1. Angiographic and procedural characteristics:

a) Syntax score

Statistically significant correlation between Syntax score and adverse outcome with a higher score, one patient out of 20 (5%) had a lower score than 23. In contrast, eight patients with intermediate scores had adverse events, and 11 patients (55%) with a high score of more than 32 had adverse events with a P-value of 0.004, the mean syntax score in the complication group was 32.3 Vs. 27.6 in the group with no complications (P-value 0.006), Syntax II Score was significantly higher in the complication group 36.24 Vs. 27.26 in The group without complications (P value < 0.001), Residual syntax shows a less significant correlation with a mean value of 7.3 in the complication group versus 4.9 in the other group (P value = 0.016) (Table 7).

At One month, the Syntax score still correlates with adverse events where the Mean syntax I score was 31.76 in the complication group Vs. 28 in the other Group (P-value 0.07), and Syntax II PCI a mean of 38.47 in the complication Group Vs. 27.69 in another group, the residual syntax score shows again statistically significant differences at one month with a mean of 10.75 in complication Vs. 4.77 in another group (P-value = 0.018) but not at six months follow-up between the complication group and the other group

b) LCX

Neither LCX dominance nor significant ostial disease showed a statistically significant correlation with the adverse events during in-hospital and follow-up periods, as well as the angle between LAD, and LCX in this study

c) Kissing

Final kissing balloon inflation shows no statistically significant difference compared to non-kissing regarding complications, procedural in-hospital, and follow-up period.

d) Other stents

Implantation of more than one stent shows no statistically significant differences compared to the single stent regarding complications, procedural in-hospital, and follow-up period.

The present study evaluated the feasibility of stenting LMCA without the utilization of IVUS.

We successfully treated one hundred twenty such patients with drug-eluting stents. The percentage of complications was not inferior to the incidence when IVUS was utilized. Thus the strategy of stenting LMCAD without these techniques is safe and effective when performed by experienced interventional cardiologists (22–31).

We followed all patients in a cardiology outpatient clinic one month after PCI, followed by a visit or phone call after six months, and then after one year. No routine angiography was performed unless symptomatic or positive stress test; 24 patients had exercise testing during the follow-up period, four were positive, and fifteen patients had follow-up angiography either following a positive stress test or ACS.

In our study, the mean age of the patients was 60 years; this is six years younger than the mean age in the EXCEL trial, in which the mean age was 66.5 years; this may reflect the earlier or aggressive atherosclerotic cardiovascular burden.

As regards other demographic criteria in our study predominant male sex (73.3%) was shared in different left main trials; in the Indian registry published in the Indian heart journal by Ray et al., 2016 ^(25), around 76% of the patients were male, of note the mean age was 60 years in this registry.

In our study, neither the age nor the sex had influenced the outcome, including MACE at one-year follow-up significantly; still, at one-month follow-up, the reported complications were higher (9 patients out of 12) more than 65 years, and only three were below than 50 years, worth mentioning recent systematic review, ^(29,30) published in Cardiovascular Revascularization Medicine Journal in 2020 shows that women who undergo PCI for unprotected LMCD are at higher risk of MACE and MI compared to men such finding was not validated in our study primarily due to relatively small sample size.

As regards the risk factors and their relation to complications in our study, only hypertension had a statistically significant association with the adverse outcome, unlike DM, dyslipidemia, and smoking. These findings correlate with results published before (25).

One of our study's most important predictors of MACE is the SYNTAX I score. The mean syntax score in the complication group was 32.3 Vs. 27.6 in the group with no complications (P-value 0.006). The same finding was reproducible at one month and six months outcome these findings consider revalidation of the value of SYNTAX score I as one of the most important prognostic factors in UPLM PCI. Capodanno Et al. found that the SYNTAX score is an important tool to suggest cardiac mortality and MACE in patients undergoing percutaneous revascularization of the left main coronary artery even at short and mid-term follow-up at one year. (27)

As regards the SYNTAX II score, it showed statistically significant results concerning MACE in our study. Syntax II Score was significantly higher in complication group 36.24 Vs. 27.26 in The group without complications (P value < 0.001). This finding comes in agreement with a study published by Madeira et al. from Portugal in 2016 titled Potential Utility of the SYNTAX Score II in Patients Undergoing Left Main Angioplasty over 132 patients undergoing UPLM PCI and concluded that The SYNTAX Score II might allow a better and individualized risk stratification of patients who need revascularization of an unprotected left main coronary artery The authors suggested that a difference more significant than 5.7% between SYNTAX Score 2 estimates for PCI versus CABG may be clinically relevant in selecting the optimal revascularization strategy (28)

Another important prognostic factor in our study is the residual syntax score (RSS) which was significantly higher in the complication group at one month, with a mean of 10.75 in complication Vs. However, 4.77 in another group (P-value = 0.018) was less significant at one-year follow-up; the value of RSS in many trials did not address UPLM PCI specifically.

