Unprotected Left Main Coronary Intervention with Drug‐Eluting Stents

The accepted treatment of unprotected left main coronary artery disease is coronary artery bypass surgery (CABG). The approval of drug‐eluting stents (DES) has increasingly led to their off‐label use in this patient population. Currently, the data supporting the safety and efficacy of DES for unprotected left main disease are derived from nonrandomized, single‐center studies. Several conclusions can be drawn from these studies despite their inherent limitations. Procedural mortality in elective patients with low surgical risk is minimal. One year mortality and 1 year major adverse cardiac events appear to be similar to that of CABG. Technical difficulty and clinical outcome depend crucially on the anatomic location of the left main obstruction. While DES implantation for ostial and shaft lesions is technically straightforward and provides excellent results over follow‐up, distal left main lesions are technically challenging and efficacy is limited largely by target vessel revascularization, most frequently for restenosis within the branch ostia. A systematic approach to the left main lesion can help provide safe and more effective results. Prospective, randomized trials comparing DES to CABG must be completed before percutaneous coronary intervention for unprotected left main coronary artery disease can be considered standard‐of‐care.