Sir, your topic is very, very interesting is on the left main bifurcation, so how is this left main bifurcation different from like bifurcation or may be stenosis in any of the part of the coronary tree?
I think that is a very important and a very justifiable question because if one understands the hemodynamics and also the extent of area subserved by different aspects of the coronary tree, it is easy to answer that left main artery which divides into LAD and circumflex, together supplies almost about 80% of the heart muscles and the right coronary artery about 15% to 20%. Any intervention on the left main coronary artery stenosis has to be taken very carefully because any serious complication on the table in the cath lab can lead to catastrophic outcome so also on followup any resources, any thrombus formation can lead to serious consequences in terms of morbidity or mortality. So any patient coming to you with left main stenosis particularly bifurcation before he is given the option of intervention, several aspects have to be considered and then the strategy has to be defined in your mind and then the patient to be taken up for left main coronary intervention.
So, what is your take on one stent versus two-stent technique?
Well, left main bifurcation can be treated by one single stent or by two stents depending upon whether the left main distal disease involves the origin of the LAD and/or also the origin of the circumflex. Now if the patient has got LAD distal stenosis extending on to the origin of the LAD and there is no significant stenosis at the origin of circumflex then a single stent technique is good enough.There is only a stent crossover technique. You need not put a stent in the circumflex whereas if there is a significant stenosis involving the origin of circumflex as well then it is risky to do a single stent crossover technique because then you might occlude the circumflex and the patient may have serious consequences. So depending upon situation, you may use one-stent or two-stent technique, but in general the outcome is in long term that the adverse events are less common with single stent technique compared to the two-stent technique, but then technique has to be chosen based upon the anatomy and the morphological features of the lesion.
So, what is you recommendation which technique?
Well, as I told you, that it depends on whether the patient has got a significant stenosis involving the both the main branches coming from the left main and if there is a Medina classification 111 that means there is no stenosis involving all three distal left main, LAD circumflex, you have to use a two-stent technique. But if there is a stenosis involving only the left main and the LAD origin, circumflex region is free of disease or visa versa if the patient has got left main distal with circumflex origin and LAD is free of stenosis, one can do only a single-stent crossover technique.
Why not put this patient to surgery, surgery is not a better alternative in such cases?
There is no head to head comparison of left main distal bifurcation with bypass graft surgery, but certainly if the patient has got only left main distal bifurcation and no significant stenosis in the downstream coronary tree or focal stenotic lesions in the downstream coronary tree then the results on even up to five years followup are equal whether you treat them by angioplasty or by bypass surgery, but if the patient has got complex left main distal bifurcation which is highly calcified or a trifurcation with a lot of stenotic lesions in the downstream vessels, particularly if the patient is diabetic then these patients do 04:00 not do as well with intervention as with bypass graft surgery, so surgery may be better option. So in nutshell I would say that if the patient has got left main distal bifurcation and is diabetic, I would like to possibly send him for bypass surgery, but if he is nondiabetic then I would like to take into consideration of other factors and then decide whether intervention or bypass surgery.
So that means the comorbid conditions do play an important role.
Very important role, because diabetes, degree of left ventricular dysfunction, they are the two very important comorbidities which influence the outcome.
Does age also play a major decision sir?
Yes, if the patient is very old then obviously surgery is also not a very good option, but if the patient is of middle age group then certainly intervention is a good option provided arteries are not calcified. In calcified arteries again, it is not highly recommended to do a stenting because the stents do not get fully expanded and do not get the optimal results and the restenosis rate is higher.
Than you sir, thanks for your time and thanks for sharing your insides on the topic.
Thank you very much.