Another important angiographic criterion that shows significance is the location of the left main lesion. Ostial LM lesion PCI in our study, when compared to the distal site, offers a significantly lower incidence of MACE that was evident at one-year follow-up, where 10% of the distal LM PCI showed complication versus no reported complications in the ostial LM PCI group (P value = 0.001). This finding agrees with Hyun et al.'s essential registry in 2020 ⁽³⁰⁾.

Regarding the procedural characteristics, there was no significant difference in MACE in our study between the 2-stent strategy, including different techniques of 2-stent strategies and one stent during the follow-up period. This is shown in The Milan and New-Tokyo Registry published by Takagi et al. in 2016, and they compared one versus two stents strategy in UPLMD in more than nine hundred and thirty patients in three different centers. The main issue observed was more TLR in single stent strategy, but no significant mortality difference; needless to say, ostial compromise of side branch ostium (whether LAD or LCX) is among the important reasons for increased side branch revascularization, but as they concluded, it did not affect mortality (31–35)

PCI in unprotected left coronary artery disease is a possible option with a high technical success rate and acceptable outcome at follow-up when IVUS is unavailable.
The following parameters were associated with increased MACE rate in our study: Hypertension as a risk factor was associated with an increased risk of complication at follow-up; elevated SYNTAX score; distal left main lesion location versus ostial and mid-shaft; reduced left ventricular ejection fraction; residual SYNTAX score as a marker of incomplete revascularization
Risk stratification is crucial for strategy selection in managing LMCAD patients based on current validated anatomic and physiologic complexity scores.
Absence of assisting imaging techniques, namely IVUS, is not prohibitive to practicing UPLM PCI, as demonstrated in our study, despite its valuable role in stent optimization.

ACS: Acute coronary syndrome

BMS: Bare metal stent

CIN: Contrast-induced nephropathy

CABG: Coronary artery bypass graft

CAD: Coronary artery disease

CCS: Chronic coronary syndrome

CTO: Chronic total occlusion

DES: Drug-eluting stent

ISR: In-stent restenosis

IVUS: Intravascular ultrasound

LMCAD: Left main coronary artery disease

LMB: Left main bifurcation

LAD: Left anterior descending

LCX: Left circumflex

MACE: Major adverse cardiac event

PCI: Percutaneous coronary intervention

LVEF: Left ventricular ejection fraction

STEMI: ST-elevation myocardial infarction

NSTEMI: Non-ST elevation myocardial infarction

TLR: Target lesion revascularization

TVR: Target vessel revascularization

-Ethics approval and consent to participate: The local ethics committee: The Ethical Committee of the Faculty of Medicine Alexandria University, number 00012098, approved the study. We obtained informed consent: written/verbal permission from the patient or the patient's parent/carer. all methods were carried out following relevant guidelines and regulations (Declaration of Helsinki).

-Consent for publication: All authors consent for publication
-Availability of data and materials. The datasets used and/or analyzed during the current study are available from the corresponding author on request.
-Competing interests: None. Conflict of interest: The authors declare no conflict of interest in preparing this article
-Funding: None
-Authors' contributions:

AZ, involved in the study concept, design, and stenting

ML, involved in the study’s concept, design, and stenting

MS, involved in the study concept, design, and stenting

SR was involved in writing the paper and submitting it. All authors contributed to the writing—original draft preparation, and approved the final version.

-Acknowledgements: All the nursing staff, technicians, and residents

-Authors' information (optional)

Acknowledgments

All the nursing staff, technicians, and residents

Authors' contributions

AZ, involved in the study concept, design, and stenting

ML, involved in the study’s concept, design, and stenting

MS, involved in the study concept, design, and stenting

SR was involved in writing the paper and submitting it. All authors contributed to the writing—original draft preparation, and approved the final version.

Availability of data and materials

Data sharing does not apply to this article as no datasets were generated or analyzed during the current study. Data and master charts are available with Dr. MS

•Funding: This research received no specific grant from any public, commercial, or not-for-profit funding agency.

•Conflict of interest: The authors declare no conflict of interest in preparing this article.

We obtained written consent from the local Ethics Committee: The Ethical Committee of the Faculty of Medicine Alexandria University, number 00012098

We obtained consent: written/verbal permission from the patient or the patient's parent/carer.

