Stent area by intravascular ultrasound and outcomes in left main intervention with drug-eluting stents: small stents, more events.

While the standard revascularization for left main lesions traditionally has been surgical coronary artery bypass grafting, increasingly studies suggest that percutaneous coronary intervention (PCI) with drug-eluting stents (DES) may be an acceptable alternative to surgery for selected patients. In total, the current evidence suggests that rates of death, myocardial infarction, and stroke may be similar between patients managed with PCI and coronary artery bypass grafting, but revascularization occurs less frequently in patients undergoing surgery. This was illustrated in the recently published randomized PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease) trial, where the 2-year risk of death, myocardial infarction, or stroke was similar (hazard ratio: 0.92; 95% confidence interval (CI), 0.43 to 1.96; P 0.83) in patients with unprotected left main disease managed with PCI using DES (N 300) and coronary artery bypass grafting (N 300), but revascularizations were more common in patients undergoing PCI (hazard ratio: 2.18; 95% CI, 1.10– 4.32; P 0.02).1 A recent meta-analyses of 1611patients from 4 randomized trials comparing PCI with coronary artery bypass grafting for unprotected left main lesions found similar results.2