Coronary Aorto-Ostial Lesion Interventions

Chapter

Abstract

Aorto-ostial lesions (AOLs), defined as a significant stenosis within 3 mm of the aortic orifice, are an uncommon but challenging lesion subset to manage. AOLs account for roughly 2.6% of interventions and frequently involve the right coronary artery. Risk factors for target lesion failure include treatment of bypass grafts, prior in-stent restenosis, direct stenting, and narrow postprocedure luminal diameter; all factors that can be influenced by the operator. Intravascular ultrasound (IVUS) is a key tool that provides a means of identifying the optimal landing zone and ensures optimal luminal gain and stent coverage after stent deployment. IVUS is strongly recommended for treatment of all AOLs. Additionally, appropriate lesion preparation with atherectomy or specialty angioplasty balloons is crucial in achieving maximal luminal gain. Although specialized AOL devices and techniques have been developed, the simple algorithm of adequate lesion preparation and heavy use of IVUS provides a robust and broadly applicable approach to AOLs. Successful long-term results can be obtained with AOLs involving the right coronary artery, left main, or the anastomosis of surgical bypass grafts.

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References

  1. 1.
    Jaffe R, Halon DA, Shiran A, Rubinshtein R. Percutaneous treatment of aorto-ostial coronary lesions: current challenges and future directions. Int J Cardiol. 2015;186:61–6.CrossRefGoogle Scholar
  2. 2.
    Thompson R. Isolated coronary ostial stenosis in women. J Am Coll Cardiol. 1986;7:997–1003.CrossRefGoogle Scholar
  3. 3.
    Pritchard CL, Mudd JG, Barner HB. Coronary ostial stenosis. Circulation. 1975;52:46–8.CrossRefGoogle Scholar
  4. 4.
    Darabian S, et al. Ostial lesions of left main and right coronary arteries: demographic and angiographic features. Angiology. 2008;59:682–7.CrossRefGoogle Scholar
  5. 5.
    Rissanen V. Occurrence of coronary ostial stenosis in a necropsy series of myocardial infarction, sudden death, and violent death. Br Heart J. 1975;37:182–91.CrossRefGoogle Scholar
  6. 6.
    Chieffo A, et al. Early and mid-term results of drug-eluting stent implantation in unprotected left main. Circulation. 2005;111:791–5.CrossRefGoogle Scholar
  7. 7.
    Valgimigli M, et al. Distal left main coronary disease is a major predictor of outcome in patients undergoing percutaneous intervention in the drug-eluting stent era: an integrated clinical and angiographic analysis based on the rapamycin-eluting stent evaluated at Rotterdam Cardiology Hospital (RESEARCH) and Taxus-stent evaluated at Rotterdam Cardiology Hospital (T-SEARCH) registries. J Am Coll Cardiol. 2006;47:1530–7.CrossRefGoogle Scholar
  8. 8.
    Valgimigli M, et al. Short- and long-term clinical outcome after drug-eluting stent implantation for the percutaneous treatment of left main coronary artery disease: insights from the rapamycin-eluting and Taxus stent evaluated at Rotterdam Cardiology Hospital registries (RESEARCH and T-SEARCH). Circulation. 2005;111:1383–9.CrossRefGoogle Scholar
  9. 9.
    Rathore S, et al. Predictors of angiographic restenosis after drug eluting stents in the coronary arteries: contemporary practice in real world patients. EuroIntervention (J Eur Collab Work Group Interv Cardiol Eur Soc Cardiol). 2009;5:349–54.Google Scholar
  10. 10.
    Popma JJ, Dick RJ, Haudenschild CC, Topol EJ, Ellis SG. Atherectomy of right coronary ostial stenoses: initial and long-term results, technical features and histologic findings. Am J Cardiol. 1991;67:431–3.CrossRefGoogle Scholar
  11. 11.
    Yates JD, Kirsh MM, Sodeman TM, Walton JA, Brymer JF. Coronary ostial stenosis, a complication of aortic valve replacement. Circulation. 1974;49:530–4.CrossRefGoogle Scholar
  12. 12.