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Table (1): Clinical, ECG, ECHO characteristics of the studied cases (n = 120)

	No.	%
Presentation
Acute	92	77.3
DiNovo ACS	65	54.6
ACS (Previous intervention)	27	22.7
CCS (No previous intervention)	27	22.7
ECG
Normal resting	40	33.3
Diffuse ST depression / raising aVR	36	30.0
ST elevation	6	5.0
Left BBB	8	6.6
Atrial fibrillation	1	0.8
Stigmata of previous infarction
Anterior Q waves	20	16.0
Inferior Q waves	9	7.5
ECHO
Severe MR	5	4.1
RWMA	50	41.6
ECHO (LVEF) (%)
Min. – Max.	25.0 – 75.0
Mean ± SD.	49.35 ± 12.22

EURO score (%)
0 – 3	100	84.0
3 – 5	12	10.1
>5	7	5.9

Table (2): Angiographic characteristics (n = 120)

	No.	%
CAD extent
Non-distal	19	15.8
Distal	101	84.2
Bifurcation	94	78.3
Trifurcation	7	5.8
LCX dominance
No	90	75.0
Yes	30	25.0
Ostial LCX significant disease
No	70	58.3
Yes non-dominant LCX	35	29.1
Yes dominant LCX	15	12.5
Bifurcation angle
<70	92	76.7
>70	28	23.3
Number of diseased vessels
1	19	15.8
2	65	54.1
3	36	30
Presence of calcification	55	45.8
Presence of thrombi	39	32.5
RCA lesion	29	24.1
Medina classification (Distal LM)
1,0,0	11	10.8
0,1,0	0	0
1,1,0	33	32.6
0,0,1	0	0
1,0,1	12	11.88
0,1,1	0	0
1,1,1	45	44.5
Syntax I
<23	17	14.3
23 – 32	73	61.3
>32	29	24.4

Mean ± SD.	28.37 ± 6.53

Table (3): Procedural characteristics of the studied population (n = 120)

PCI characteristics	No.	%
LM stent type: Xience Xpedition/Alpine/V/Prime	76	63.33
Promus Element /Element plus/premiere	12	10
Biomatrix	10	8.3
Taxus Liberte	8	6.66
Onyx	6	5
Other stents (Osirio-Eucalimus-Isaar-Ultimaster)	8
-Technique (n=120)
Predilatation	85	70.8
One stent	87	72.5
Provisional	71	59.2
Direct (non-distal lesions)	16	13.3
Two stents	33	27.9
Cullotte	14	11.9
SKS	3	2.5
TAP	13	11.0
Mini crush	3	2.5
Post stenting balloon dilatation
POT	53	44.1
Re POT	22	18.3
Final kissing
No	65	54.2
Yes	55	45.8
IVUS guidance	0	0
-Size (mm)
Length
Min. – Max.	8.0 – 48.0
Mean ± SD.	27.82 ± 10.42

Diameter
Min. – Max.	3.5 – 5
Mean ± SD.	4 ± 0.50
Median (IQR)	3.50 (3.50–4.0)
Other vessels treated
1 vessel	59	49.2
2 vessels	35	29.1
3 vessels	7	5.8
Residual syntax
Min. – Max.	0.0 – 24.0
Mean ± SD.	5.37 ± 6.35
Median (IQR)	4.0 (0.0–8.0)

Table (4): Distribution of the studied cases according to complications (n=120)

	Complications
	Procedural & In hospital		One month		Six months
	No.	%	No.	%	No.	%
No	100	83.3	108	90.0	104	86.7
Yes	20	16.7	12	10.0	16	13.3

Table (5): Distribution of the studied cases according to complications (n=120)

Complication	No.	%
Procedural
Access site hematoma	8	6.6
PCI complications (dissection)	2	1.66
In hospital
CIN	3	2.5
Heart failure	7	5.8
One month
Heart failure	3	2.5
Bleeding	4	0.83
Angina	3	2.5
Non- TLR Stroke	1 1	0.83 0.83
Six months- One year follow up
TLR	2	1.66
Non- TLR	4	3.33
Follow up exercise test	24 (20)	20 (16.6)
Follow up angiography	15	12.5
ACS/CCS	6	5
Death	2	1.66
LVEF improvement	12	10

Table (6): Distribution of the studied cases according to total MACE during follow up (n=120)

	No.	%
Death	2	1.7
Nonfatal ACS	6	5.0
TLR	2	1.7
Combined (Death / ACS /TLR)	10	8.3
Non TLR	5	4.2
Stroke	1	0.8
Heart failure	7	5.8
CABG referral	0	0.0

