PCI in the ostial lesion

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
"'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."
 * 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.

"'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."
 * 1) Use a Low Pressure Inflation to define the extent of the lesion proximally.


 * 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.

==2011 ACCF/AHA/SCAI Guideline Recommendations: Aorto-Ostial Stenoses == {{cquote|

Class IIa
1. IVUS is reasonable for the assessment of angiographically indeterminant left main CAD. (Level of Evidence: B)

2. Use of DES is reasonable when PCI is indicated in patients with an aorto-ostial stenosis. (Level of Evidence: B)}}

Guideline Resources

 * 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


 * 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update)