Coronary ostial stenosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and Keywords: Ostial lesion, ostial stenosis, aorto-ostial stenosis

Overview

Coronary ostial stenosis refers to the narrowing of the ostium part of the coronary arteries. An ostial lesion is defined as a lesion which begins within 3-5 mm of the origin of a major epicardial artery. Ostial lesions represent a challenge to the interventional cardiologist because they often involve the wall of the aorta, they are often calcified, they may not fully dilate and they are prone to restenosis. A key issue in the treatment of an ostial lesion is to assure that the stent is inserted proximal enough to fully cover the aorto-ostial junction (particularly in the right coronary artery). Essentially the operator must realize that the aortic wall is being stented as well.

Causes

Diagnosis

Angiography

PCI in The Ostial Lesion

Technical Considerations

Pre-Dilation

Direct stenting confers many benefits in lesions other than the ostial lesion. Pre-dilation is critical in the ostial lesion for may reasons:

1. Assurance that the aorto-ostial junction will dilate. The aorto-ostial junction may be more refractory to dilation and may have greater recoil. If the aorto-ostial junction will not dilate, it may not be a good idea to insert a stent because you may not be able to fully expand the stent.

"Following stent placement with a residual lesion I once ruptured three balloons trying to dilate the stent at high pressures." C. Michael Gibson, M.S., M.D.

2. Use a Low Pressure Inflation to define the extent of the lesion proximally.

"I like to inflate the balloon to 1-2 atmosphere and see how for the lesion extends proximally. While doing this I spin the gantry to gauge the proximal extent of the lesion in multiple angles. Any one view may underestimate the proximal extent of the lesion." C. Michael Gibson, M.S., M.D.

Debulking

Debulking in the calcified ostial right coronary artery may be necessary using rotational atherectomy before stenting.

Use of a Longer Stent

Use a longer stent than you anticipate:

1. It is often tempting to use a short 8 mm stent to cover such a short lesion. However, use of a longer stent will reduce the "rocking" of the stent that occurs during systole and diastole during stent deployment.

2. It will also reduce the risk of "watermelon seeding".

3. It increases the chances that sufficient stent is available to cover the aortic wall.

2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[3]

Aorto-Ostial Stenoses (DO NOT EDIT)[3]

Class IIa
"1. IVUS is reasonable for the assessment of angiographically indeterminant left main CAD.[4][5] (Level of Evidence: B) "
"2. Use of DES is reasonable when PCI is indicated in patients with an aorto-ostial stenosis.[6][7] (Level of Evidence: B) "

References

  1. Pritchard CL, Mudd JG, Barner HB (1975). "Coronary ostial stenosis.". Circulation. 52 (1): 46–8. PMID 1132121. 
  2. Kharge J, Bharatha A, Ramegowda Raghu T, Nanjappa Manjunath C (2013). "Bilateral coronary ostial stenosis with bilateral renal ostial stenosis in cardiovascular syphilis: de novo percutaneous coronary intervention and in-stent restenosis.". Eur Heart J. PMID 23386712. doi:10.1093/eurheartj/eht036. 
  3. 3.0 3.1 Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions" (PDF). Journal of the American College of Cardiology. 58 (24): 2550–83. PMID 22070837. doi:10.1016/j.jacc.2011.08.006. Retrieved 2011-12-08.  Text "PDF" ignored (help); Unknown parameter |month= ignored (help)
  4. Gil RJ, Gziut AI, Prati F, Witkowski A, Kubica J (2005). "Threshold parameters of left main coronary artery stem stenosis based on intracoronary ultrasound examination". Kardiologia Polska. 63 (3): 223–31; discussion 232–3. PMID 16180175.  Unknown parameter |month= ignored (help);
  5. Sano K, Mintz GS, Carlier SG, de Ribamar Costa J, Qian J, Missel E, Shan S, Franklin-Bond T, Boland P, Weisz G, Moussa I, Dangas GD, Mehran R, Lansky AJ, Kreps EM, Collins MB, Stone GW, Leon MB, Moses JW (2007). "Assessing intermediate left main coronary lesions using intravascular ultrasound". American Heart Journal. 154 (5): 983–8. PMID 17967608. doi:10.1016/j.ahj.2007.07.001. Retrieved 2011-12-15.  Unknown parameter |month= ignored (help)
  6. Park DW, Hong MK, Suh IW, Hwang ES, Lee SW, Jeong YH, Kim YH, Lee CW, Kim JJ, Park SW, Park SJ (2007). "Results and predictors of angiographic restenosis and long-term adverse cardiac events after drug-eluting stent implantation for aorto-ostial coronary artery disease". The American Journal of Cardiology. 99 (6): 760–5. PMID 17350360. doi:10.1016/j.amjcard.2006.10.028. Retrieved 2011-12-15.  Unknown parameter |month= ignored (help)
  7. Iakovou I, Ge L, Michev I, Sangiorgi GM, Montorfano M, Airoldi F, Chieffo A, Stankovic G, Vitrella G, Carlino M, Corvaja N, Briguori C, Colombo A (2004). "Clinical and angiographic outcome after sirolimus-eluting stent implantation in aorto-ostial lesions". Journal of the American College of Cardiology. 44 (5): 967–71. PMID 15337205. doi:10.1016/j.jacc.2004.05.058. Retrieved 2011-12-15.  Unknown parameter |month= ignored (help)

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