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