International Circulation:  For how long of a period do you recommend to continue dual anti-platelet therapy?
　　Prof. Renu Vermani:  I think it is appropriate to continue for up to 2 years.  In fact， I showed cases that were beyond 2 years post-implantation and still had thrombosis.  If I had a left main stent implanted in myself， I would make sure I was permanently on dual anti-platelet therapy.  In cases of bifurcation there is much more turbulent flow of blood and therefore more likelihood of developing thrombosis because these stents do not get covered well through the slowed healing process.
　　International Circulation:  When you talked about longer left main arteries and their greater susceptibility to greater amounts of atherosclerosis， do you think that is connected to the turbulent flow in these arteries or is it more due to the fact that these plaques have such a longer area with lower shear?
　　Prof. Renu Vermani:  The reason it has a longer region of low shear and leads to greater development of disease is because of the length of the artery.  For the left main， it almost immediately divides and therefore leads to less development of disease.  This is a sort of protection that may even be evolutionarily driven， that if it remains small there would be less development of disease.  We need a high degree of flow in the left main and circumflex arteries because they supply 75% of blood to the left ventricle.  Because there is a greater need for flow the left main artery must become shorter.  It is just logical thinking.  In about a third of cases the artery trifurcates rather than bifurcates， and this could be important from a protective perspective.  Sometimes 3 stents are placed in areas that have trifurcation， which is a strategy I do not think will work.  My recommendation is the less number of stents the better because I don’t believe in T-stenting and other such strategies.  We actually had 30 cases of bifurcations without left main and whenever 2 stents were placed 80% of lesions had thrombosis.   It must be remember though that we are at least a little biased because we are autopsy driven， not clinically driven.  These cases are deaths that come to autopsy and are studied from a post-mortem perspective; therefore it results in some bias.  It still teaches us something.
　　International Circulation:  Certainly， from the pathologists perspective there is a more pessimistic view of things when seeing cessation of dual anti-platelet therapy.
　　Prof. Renu Vermani:  My view is more pessimistic because in cases of left main disease from what I have seen I would not stop taking dual anti-platelet therapy.  If I were an older individual and had a drug-eluting stent placed in me， I would be a little skeptical.  I would thing that second generation stents would be better than first generation and in such patients you really want dual anti-platelet therapy for the shortest period because dual anti-platelet therapy carries risks of bleeding.  It is not advised to keep older patients on dual anti-platelet therapy.  In such situations I would use the Endeavor stent and not do 2.5mm stenting.

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