    Sintek MA, Singh J, Billadello JJ. Dynamic evaluation of coronary anomalies originating from the opposite sinus of Valsalva (ACAOS). Curr Treat Options Cardiovasc Med. 2015;17:47.CrossRefGoogle Scholar
  13. 13.
    Patel Y, et al. Impact of intravascular ultrasound on the long-term clinical outcomes in the treatment of coronary ostial lesions. Catheter Cardiovasc Interv (Off J Soc Card Angiogr Interv). 2016;87:232–40.CrossRefGoogle Scholar
  14. 14.
    Sonoda S, et al. Impact of final stent dimensions on long-term results following sirolimus-eluting stent implantation: serial intravascular ultrasound analysis from the Sirius trial. J Am Coll Cardiol. 2004;43:1959–63.CrossRefGoogle Scholar
  15. 15.
    Topol EJ, et al. Multicenter study of percutaneous transluminal angioplasty for right coronary artery ostial stenosis. J Am Coll Cardiol. 1987;9:1214–8.CrossRefGoogle Scholar
  16. 16.
    Popma JJ, et al. Rotational coronary atherectomy of ostial stenoses. Am J Cardiol. 1993;71:436–8.CrossRefGoogle Scholar
  17. 17.
    Bersin RM, Simonton CA. Rotational and directional coronary atherectomy. Catheter Cardiovasc Interv (Off J Soc Card Angiogr Interv). 2003;58:485–99.CrossRefGoogle Scholar
  18. 18.
    Eigler NL, et al. Excimer laser coronary angioplasty of aorto-ostial stenoses. Results of the excimer laser coronary angioplasty (ELCA) registry in the first 200 patients. Circulation. 1993;88:2049–57.CrossRefGoogle Scholar
  19. 19.
    Mehran R, et al. Treatment of in-stent restenosis with excimer laser coronary angioplasty: mechanisms and results compared with PTCA alone. Circulation. 1997;96:2183–9.CrossRefGoogle Scholar
  20. 20.
    Mehran R, et al. Treatment of in-stent restenosis with excimer laser coronary angioplasty versus rotational atherectomy: comparative mechanisms and results. Circulation. 2000;101:2484–9.CrossRefGoogle Scholar
  21. 21.
    Kurbaan AS, Kelly PA, Sigwart U. Cutting balloon angioplasty and stenting for aorto-ostial lesions. Heart Br Card Soc. 1997;77:350–2.Google Scholar
  22. 22.
    Muramatsu T, et al. Efficacy of cutting balloon angioplasty for lesions at the ostium of the coronary arteries. J Invasive Cardiol. 1999;11:201–6.Google Scholar
  23. 23.
    Fonseca A, et al. Intravascular ultrasound assessment of the novel AngioSculpt scoring balloon catheter for the treatment of complex coronary lesions. J Invasive Cardiol. 2008;20:21–7.Google Scholar
  24. 24.
    Schmidt T, et al. Safety and efficacy of lesion preparation with the AngioSculpt scoring balloon in left main interventions: the ALSTER left main registry. EuroIntervention (J Eur Collab Work Group Interv Cardiol Eur Soc Cardiol). 2016;11:1346–54.Google Scholar
  25. 25.
    Jain SP, et al. Comparison of balloon angioplasty versus debulking devices versus stenting in right coronary ostial lesions. Am J Cardiol. 1997;79:1334–8.CrossRefGoogle Scholar
  26. 26.
    Iakovou I, et al. Clinical and angiographic outcome after sirolimus-eluting stent implantation in aorto-ostial lesions. J Am Coll Cardiol. 2004;44:967–71.CrossRefGoogle Scholar
  27. 27.
    Park D-W, et al. Results and predictors of angiographic restenosis and long-term adverse cardiac events after drug-eluting stent implantation for aorto-ostial coronary artery disease. Am J Cardiol. 2007;99:760–5.CrossRefGoogle Scholar
  28. 28.
