Coronary Ostial stenting techniques:Current status

Ostial stenting
techniques
Dr Pawan Kumar Ola
PGIMER,Dr RML Hospital
New Delhi

• Ostial lesion- within 3 mm of the vessel origin.
• Classification based on location:-
 Aorto-ostial
 Non aorto-ostial
 Branch ostial

• Isolated aorto-ostial disease is more frequent in
women and is more common at the RCA than at the
LMS.
Stewart JT, Eur Heart J. 1987;8:917-20
Rissanen V, Br Heart J. 1975;37:182-91
• Causes-
 Atherosclerotic (accompanying downstream plaque)
 Aortitis (syphilis or Takayasu arteritis)
 Mediastinal radiotherapy

• Ostial lesions are usually fibrotic, calcified, and
relatively rigid.
• Aorto-ostial disease is felt to be additionally resistant
to dilatation and prone to recoil due to the greater
thickness of muscular and elastic tissue in the aortic
wall.
Popma JJ, Am J Cardiol 1991;67:431-3

• Ostial lesions including Aorto-ostial and Medina
001, are difficult to treat.
• PCI of an ostial lesion requires precise implantation
of a stent in order to prevent adverse clinical
outcomes.
• “Geographic miss” occurs when the ostial side-
branch lesion is not fully covered by the stent.

• Conversely, a stent placed too proximal into the main
vessel may complicate future coronary intervention
or lead to acute problems in the main branch.
Comparison of outcomes of percutaneous coronary
intervention of ostial versus nonostial narrowing of
the major epicardial coronary arteries
Am J Cardiol. 2004;94:583-587

We evaluated data from all PCIs performed from 1998 to 2001 in the proximal
segments of the major epicardial coronary arteries entered into a large cardiac
database and compared ostial with nonostial PCI outcomes. Of 2,484 patients who
underwent PCI of a proximal coronary artery (left anterior descending, left
circumflex, or right coronary), 223 patients had ostial narrowing and 2,261
patients had proximal, nonostial narrowing. Baseline characteristics were similar
between the 2 groups. Stenting occurred in 89% of all patients and was similar in
patients with ostial or nonostial narrowings. Procedural success was the same for
ostial and nonostial PCI (96% vs 95%, p = 0.95). One-year event-free survival rate
was lower in patients who underwent ostial PCI (69% vs 80%, p = 0.0019), largely
due to a greater need for repeat PCI (19% vs 10%, p <0.0001). Multivariate
analysis showed that ostial location, age, angina class, and number of diseased
vessels were independent predictors of the occurrence of cardiac events.
Am J Cardiol. 2004;94:583-587

Additional judgements……
• Exclusion of coronary spasm-
• Ostial LAD stenosis-
Whether precise positioning of the stent at the
ostium should be attempted or stenting across the
Cx back into the LMS ?

Technical considerations for ostial LAD stenosis
Presence or absence of an ostial ‘nub’ or stump…
Angle of bifurcation-
angles <75 ̊ associated with greater difficulty in stent
positioning and increased risk of plaque shift.

Presence of significant plaque in the distal LM or CX
ostium…
Presence of heavy calcification…

• Side-branch ostial stenosis-
The balance of risk vs. benefit may favour
medical therapy.
Am J Cardiol 2004;93:1162–1164

• Total 302 patients of isolated stenosis of diagonal branches ≥2
mm included (Medical 233 vs. 69 angioplasty).
Am J Cardiol 2004;93:1162–1164

Conclusion: PCI of ostial stenosis of diagonal branches
in patients without further significant coronary artery
stenoses did not reduce adverse cardiac events, nor did
it result in a greater portion of freedom from angina
pectoris

• Ostial stenosis following previous bifurcation
PCI…
- to establish whether the ostium was originally covered and
whether stent sizing and expansion was optimal.

Intravascular Ultrasound
 Ability to confirm or refute the presence of
significant aorto-ostial disease.
 Assessment of vessel size to guide stent selection
 Assessment of adequacy of stent expansion
 Assessment of degree of calcification and need for
adjunctive devices
 Assessment of ostial site restenosis
 To assess for the presence of proximal or branch
vessel disease prior to deciding on a treatment
strategy

• IVUS is non-physiological
• Guidecatheter disengagement during pullback risks
non-coaxial imaging of the ostium and overestimation
of the luminal area.

