Coronary ostial stenosis

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

Overview

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.

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-osital 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.

1. 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 in the Calcified Ostial Right Coronary Artery may be necessary using rotational atherectomy before stenting.

• 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.