Reply to Letter to the Editor

We thank Dr. Shammas for the interest he has shown our manuscript. We are pleased to see that operators from highly qualified centers share our interest about this complex and rare procedure.^1,2 Unfortunately, along with the enthusiasm for such challenging procedures, we also share some concerns about potential risks in terms of stent thrombosis, the need for extended antiplatelet therapy and the lack of data regarding long-term outcomes. These concerns are even more relevant due to the fact that trifurcation lesions are frequently located in critical sites like the left main trunk or the anterior descending artery. Regrettably, it is difficult to provide an unbiased judgment about the safety and efficacy of this type of procedure since it is performed in an extremely rare number of patients, as clearly witnessed by our series of 15 cases collected over a 4-year period out of more 8,000 patients. Initial enthusiasm began immediately after the arrival of drug-eluting stents, which many thought would allow operators to tackle any lesion and anatomy with multiple stent implantations. This enthusiasm has now evolved into a more mature vision of percutaneous therapies. The advantages of stent implantation in comparison to bypass surgery continue to face some shortcomings present in each of the two approaches, and a clear winner has not yet been declared, at least for some complex and unique anatomical locations such as trifurcation lesions of the distal left main coronary artery. Despite some potential problems occasionally seen with drug-eluting stent implantation such as late stent thrombosis and uncertainty regarding the need for double antiplatelet therapy,^3,4 we cannot deny that the results we are presenting are very encouraging and so far do not seem to deter from the careful utilization of drug-eluting stents in appropriate patients with a suitable trifurcational anatomy.
A registry collecting all these cases from different qualified centers would be more than welcome. We believe it could be a useful means to better recognize caveats and limitations of stenting these lesions and finally to improve our approach to this specific field.

References

1. Shammas NW. Trifurcating coronary artery disease: A proposed classification and treatment methodology. J Invasive Cardiol 2007;19:32–35.
2. Shammas NW, Dippel EJ, Avial A. et al. Long-term outcomes in treating left main trifurcation coronary artery disease with the paclitaxel-eluting stent. J Invasive Cardiol 2007;19:77–82.
3. Stone GW, Moses JW, Ellis SG, et al. Safety and efficacy of sirolimus- and paclitaxel-eluting coronary stents. N Engl J Med 2007;356:998–1008.
4. Lagerqvist B, James SK, Stenestrand U, et al. Long-term outcomes with drug-eluting stents versus bare-metal stents in Sweden. N Engl J Med 2007;356:1009–1019.