JACC Interv. 2013; Vol.6 (2) Suppl

“Eyebrow Sign”
Medina A et al.Rev Esp Cardiol. 2009;62(11):1240-9
peculiar spiky morphology termed the “eyebrow sign”.

baseline and post-treatment
ultrasound studies showing the
“eyebrow sign” (arrow) and carina
displacement (arrow heads).
IVUS examination showing the
carina without the “eyebrow sign”
Medina A et al.Rev Esp Cardiol. 2009;62(11):1240-9

Fractional flow reserve (FFR)
FFR in aorto-ostial disease may be valuable, but it
requires:
(a) initial pressure equalisation in the ascending aorta prior to vessel
engagement
(b) guide catheter disengagement during FFR measurement so as
not to occlude flow;
(c) ideally, an intravenous infusion of adenosine rather than an
intracoronary bolus, as the latter requires catheter engagement to allow
selective injection and flush followed by rapid disengagement to allow FFR
measurement.

• Hyperemia induced with an intracoronary bolus administration
(80 ug in left coronary artery, 40ug in right coronary artery) or
intravenous infusion (140ug/kg/min) of adenosine.
• Branch-ostial disease – Studies measuring fractional flow
reserve (FFR) have frequently shown a lack of relation between
apparent angiographic severity of side-branch ostial disease
and ability to cause ischaemia.
Ziaee A et al. Am J Cardiol 2004;93:1404-7, A9.
Lim MJ et al. Catheter Cardiovasc Interv 2005;65:461-8

Before Ostial side branch PCI we should know…..
 What is the size of the side branch and the area of
myocardium supplied?
 What is the significance of the degree of stenosis of the ostial
lesion and is there evidence of ischemia either based on
stress testing or clinical symptoms that warrant treatment?
 Would fractional flow reserve be required since the side-
branch procedure may jeopardize the main branch?

Guide catheter
• For aorto-ostial lesions less aggressive catheters like
Judkins, are recommended to avoid deep engagement
and to facilitate disengagement during stent placement.

• For aorto-coronary bypass grafts, a guide catheter
which provides adequate reach and support without
deep intubation is required.
• Judkins right, Multipurpose, RCB, LCB and Amplatz
left catheters are commonly used.

Additional distal disease should be treated first.
 Side-hole catheters, although commonly used, are not
recommended as the warning sign of pressure
damping from catheter wedging and occlusion of flow
is obscured.
For intervention on aorto‐ostial disease, it is advisable
to preload the wire in the guide before vessel Intubation -
to facilitate rapid wiring and catheter disengagement if necessary.

Lesion Preparation & Debulking
• Greater calcification and lesion rigidity at ostial sites plus the
risk of significant plaque shift may dictate a plaque
modification or debulking strategy.
• Cutting balloon (Flextome),Scoring balloon (AngioSculpt) and
Rotational Atherectomy may be considered.

Angiographic Views
Vessel with
ostial lesion
Suggested view
LMS AP cranial or LAO cranial
RCA LAO or ideally LAO caudal to demonstrate the plane of
the ostium
LAD A combination of caudal views (LAO caudal typically
shows least overlap with ramus or Cx but is more
foreshortened than the RAO caudal view).
Cx LAO caudal usually best, but if overlap present, LAO
cranial may help
Bypass graft Usually LAO ± caudal for RCA grafts (as for native RCA)
For LCA grafts, the ostium is usually least
foreshortened in an RAO view

Angiographically assisted Stent placement
• Most common technique used
• Precise stent placement is very difficult
• Large volume of contrast & multiple views required

• In a retrospective analysis of 100 ostial lesions, Dishmon et
al found that the true ostium was missed in 54% of cases.
• Proximal miss was found in 52%, resulting in the inability to
engage the guiding catheter in 93% of cases.
• Distal miss was found in 48% of cases, resulting in additional
stents for 38% of cases.
• Furthermore, the target lesion revascularization (TLR) rates
were increased 3-fold when compared to patients without
geographic miss.
Dishmon DA et al.J Invasive Cardiol. 2011;23(8):322-326.

Aorta free-floating wire technique
(for aorta-ostial lesion only)
“Sepal Wire Technique” — A Novel Technique for Aorto-ostial
Left Main Stenting
Chan et al. J INVASIVE CARDIOL 2011;23:211–212

The guide catheter is backed out
of the ostium and the second wire
is advanced into the aorta. This
second wire acts as a marker for
the ostium and prevents the guide
from deeply engaging the vessel

JACC Interv. 2014;Vol 7 (25) Suppl.

Stent draw-back technique
Schwartz L, Morsi A. J Invasive Cardiol 2002;14:66-71.
(a) The stent is advanced on the target vessel wire beyond the lesion; (b) a
balloon is advanced over the second wire opposite the ostium of the target
vessel; (c) the balloon is then inflated at low pressure (6-8 atm); (d) the
undeployed stent catheter is pulled back against the inflated balloon until a
dent is seen; (e) both balloons are deflated.

Schwartz L, Morsi A. J Invasive Cardiol 2002;14:66-71.

