Abstract
Percutaneous coronary intervention of aorto-ostial lesions is associated with high rates of major adverse cardiovascular events. Precise implantation of coronary stents in the ostium is important in order to prevent adverse clinical outcomes. The presented case demonstrates a simple technique to accurately position a stent during aorto-ostial percutaneous coronary intervention.
1
Introduction
Percutaneous coronary intervention (PCI) of aorto-ostial lesions is associated with high major adverse cardiovascular rates . Precise implantation of coronary stents in the ostium is important in order to prevent adverse clinical outcomes. “Geographic miss” occurs when the lesion is not fully covered, thereby requiring implantation of additional stents, which may increase risk for edge restenosis and stent thrombosis. Conversely, stent placement should be no more than 1–2 mm proximal to the aorto-ostial origin so as to not complicate future attempts to engage the vessel coaxially during future coronary interventions. Several techniques to assist in stent positioning have been proposed . We report on a new, simple technique to guide accurate positioning of stents in aorto-ostial lesions.
2
Case Report
A 76-year-old female presented with crescendo angina pectoris. The patient had known coronary artery disease with a history of coronary artery bypass surgery in 2006. She also had peripheral vascular disease with history of stenting of left internal carotid artery and right carotid endarterectomy. The patient was treated for hypertension, hypercholesterolemia and received immunosuppression for rheumatoid arthritis. The patient underwent diagnostic coronary angiography in another institution, which showed advanced coronary artery disease. An attempt to maximize medical therapy was done and included aspirin, clopidogrel, statins, beta-blockers and ranolazine. The patient, however, remained symptomatic and was thus referred for percutaneous coronary intervention.
Coronary angiogram showed 90% stenosis of the distal left main (LM) involving the bifurcation to ramus and 80% right coronary artery (RCA) aorto-ostial stenosis ( Fig. 1 A ). Neither lesion was grafted in the past. Left internal mammary graft to the left anterior descending artery was widely patent as were the saphenous vein graft to the diagonal branch and a second saphenous vein graft to the obtuse marginal branch. Given the clinical presentation and persistent symptoms despite maximal medical therapy, percutaneous coronary intervention of the two native lesions (distal left main and ostial right coronary artery) was pursued. PCI to LM was performed successfully using standard techniques.
Intravascular ultrasound (IVUS) demonstrated a heavily calcified lesion in the ostial RCA with a minimal lumen area (MLA) of 2.09 mm 2 ( Fig. 1 B). A cutting balloon (Flexotome, Boston Scientific, Natick, MA) was used to predilate the lesion. In order to position the stent precisely at the ostium of the vessel, the IVUS probe was re-inserted and then pulled manually until the true ostium was identified by the ultrasound short and long axis images ( Fig. 2 ). At this point, a brief cine was acquired with injection of a minimal amount of iodinated contrast ( Fig. 3 A ). The proximal edge of a 3.0 × 12.0-mm zotarolimus-eluting stent (Endeavor, Medtronic, Minneapolis, MN) was positioned with the aid of the previously acquired reference image while a minimal amount of iodinated contrast was injected ( Fig. 3 B). Once final position was determined, the stent was deployed at high pressure. Stent expansion and position in the true ostium were verified by angiography and IVUS ( Figs. 2, 4 ).
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