RIGHT CORONARY ARTERY OSTIAL LESION
Ostial lesion

• Intervention of ostial lesions can sometimes be challenging
• This is because the guiding catheter may not engage properly
• During engagement, there may be damping of pressure
• Optimum angle for angiogram may not be achieve making stent placement difficult
• Movement of the heart with each beat and respiration may result in excessive to and fro movement of stent during inflation resulting in inaccurate placement position
• This patient presented with anginal symptoms and positive stress test
• The intervention was performed via the right radial route
• Initial angiogram shows a very tight ostial lesion
• Various guiding catheters could not engage the ostium to provide support
• The final choice was a 6F AL 1 guide

The JR guide although could engage the RCA, it did not provide support for intervention

1 Base LAO

The AP cranial view shows the very ostial stenosis

2 Base Cran

AL1 guide could not engage at all
The Fielder wire search the aortic root and entered the RCA with the guide non-coaxially engaged

3 Non Coaxial wiring

Pre-dilatation with a 1.5 x 12 mm balloon

4 Balloon one point five

Even with the balloon seated in RCA the guide still could not be co-axially engaged

5 Still cannot get coaxial

• To provide more support and to prevent the guide being kicked out, a buddy wire was used
• The ostium was dilated with 2.5 x 15balloon
• However, after dilatation with this balloon, a 3.0 x 15 balloon still could not be delivered due to poor guide support

6 double wire and balloon

• To deliver the 3.0 balloon into the lesion, the 2.5 x 15 balloon was stationed in mRCA and inflated as anchor
• The 30 x 15 balloon was then inflated to dilate the ostial lesion
• However, after dilatation, the guide was still not able to engage ostium to enable adequate

7 double wire three mm balloon

• To obtain an adequate ostial angiogram, the 3.0 x 15 balloon was inflated in the mRCA, the guide railroaded into position and the dye injected while the 3.0 x 15 balloon was still inflated
• This allows the ostium to be visulised

8 Using balloon to obtain os angio

The stent can now be placed

9 stent placement

• After deploying the stent, the stent balloon was pushed down to mRCA and again inflated while dye was injected
• This allows visualisation of the ostium

10 Post stent balloon assisted pic

• To see the whole of RCA, the deflated balloon is pulled back into the guide while dye is being injected
• This maneuver sucks the guide into the RCA ostium thus allows adequate dye to flow down RCA

11 Deflated balloon shot

• For the final shot, the wires and balloon have been removed
• Thus the guide again cannot be coaxed to sit in proper co-axial position
• The angiogram although adequate, is non-the-less not perfect

12 without wire is hard to see

Conclusion

• Ostial lesion may be tricky to treat
• But there are tricks to overcome the difficulties to facilitate satisfactory treatment