Table (7): Relation between complications (in hospital) and different parameters

	Complications (in hospital)				p
	No (n = 100)		Yes (n = 20)
	No.	%	No.	%
Positive DM	78	78.0	17	85.0	0.763
Positive HYPERTENSION	66	66.0	17	85.0	0.093
Presentation	(n = 99)		(n = 20)
Acute	77	77.8	15	75.0	0.775
CCS	22	22.2	5	25.0	0.775
ECHO (LVEF) (%)
<40	17	17.0	12	60.0	0.033^*
≥40	83	83.0	8	40.0	0.033^*
Positive LCX dominance	29	29.0	1	5.0	0.024^*
Ostial LCX significant disease	40	40.0	10	50.0	0.408
Bifurcation angle
<70	77	77.0	15	75.0	0.781
>70	23	23.0	5	25.0	0.781
Kissing	47	47.0	8	40.0	0.566
Access
Femoral	83	83.0	18	90.0	0.737
Radial	17	17.0	2	10.0	0.737
Other stents	60	60.0	14	70.0	0.401
Syntax I	27.63 ± 6.54		32.03 ± 5.26		0.006^*
Syntax II (PCI)
Number	27.26 ± 7.59		36.24 ± 8.63		<0.001^*
%	6.55 ± 4.95		13.80 ± 11.58		<0.001^*
Syntax II (CABG)
Number	27.75± 10.46		36.26± 10.73		0.003^*
%	7.36 ± 6.73		16.23 ± 13.01		0.001^*
Residual syntax	4.98 ± 6.58		7.30 ± 4.73		0.016^*

Table (8): Relation between Complications (one month) and different parameters

	Complications (one month)				χ²	p
	No (n =108)		Yes (n = 12)
	No.	%	No.	%
Positive DM	84	77.8	11	91.7	1.263	^FEp=0.456
Positive HYPERTENSION	71	65.7	12	100.0	5.944^*	^FEp=0.017^*
Presentation	(n =107)		(n =12)
Acute	81	75.7	11	91.7	1.568	^FEp=0.293
CCS	26	24.3	1	8.3	1.568	^FEp=0.293
ECHO (LVEF) (%)
<40	20	18.5	5	41.7	3.509	^FEp=0.125
≥40	88	81.5	7	58.3	3.509	^FEp=0.125
Positive LCX dominance	28	25.9	2	16.7	0.494	^FEp=0.728
Ostial LCX significant disease	48	44.4	2	16.7	3.429	0.064
Bifurcation angle	26	24.1	2	16.7	0.331	^FEp=0.730
Kissing	51	47.2	4	33.3	0.839	0.360
Access
Femoral	90	83.3	11	91.7	0.563	^FEp=0.688
Radial	18	16.7	1	8.3	0.563	^FEp=0.688
Other stents	65	60.2	9	75.0	1.003	^FEp=0.368
Syntax I	28.0 ± 6.47		31.67 ± 6.43		U=847.0	0.070
Syntax II (PCI)
Number	27.69 ± 7.27		38.47 ± 11.88		U=975.0^*	0.003^*
%	6.62 ± 4.24		18.0 ± 15.14		U=974.0^*	0.003^*
Syntax II (CABG)
Number	28.09 ± 10.51		38.94 ± 10.14		U= 295.5^*	0.002^*
%	7.85 ± 7.93		17.73 ± 10.60		U= 243.0^*	<0.001^*
Residual syntax	4.77 ± 5.74		10.75 ± 8.94		U=899.0^*	0.018^*

Table (9): Relation between Complications (six months) and different parameters

	Complications (six months)				p
	No (n =104)		Yes (n = 16)
	No.	%	No.	%
Positive DM	83	79.8	12	75.0	0.741
Positive HYPERTENSION	75	72.1	8	50.0	0.087
Presentation	(n =103)		(n =16)
Acute	80	77.7	12	75.0	0.757
CCS	23	22.3	4	25.0	0.757
ECHO (LVEF) (%)
<40	25	24.0	16	100.0	0.023^*
≥40	79	76.0	0	0.0	0.023^*
Positive LCX dominance	24	23.1	6	37.5	0.226
Ostial LCX significant disease	42	40.4	8	50.0	0.468
Bifurcation angle
<70	82	78.8	10	62.5	0.201
>70	22	21.2	6	37.5	0.201
Kissing	47	45.2	8	50.0	0.719
Access
Femoral	85	81.7	16	100.0	0.072
Radial	19	18.3	0	0.0	0.072
Other stents	64	61.5	10	62.5	0.941
Syntax I	28.82 ± 5.93		25.44 ± 9.29		0.149
Syntax II (PCI)
Number	29.43 ± 8.38		24.57 ± 7.83		0.029^*
%	8.13 ± 7.37		5.40 ± 3.43		0.066
Syntax II (CABG)
Number	30.20 ± 10.74		22.68 ± 10.23		0.023^*
%	9.44± 9.14		5.02 ± 3.24		0.095
Residual syntax	5.30 ± 6.66		5.81 ± 3.99		0.241

*: Statistically significant at p ≤ 0.05

No competing interests reported.

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Stenting the unprotected left main coronary artery without invasive imaging techniques

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Abstract

Background

Methods

Results

Conclusions

Introduction

Methods

Statistical analysis of the data

Results

Anatomical characteristics:

a) Demographic data

The study included 120 patients

b) Risk Factors

C) LV function

a) Syntax score

b) LCX

c) Kissing

d) Other stents

Discussion

Conclusions

Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

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