Stenting of unprotected left main stem stenoses for refractory unstable angina in elderly patients unsuitable for surgery

Severe left main stem stenosis has conventionally been regarded as an absolute contraindication to PTCA. Increasing numbers of elderly patients with unstable coronary symptoms are now referred for diagnostic angiography who are not candidates for CABG due to the presence of coexisting medical conditions. The discovery of a culprit left main stenosis under these circumstances produces a difficult clinical dilemma. We report on six patients (mean age 79 years) deemed unsuitable for CABG (renal impairment n=1, severe airflow limitation n=3, severely impaired LV function n=2, lack of target vessels n=1). Mean Parsonnet score = 20. All were confined to hospital with unstable angina refractory to maximum medical management including nitrates and heparin. All had a severe left main stem stenosis at diagnostic angiography. Predilation was undertaken with a 3.0-3.5 mm Viva balloon (Boston Scientific) followed by deployment of a 3.5-4.0 mm Multilink stent (ACS). A premounted stent was used to permit rapid stent deployment. A prophylactic pacing wire was inserted in 5 patients, an intra-aortic balloon pump in 2, contralateral arterial access for a balloon pump placement in a further two and abciximab in one patient. One patient died of respiratory failure within the first 24 hours, subsequent necroscopy demonstrated stent patency. The remaining five patients were alive at a mean of 13 months follow up. All continued to experience exertional angina, but none has required hospital readmission with unstable symptoms. Unprotected left main stem PTCA and stenting is a feasible option in elderly patients with refractory unstable surgery who are unsuitable for CABG.