Abstract Body (Do not enter title and authors here): Introduction: Significant coronary atherosclerotic lesions that involve the ostium of the left anterior descending (LAD) artery (Medina 0,1,0) pose unique challenges. The two main techniques used for percutaneous coronary intervention (PCI) of ostial LAD lesions are ostial stenting (OS) and crossover stenting (CS), in which a stent is deployed across the lesion extending from the left main (LM) artery into the LAD. Several observational studies have compared the efficacy of the two techniques, but the results have been mixed with respect to clinical outcomes.
Research Question: Is there a difference in efficacy between CS and OS in ostial LAD lesions based on pooled data from existing studies?
Methods: A systematic review was performed for studies comparing CS and OS techniques with respect to long-term outcomes (≥1 year). We used the Mantel-Haenszel random effects model to compute relative risk (RR) with 95% confidence intervals (CI) comparing rates of major adverse cardiovascular events (MACE), all-cause mortality, myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis (ST) between groups using the CS and OS techniques. In the secondary analysis, we included only studies with a high proportion (>50%) of intravascular ultrasound (IVUS) use in the CS group, given guideline recommendations of intravascular imaging in LM stenting.
Results: We included 1448 patients across eight studies. In the primary meta-analysis, there was no significant association between the stenting technique and MACE (RR 0.72, 95% CI 0.38-1.39), all-cause mortality (RR 0.88, 95% CI 0.34-2.33), MI (RR 0.73, 95% CI 0.36-1.48), and TLR (RR 0.62, 95% CI 0.38-1.01). CS was favored with respect to ST (RR 0.34, 95% CI 0.13-0.93, p=0.04). There was significant heterogeneity between studies. In the secondary analysis, CS was favored with respect to MACE (RR 0.56, 95% CI 0.34-0.94, p=0.03) when including only studies that employed a high percentage of IVUS use in LM stenting. No significant differences were found with respect to all-cause mortality, MI, TLR, or ST.
Conclusion: Based on our study, CS and OS appeared similar with respect to MACE, death, MI, and TLR, though there was significant heterogeneity across studies. CS did appear to be associated with lower ST. Moreover, CS was more favorable with a lower risk for MACE when IVUS was used more frequently, suggesting the importance of intravascular imaging in ostial LAD PCI.