Left main coronary artery disease: a pratical guide for the interventional cardiologist A Practical Guide for the Interventional Cardiologist

Recent developments in the field of percutaneous coronary intervention and encouraging data relating to feasibility and safety have led to a renewed interest in left main angioplasty. Interventional cardiologists are faced with the challenge represented by this complex subset of lesions.

The first part of this practical handbook specifically deals with the development of the anatomical classification and gives an overview of the frequency of different anatomic phenotypes. The second part provides a comprehensive knowledge on the techniques and approach to left main coronary artery disease and discuss the potential complications. The authors draw on their practical experience to look at expected or potential morbidity from percutaneous coronary intervention.

The aim of this book is to provide interventional cardiologists with useful tips and tricks for percutaneous coronary intervention of the left main coronary artery.

1 Anatomy.- 1.1 Normal Anatomy: Angle of Take-off.- Course.- Designation of Bifurcation.- Length and Diameter.- 1.2 Coronary Artery Abnormalities.- Pathological Anatomy of the Left Main Coronary Artery: Atheromatous Lesions of the Trunk: Distribution and Localization.- Other Pathological Presentations.- 2 Review of Literature.- 2.1 Data on Surgical Treatment.- 2.2 Data on Angioplasty with Bare Metal Stents in the Unprotected Left Main Coronary Artery.- 2.3 Data on Drug-eluting Stents in the Unprotected Left Main Coronary Artery.- 2.4 Observational Studies on Populations Treated with Drug-eluting stents Only.- 2.5 Observational Studies of Drug-eluting Stents Versus Bare Metal Stents.- 2.6 Non-randomized Studies of Drug-eluting Stents Versus Coronary Artery Bypass Grafting.- 2.7 Randomized Studies of Drug-eluting Stents Versus Coronary Artery Bypass Grafting.- 2.8 Studies on the Prognostic Implications of Stenosis Location.- 2.9 Data on Drug-eluting Stents in Left Main Coronary Artery Trifurcation Lesions.- 2.10 Final Considerations Based on Available Data.- 3 Morpho-functional Assessment of Left Main Coronary Artery Disease.- 3.1 Introduction.- 3.2 The Role of Intravascular Ultrasound.- 3.3 Procedure for Performing Intravascular Ultrasound in the Left Main Coronary Artery.- 3.4 The Role of Fractional Flow Reserve.- 3.5 The Role of Optical Coherence Tomography.- 3.6 Three-dimensional Quantitative Coronary Analysis Reconstruction of the Left Main Coronary Artery.- 3.7 The Role of Multi-slice Computed Tomography.- 3.8 The Role of Cardiovascular Magnetic Resonance.- 4 Left Main Coronary Artery Percutaneous Interventions: Materials and Techniques.- 4.1 Introduction.- 4.2 Materials: Guiding Catheters.- Coronary Wires.- Coronary Balloons.- Coronary Stents.- 4.3 Ostial Lesions: Pitfalls.- Elastic Recoil.- Stent Hang-out.- Ostial Missing.- Sliding.- Proximal–Distal Dissection.- 4.4 Body Lesions: Elastic Recoil.- Difficult Stent Centering.- Sliding.- Proximal–DistalDissection.- 4.5 Distal Lesions: Guiding Catheter.- PCI Wires.- 4.6 Percutaneous Coronary Intervention Technique: Lesion Preparation.- Single Stent Technique.- T-provisional.- Skirt.- Isolated Treatment of LAD and LCX Ostia.- Two-stent Technique.- T-stenting and T-modified Stenting.- Crush and Mini-crush.- Culotte.- 'Reverse' techniques.- V-stenting or V-touching.- Simultaneous Kissing Stents (SKS).- 4.7 Treatment Classification.- A new classification for Left Main Coronary Artery treatment: the 'one-two-three'.- 4.8 Technical Considerations, Pitfalls, Tips, and Tricks.- Crossing Wires.- Size Discrepancy.- Angulated Take-off.- Jailed Wire.- Buddy.- Wire.- Rotablator.- Cutting Balloons.- Recoil.- Thrombus.- Dissection: Anterograde, Retrograde.- 4.9 Intra-aortic Balloon Pump.- 4.10 Specific Anatomical Scenarios.- Left Main Coronary Artery Trifurcation.- Stenosis of Both the Right Coronary Artery and the Left Main Coronary Artery.- Occluded Right Coronary Artery.- Diseased Right Coronary Artery.- 5 Thrombosis and Antiplatelet Therapy