Distal Ana Koroner Bifurkasyon Stentleme
Özet
Distal sol ana koroner arter (LMCA) bifurkasyon lezyonlarında uygulanan perkütan koroner girişim (PKG) ve koroner arter baypas greftleme (CABG) tedavileri, güncel klinik çalışmalar, kılavuzlar ve teknik yaklaşımlar ışığında değerlendirilmektedir. Geniş bir miyokard alanını besleyen LMCA'daki darlıklar, majör olumsuz kardiyak olay riskini artırmaktadır. EXCEL ve NOBLE gibi büyük randomize çalışmalar bu iki stratejiyi karşılaştırmış; EXCEL düşük-orta anatomik karmaşıklıkta PKG'nin cerrahiye non-inferior olduğunu gösterirken, NOBLE çalışması uzun dönem takipte PKG'nin tekrarlayan revaskülarizasyonlar nedeniyle inferior olduğunu bildirmiştir. Stentleme yaklaşımlarında, basamaklı provizyonel teknik yaygın olarak benimsense de, DK-CRUSH V çalışması kompleks lezyonlarda DK-crush tekniğinin üstünlüğünü ortaya koymuş; EBC MAIN ise daha kısa yan dal lezyonlarında provizyonel yaklaşımın planlı çift stent ile benzer sonuçlar verdiğini göstermiştir. İşlem başarısı için Proksimal Optimizasyon Tekniği (POT) hayati önem taşırken, lezyon ciddiyetinin ve stent optimizasyonunun belirlenmesinde FFR, iFR ile birlikte IVUS ve OCT gibi intravasküler görüntüleme yöntemlerinin kullanımı (MLA <4,5 mm² eşiği gibi) güçlü şekilde önerilmektedir. Kılavuzlar, düşük anatomik karmaşıklıkta (SYNTAX skoru ≤22) PKG'yi Sınıf I, orta düzeyde (23-32) Sınıf IIa olarak önermekte, yüksek karmaşıklıkta (≥33) ise tavsiye etmemektedir.
Distal left main coronary artery (LMCA) bifurcation lesions treated via percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) are evaluated in light of recent clinical trials, guidelines, and technical developments. Because the LMCA supplies a significant portion of the myocardium, critical stenoses increase the risk of major adverse cardiac events. Large-scale randomized controlled trials, including EXCEL and NOBLE, compared both strategies; EXCEL demonstrated that PCI is non-inferior in low-to-moderate anatomical complexity, while NOBLE reported PCI inferiority at 5 years due to higher rates of non-procedural myocardial infarction and repeat revascularization. Regarding stenting methods, although the stepwise provisional approach remains standard, the DK-CRUSH V trial demonstrated the superiority of the DK-crush technique in complex lesions, whereas the EBC MAIN trial showed similar macro outcomes between provisional and planned dual stenting in shorter side-branch lesions. Proximal Optimization Technique (POT) is crucial for structural integrity, and intravascular imaging techniques such as IVUS and OCT—alongside FFR/iFR physiological assessment—are strongly recommended for lesion evaluation (utilizing a minimal lumen area threshold of <4.5 mm²) and stent optimization. Current European and American guidelines recommend PCI as Class I for low complexity (SYNTAX score ≤22), Class IIa for intermediate complexity (23-32), and Class III (not recommended) for high complexity (≥33).
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