    Kern MJ, Ouellette D, Frianeza T. A new technique to anchor stents for exact placement in ostial stenoses: the stent tail wire or Szabo technique. Catheter Cardiovasc Interv (Off J Soc Card Angiogr Interv). 2006;68:901–6.CrossRefGoogle Scholar
  29. 29.
    Vaquerizo B, et al. Bench top evaluation and clinical experience with the Szabo technique: new questions for a complex lesion. Catheter Cardiovasc Interv (Off J Soc Card Angiogr Interv). 2012;79:378–89.CrossRefGoogle Scholar
  30. 30.
    Chan CK, Fung RC. ‘Sepal wire technique’ – a novel technique for aorto-ostial left main stenting. J Invasive Cardiol. 2011;23:211–2.Google Scholar
  31. 31.
    Fischell TA, Malhotra S, Khan S. A new ostial stent positioning system (Ostial Pro) for the accurate placement of stents to treat aorto-ostial lesions. Catheter Cardiovasc Interv (Off J Soc Card Angiogr Interv). 2008;71:353–7.CrossRefGoogle Scholar
  32. 32.
    Fischell TA, et al. Initial clinical experience using an ostial stent positioning system (Ostial Pro) for the accurate placement of stents in the treatment of coronary aorto-ostial lesions. J Invasive Cardiol. 2009;21:53–9.Google Scholar
  33. 33.
    Fihn SD, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, preventive cardiovascular nurses association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2012;60:e44–e164.CrossRefGoogle Scholar
  34. 34.
    Naganuma T, et al. Long-term clinical outcomes after percutaneous coronary intervention for ostial/mid-shaft lesions versus distal bifurcation lesions in unprotected left main coronary artery: the DELTA registry (drug-eluting stent for left main coronary artery disease): a multicenter registry evaluating percutaneous coronary intervention versus coronary artery bypass grafting for left main treatment. JACC Cardiovasc Interv. 2013;6:1242–9.CrossRefGoogle Scholar
  35. 35.
    Naganuma T, et al. First generation versus new generation drug-eluting stents for the treatment of ostial/midshaft lesions in unprotected left main coronary artery: the Milan and New-Tokyo (MITO) registry. Catheter Cardiovasc Interv (Off J Soc Card Angiogr Interv). 2015;85:E63–9.CrossRefGoogle Scholar
  36. 36.
    Chieffo A, et al. Favorable long-term outcome after drug-eluting stent implantation in nonbifurcation lesions that involve unprotected left main coronary artery: a multicenter registry. Circulation. 2007;116:158–62.CrossRefGoogle Scholar
  37. 37.
    Lee S-W, et al. Comparative long-term efficacy and safety of drug-eluting stent versus coronary artery bypass grafting in ostial left main coronary artery disease: analysis of the MAIN-COMPARE registry. Catheter Cardiovasc Interv (Off J Soc Card Angiogr Interv). 2012;80:206–12.CrossRefGoogle Scholar
  38. 38.
    Dangas GD, et al. Impact of hemodynamic support with Impella 2.5 versus intra-aortic balloon pump on prognostically important clinical outcomes in patients undergoing high-risk percutaneous coronary intervention (from the PROTECT II randomized trial). Am J Cardiol. 2014;113:222–8.CrossRefGoogle Scholar
  39. 39.
    O’Neill WW, et al. A prospective, randomized clinical trial of hemodynamic support with Impella 2.5 versus intra-aortic balloon pump in patients undergoing high-risk percutaneous coronary intervention: the PROTECT II study. Circulation. 2012;126:1717–27.CrossRefGoogle Scholar
  40. 40.
    Aggarwal V, et al. Safety and effectiveness of drug-eluting versus bare-metal stents in saphenous vein bypass graft percutaneous coronary interventions: insights from the Veterans Affairs CART program. J Am Coll Cardiol. 2014;64:1825–36.CrossRefGoogle Scholar
  41. 41.
    Rocha-Singh K, Morris N, Wong SC, Schatz RA, Teirstein PS. Coronary stenting for treatment of ostial stenoses of native coronary arteries or aortocoronary saphenous venous grafts. Am J Cardiol. 1995;75:26–9.CrossRefGoogle Scholar
  42. 42.
