Demystifying the Quandary of Ostial Stenting

Abstract

Accurate stent placement is known to be hampered by the anatomical nature of percutaneous coronary intervention (PCI) of ostial lesions, such as aorta-ostial lesions and Medina 001 bifurcation lesions. The Ostial Pro device, the aorta floating wire technique, the stent pull-back technique, the Szabo (tail-wire) techniques, the marker wire technique, the T-stent and small protrusion technique, the cross-over 1-stent technique, and new dedicated ostial stents are some of the techniques used to achieve perfection in precise ostial stent placement. The current state of knowledge about ostial PCI and novel approaches for optimizing these procedures are compiled in this review.

Keywords: Coronary angiography; Percutaneous coronary intervention; Stent.

Figure 1. Location of the proximal stent edge in relation to the aorto-ostial plane and AOLZ.

(A) The optimal site for positioning the proximal stent edge of aorto-ostial stent is inside an AOLZ located within 1 mm of the aorto-ostial plane. (B) Location of the proximal edge of the stent proximal to the AOLZ (Proximal geographic miss). (C) Location of the proximal edge of the stent distal to the AOLZ (distal geographic miss). AOLZ = aorto-ostial landing zone.

Figure 2. Schematic depiction of aortic sinus floating guidewire technique.

Figure 3. Schematic depiction of stent-pullback technique.

(A) Placement of the stent on the target artery wire beyond the lesion. (B) Navigation of a balloon over the second wire opposite the target artery ostium. (C) Inflation of a balloon at low pressure (6–8 atm). (D) Pulling back of undeployed stent against the inflated balloon until a dent is apparent. (E) Deflation of both the balloons.

Figure 4. Schematic illustration of Ostial Pro stent system.

Figure 5. Crossing the proximal end of the second wire (anchor wire) through the most proximal stent cell while stent balloon is inflated at low atmosphere (2–4 atm) before stent introduction into the guide catheter.

Figure 6. Schematic illustration of the tail-wire technique (anchoring of the stent at LAD ostium by a second wire in LCX.

LAD = left anterior descending; LCX = left circumflex artery.

Figure 7. Angiographic depiction of tail-wire technique.

(A) Coronary angiogram showing total occlusion of ostial LAD that has a narrow angle with LCX. (B) Predilation of ostial lesion with a small balloon. (C) Anchoring of the stent exactly at LAD ostium by a second wire in LCX. (D) Final result after deployment of the stent. LAD = left anterior descending; LCX = left circumflex artery.

Figure 8. Schematic illustration of ostial flaring by FLASH™ Ostial System.

(A) The stent in position. (B) Alignment of the markers ensuring that the middle marker is at the ostium, the distal marker is proximal to the distal edge of the stent and the proximal marker is outside of the guide catheter. (C) Inflation of the distal balloon. (D) Inflation of the compliant, low-pressure proximal balloon. (E) Final result.