Evolution of Treatment Tactics for Patients with Trunk Lesions of Coronary Arteries

Abstract

Damage to the trunk of the left coronary artery is the most dangerous manifestation of coronary atherosclerosis. Mortality with this type of lesions occurs by 3–4 times more often compared to lesions of other segments of coronary arteries. On the basis of previous clinical studies demonstrating advantages of coronary artery bypass grafting over drug therapy in terms of patient survival, coronary artery bypass grafting has long been considered the gold standard for the treatment of these lesions. The purpose of the work was to study the literature data on the evolution and peculiarities of the choice of methods of surgical treatment of coronary heart disease in patients with severe lesions of the trunk of the left coronary artery. Results and discussion. Along with the improvement of endovascular instrumentation, stenting procedures, antithrombotic agents, as well as concomitant drug therapy, percutaneous coronary interventions for lesions of the left trunk are becoming more and more widespread and show favorable clinical results in these patients. This is evidenced by the data of many randomized multicenter studies (SYNTAX, EXCEL). Based on the results of these studies, ESC/EACTS approved the following guidelines for myocardial revascularization in 2018. Percutaneous coronary interventions are indicated in the case of damage to the left trunk with scores on the SYNTAX scale less than 22 – class I, scores on the SYNTAX scale 23–32 – class IIa, and scores on the SYNTAX scale greater than 32 – class III. However, it is worth noting that both the American and the European guidelines recommend a discussion by a team of endovascular surgeons, cardiologists and cardiac surgeons (Heart Team) when choosing a treatment strategy for coronary artery disease patients with lesions of the trunk of the left coronary artery. Since the data of many studies on the treatment of patients with lesions of the trunk of the left coronary artery remain quite contradictory and ambiguous. Conclusion. Current literature data have shown that left coronary artery stenting is a fairly safe procedure, with a high rate of immediate success, low mortality, and few complications, especially in low-risk surgical patients. The use of stents with medical coating made it possible to reduce the frequency of repeated interventions to 10–12%. A number of issues remain, the solution of which would allow optimizing the application of this technique. These include: development of indications for surgical or endovascular treatment of lesions of the left coronary artery trunk, optimization of stenting techniques, assessment of the significance of concomitant pathology in the effectiveness of treatment of patients with lesions of the left coronary artery trunk