Comparative Safety and Efficacy of Left Main vs. Non-left Main PCI Optimized using Rotational Atherectomy and Drug-Eluting Stent Implantation in Patients with Chronic Kidney Disease

Abstract

Background: Left main coronary artery disease (LMCAD) is associated with poor cardiovascular outcomes, especially in patients with coexisting chronic kidney disease (CKD). Percutaneous coronary intervention (PCI) using rotational atherectomy (RA) and newer generation drug-eluting stents (DES) has been shown to improve outcomes in CKD patients with complex anatomical lesions. In this study, we assessed and compared the outcomes with this treatment strategy in CKD patients with LMCAD versus non-LMCAD. Methodology: This was a single-center, retrospective study. From January 2015 to September 2017, all CKD patients with calcified CAD who underwent RA followed by second-generation DES implantation at our center were included and divided into subgroups based on left main disease involvement. The primary endpoint was major adverse cardiac and cerebrovascular events ([MACE] composite of all-cause mortality, myocardial infarction (MI), and stroke). Key secondary endpoints include incidence of cardiac arrest, cardiogenic shock, need for emergency coronary bypass surgery and stent deployment failure. Results: A total of 203 patients were included in the analysis. The majority of the patients in both groups had mild-to–moderate CKD (45.2% vs. 33.8% mild; moderate: 487.9% vs. 60%; severe: 6.1% vs 6.8%; for LMCAD and non-LMCAD patients, respectively). Prognostically worse and procedurally more difficult lesions such as ostial lesions and calcified bifurcations were significantly higher in the LMCAD group vs. the non-LMCAD group (37% vs. 14.6%; p=0.0005 and 68.5% vs 45.4%; p=0.0025, respectively). There were no significant differences in the primary endpoint event rate, between the LMCAD and non-LMACAD groups (12 [9%] vs. 10 [13.7%]; p=0.4548). Myocardial infarction significantly varied between the LMCAD and non-LMACD groups (0% vs. 3 [4.11%]; p=0.0453). Cardiac arrest, arrhythmia, cardiogenic shock, need for emergency coronary bypass surgery, and failure to deploy stent also did not vary between the LMCAD and non-LMCAD groups. Conclusion: Percutaneous coronary intervention using RA followed by second-generation DES results in improved clinical outcomes in patients with LMCAD disease. Further, the severity of CKD does not affect cardiovascular outcomes in patients with LMCAD and non-LMCAD patients.