    Brilakis ES, et al. A randomized controlled trial of a paclitaxel-eluting stent versus a similar bare-metal stent in saphenous vein graft lesions the SOS (stenting of saphenous vein grafts) trial. J Am Coll Cardiol. 2009;53:919–28.CrossRefGoogle Scholar
  43. 43.
    Vermeersch P, et al. Randomized double-blind comparison of sirolimus-eluting stent versus bare-metal stent implantation in diseased saphenous vein grafts: six-month angiographic, intravascular ultrasound, and clinical follow-up of the RRISC trial. J Am Coll Cardiol. 2006;48:2423–31.CrossRefGoogle Scholar
  44. 44.
    Wiisanen ME, Abdel-Latif A, Mukherjee D, Ziada KM. Drug-eluting stents versus bare-metal stents in saphenous vein graft interventions: a systematic review and meta-analysis. JACC Cardiovasc Interv. 2010;3:1262–73.CrossRefGoogle Scholar
  45. 45.
    Hong YJ, et al. Impact of lesion location on intravascular ultrasound findings and short-term and five-year long-term clinical outcome after percutaneous coronary intervention for saphenous vein graft lesions. Int J Cardiol. 2013;167:29–33.CrossRefGoogle Scholar
  46. 46.
    De Bruyne B, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med. 2012;367:991–1001.CrossRefGoogle Scholar
  47. 47.
    Puri R, et al. Optimizing outcomes during left main percutaneous coronary intervention with intravascular ultrasound and fractional flow reserve: the current state of evidence. JACC Cardiovasc Interv. 2012;5:697–707.CrossRefGoogle Scholar
  48. 48.
    Courtis J, et al. Usefulness of coronary fractional flow reserve measurements in guiding clinical decisions in intermediate or equivocal left main coronary stenoses. Am J Cardiol. 2009;103:943–9.CrossRefGoogle Scholar
  49. 49.
    Hamilos M, et al. Long-term clinical outcome after fractional flow reserve-guided treatment in patients with angiographically equivocal left main coronary artery stenosis. Circulation. 2009;120:1505–12.CrossRefGoogle Scholar
  50. 50.
    de la Torre Hernandez JM, et al. Prospective application of pre-defined intravascular ultrasound criteria for assessment of intermediate left main coronary artery lesions results from the multicenter LITRO study. J Am Coll Cardiol. 2011;58:351–8.CrossRefGoogle Scholar
  51. 51.
    Fassa A-A, et al. Intravascular ultrasound-guided treatment for angiographically indeterminate left main coronary artery disease: a long-term follow-up study. J Am Coll Cardiol. 2005;45:204–11.CrossRefGoogle Scholar
  52. 52.
    Di Serafino L, et al. Long-term clinical outcome after fractional flow reserve- versus angio-guided percutaneous coronary intervention in patients with intermediate stenosis of coronary artery bypass grafts. Am Heart J. 2013;166:110–8.CrossRefGoogle Scholar
  53. 53.
    Nijjer SS, Sen S, Petraco R, Davies JE. Advances in coronary physiology. Circ J Off J Jpn Circ Soc. 2015;79:1172–84.Google Scholar
  54. 54.
    Petraco R, et al. Real-time use of instantaneous wave-free ratio: results of the ADVISE in-practice: an international, multicenter evaluation of instantaneous wave-free ratio in clinical practice. Am Heart J. 2014;168:739–48.CrossRefGoogle Scholar
  55. 55.
    Nijjer SS, et al. Pre-angioplasty instantaneous wave-free ratio pullback provides virtual intervention and predicts hemodynamic outcome for serial lesions and diffuse coronary artery disease. JACC Cardiovasc Interv. 2014;7:1386–96.CrossRefGoogle Scholar
  56. 56.
    Nijjer SS, et al. The instantaneous wave-free ratio (iFR) pullback: a novel innovation using baseline physiology to optimise coronary angioplasty in tandem lesions. Cardiovasc Revascularization Med Mol Interv. 2015;16:167–71.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Washington University in St. Louis, Division of CardiologySt. LouisUSA

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