American Journal of Cardiology
Volume 96, Issue 8 , Pages 1123-1128, 15 October 2005
Effectiveness of the Stent Pull-Back Technique for Nonaorto Ostial
Coronary Narrowings
•Annapoorna S. Kini, Pedro R. Moreno, Angelica M. Steinheimer Samin K. Sharma, MD
Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount
Sinai Hospital, New York, New York
Coronary stenting of nonaorto ostial coronary lesions is challenging because of plaque shift
into the main vessel, triggering the use of additional stents. Furthermore, inappropriate
coverage of the ostium of the side branch increases the risk of restenosis and target vessel
revascularization (TVR). To improve the treatment of nonaorto ostial coronary lesions with a
novel interventional technique, we tested the hypothesis that inflating a balloon in
the main vessel before stenting the side branch (stent pull-back technique)
will limit plaque shifting and reduce the use of additional stents. In
addition, proper coverage of the side branch ostium may also reduce 8-month TVR. A case-
control design with 100 consecutive patients who underwent drug-eluting stent placement
was performed; 55 patients were treated with the stent pull-back technique and
45 patients with a conventional stent technique. Procedural success was
100% for the 2 techniques. The use of additional stents was reduced in the
stent pull-back group compared with the conventional stent group (2% vs
18%, p = 0.007). A tendency toward lower ostial miss was also observed in
the stent pull-back group (4% vs 13%, p = 0.11). The incidence of in-hospital and
30-day cardiac events was similar between the 2 groups. TVR was lower in the stent
pull-back group compared with the conventional group (5% vs 20%; p =
0.03). In conclusion, the stent pull-back technique improves the percutaneous
treatment of nonaorto ostial coronary lesions. The technique is associated with a
lower use of additional stents and improved clinical outcome, reducing TVR at 8
months of follow-up.
Kini AS,Sharma SK. Am J Cardiol 2005;96:1123-8.

Szabo or ‘tail-wire’ or ‘anchor-wire’ technique
TCT 2005. Szabo S et.al. Am J Cardiol 2005;96:212H.
(a) proximal end of the anchor wire in the Cx is threaded through the most
proximal strut of the crimped LAD stent; (b) stent advanced into lesion until the
anchor wire prevents further onward motion. Stent balloon is then inflated at 6-8
atm to allow easy removal of anchor wire; (c) after high-pressure inflation
showing satisfactory position.

Wong P. Catheter Cardiovasc Interv 2008;72:331-4.
Proximal flaring of Cypher stent at 4 atm to facilitate threading of anchor
wire. The end of the stent is then manually crimped back onto the balloon by
gentle squeezing.

Catheterization and Cardiovascular Interventions 72:331–334 (2008)

JACC : CARDIOVASCULAR INTERVENTIONS , VOL. 7, N O. 2S, Suppl S, 2014

Author says-
“Due to these results, we designed with Hexacath (Paris
France) one Stent with a dedicated cell (coming from
factory), to simplify the threading of AGW, avoiding
balloon puncture or Stent deformation. Our Stent
called Titan V, has been successfully implanted in test
benches and animal models and currently is under
evaluation for CE mark”

• 257 lesions (78 Szabo technique)
• Cross-over occurred in nine (11.7%) Szabo cases vs. no case in
the conventional group.
EuroIntervention 2010;5:801-808

Conclusions: The Szabo technique reduces the
incidence of angiographic malpositioning in Medina
010 / 001 bifurcations and aorto-ostial lesions,
without increasing procedural complications
EuroIntervention 2010;5:801-808

Ostial Pro Stent placement system
(For Aorto-ostial lesions only)
• The Ostial-Pro (Merit Medical) is a nitinol device with
expanded gold-plated feet for treatment of aorta-ostial
lesions.
• It is advanced into the Toughy-Borst adapter using the
supplied introducer to the primary curve in the guide
catheter.
• The introducer is removed and a 0.014″ coronary wire is
advanced distal to the lesion.

• Fischell and colleagues have reported 30 patients using
the Ostial Pro stent placement system in ostial right coronary
artery, ostial left main artery, and ostial saphenous vein graft
lesions.
• They reported a high rate of success with excellent
angiographic position.
•Fischell TA et al. J Invasive Cardiol. 2009;21(2):53-59.

Conclusions
 Establish whether ostial PCI is appropriate (vs. PCI with
coverage of SB, or CABG)
 Guide catheter selection is crucial for aorto-ostial lesions
 Use optimal, non-overlapped, non-foreshortened
angiographic imaging
 IVUS to assess for proximal or SB disease, degree of
calcification,reference diameter and stent expansion
 Adequate lesion preparation (± adjunctive device use)

 Position proximal stent marker proximal to lesion
 Minimisation of stent oscillation – breath-hold/shallow
breathing,partial pre-inflation
 Stent ‘draw-back’ or Szabo techniques when conventional
positioning is difficult
 Mandatory high-pressure post-dilatation

Coronary Ostial stenting techniques:Current status

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