Optimal Percutaneous Treatment Approach to Unprotected Ostial Left Anterior Descending Artery Disease: A Meta-Analysis and Systematic Review

Background The optimal management strategy for significant fi cant unprotected ostial left anterior descending artery (LAD) disease remains undefined. fi ned. Merits of the two most common percutaneous approaches are considered in this quantitative synthesis. Method A meta-analysis was performed to compare ostial stenting (OS) and crossover stenting (CS) in the treatment of unprotected ostial LAD stenosis. The primary outcome is the disparity in target lesion revascularisation (TLR). The Mantel-Haenszel method was employed with random effect model, chosen a priori to account for heterogeneity among the included studies. Results Seven studies comprising 1,181 patients were included in the analyses. Of these, 482 (40.8%) patients underwent CS. Overall, there was a statistically significant fi cant trend in favour of CS (odds ratio 0.51, 95% confidence fi dence interval 0.30-0.86, p=0.01) with respect to the rate of TLR at follow-up. This remained true when TLR involving the left circumflex fl ex artery (LCx) was considered, even when there was a greater need for unintended intervention to the LCx during the index procedure (odds ratio 6.68, 95% confi- fi- dence interval: 1.69-26.49, p=0.007). Final kissing balloon inflation fl ation may reduce the need for acute LCx intervention. Imaging guidance appeared to improve clinical outcomes irrespective of approach chosen. Conclusions In the percutaneous management of unprotected ostial LAD disease, CS into the left main coronary artery (LMCA) appeared to reduce future TLR. Integration of intracoronary imaging was pivotal to procedural success. The higher incidence of unintended LCx intervention in the CS arm may be mitigated by routine fi nal kissing balloon inflation, fl ation, although the long-term implication of this remains unclear. In the absence of randomised trials, clinicians' discretion remains critical.