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Early and Long-Term Results of Unprotected Left Main Coronary Artery Stenting: The LE MANS (Left Main Coronary Artery Stenting) Registry
JACC - Journal of the American College of Cardiology, 10/09/09

Buszman PE et al. – Stenting of ULMCA is feasible and offers good long–term outcome. Implantation of DES for ULMCA decreased the risk of long–term MACCE, and particularly improved survival in patients with distal ULMCA disease.

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Dr. Pawel E. Buszman, 10/11/09

The prorgam of LE MANS started in 1997 and was developed by dr Stefan R. Kiesz and myself. The information that left main stenting is safe came quite easy and fast. We were lucky, that from the very begging of the left main project we developed a protocol and technique which proved safety of the procedure (LE MANS protocol). That is why we could start our registry and randomized study very soon. Therefore we immediately could pass to the second problem: what is the best patients selection and long term outcome. Based on the results of LE MANS Randomized Study, published in JACC last year, as well as the SYNTAX study, we may suggest that there is now enough clinical data to support LM stenting as an indication IA for patients with LM and one/two vessel disease and IIA for patients with high surgical risk. So far the cardiovascular surgeons have been raising the problem of the long term outcome during any discussion we had with them. Especially they put a stress on definition of “long term results”, saying that it is at least 5-10 years. LE MANS registry delivered the data, showing excellent long term outcome after left main stenting. At the begging we were very afraid about long term thrombosis after DES implantation to left main and it was definitively our concern. That is why we were trying to limit the DES only to vessel <3.8mm of diameter, especially because we did not have at beginning the stents larger than 3.5mm. We were afraid that extension of the old DES to larger diameter may cause destruction of the polymer and structure of the stent and results in higher in stent thrombosis. The same problem could be related with non-expanded undersized DES. Later results, with use of large size DES showed the safety of the procedure. In fact, DES were more effective for distal lesions, because distal reference of left main is usually much smaller than proximal and may contain a lot of plaque burden – especially in true bifurcation lesion. Proper cover of the plaques in LM, ostium LAD and ostium Cx with one or two stents guarantees better late outcome. However a proper care must taken to get optimal post dilatation with kissing technique. What may improve the outcome after left main stenting in the future? At this moment, we need a dedicated stent for left main. I think it must be different stent for ostial lesions and different for distal. bifurcation left main lesions. Probably we also need a tempered stents to fit the proximal diameter to the left main reference diameter and distal stent diameter to proximal LAD reference diameter. There is a lot of challenge for the industry and clinical scientists. Pawel Buszman, MD, FESC, FACC Medical School of Silesia Katowice, Poland

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