Catheterization and Cardiovascular Interventions 85:532 (2015)
Editorial Comment Generations: The Old Gives Way to the New, and the New is Too Soon the Old Samuel Butman,* MD Verde Valley Medical Center
Key Points
This report highlights the importance of unique lesion characteristics (ostial RCA) with regard to outcomes In practice, choosing the correct stent for the right lesion and patient does make a difference New stent delivery systems, for specific subsets of lesions will continually need to be compared to optimize long-term outcomes
The preceding article reports the outcome at 2 years of second-generation drug-eluting stents in the right coronary ostium. Now, fortunately or not, depending on one’s perspective, we are placing third-generation stents which are different in several ways, hopefully all even better than those reported. Be it platinum or cobalt chromium, stent strut thickness plays a more important role in ostial disease, while the polymer and drug delivery appear to be satisfactory at this point. The newer, third generation stents and struts are thinner, making them easier to deliver, but for an ostial lesion, this may have an adverse affect, although that remains to be determined. Stenting an ostial lesion is always something that brings out the best and worst of an interventional cardiologist. First, we must be certain that a lesion truly exists and is not related to catheter-induced spasm or an angiographic over read. Then after we predilate or not, we must place a true scaffold, knowing that we are now trying to keep a much thicker and elastic vessel, the aorta, open let alone prevent in-stent restenosis from intimal hyperplasia. In doing so, we know we must leave some of the stent in the aorta to assure that the ostium has been addressed and maximally dilated. All this typically requires closer attention, frequently with larger image intensification, more fluoroscopy, and perhaps one of the reported approaches to delivery [1–5]. C 2015 Wiley Periodicals, Inc. V
In the preceding article, the groups unfortunately were significantly different in other respects in that the “ostial” group had more stents placed, covered a longer area of the right coronary artery, and there were restenotic lesions more often, as well. All this would make one expect a higher rate of target lesion revascularization, which was the case, but a 7.5% rate is not too shabby given the drastic difference in the elastic membrane being strutted open. It would have been interesting to know how many of these restenoses were due to stent compression rather than intimal hyperplasia. If it is a question of intimal hyperplasia will we need “ostial-high-dose” stents that have higher drug concentrations owing to the thicker arterial layers of the aortic wall? Conversely, if stent compression is a significant culprit will we need “ostial-high-strength” stents, or maybe a combination for the “fourth generation” special use stent? Ostial stenting is always a non-routine time in the catheterization laboratory. With each new generation of stent delivery system that provides us with better features, we must also be vigilant that we are not giving up a feature we also valued. REFERENCES 1. Satler LF. Aorto-ostial disease and aorto-ostial in-stent restenosis: Poorly recognized but very complex lesion subsets. Catheter Cardiovasc Interv 2002;56:220–221. 2. Katoh O, Reifart N. New double wire technique to stent ostial lesions. Catheter Cardiovasc Interv 1997;40:400–402. 3. Dishmon DA, Elhaddi A, Packard K, et al. High incidence of inaccurate stent placement in the treatment of coronary aorta-istial disease. J Invasive Cardiol 2011;23:322–326. 4. Fischell TA, Saltiel FS, Foster MT, Wong SC, Dishman DA, Moses J. Initial clinical experience using an ostial stent positioning system (ostial pro) for the accurate placement of stents in the treatment of coronary aorto-ostial lesions. J Invasive Cardiol 2009;21:53–59. 5. Applegate RJ, Davis JM, Leonard JC. Treatment of ostial lesions using the Szabo technique: A case series. Catheter Cardiovasc Interv. 2008;72:823–828. Conflict of interest: Nothing to report. *Correspondence to: Samuel Butman, MD, HVCNA, 294 West Highway 89A, Cottonwood, AZ 86326. E-mail: [email protected] Received 12 January 2015; Revision accepted 16 January 2015 DOI: 10.1002/ccd.25845 Published online 19 February 2015 in Wiley Online Library (wileyonlinelibrary.com)
Editorial Comment Generations: The Old Gives Way to the New, and the New is Too Soon the Old Samuel Butman,* MD Verde Valley Medical Center
Key Points
This report highlights the importance of unique lesion characteristics (ostial RCA) with regard to outcomes In practice, choosing the correct stent for the right lesion and patient does make a difference New stent delivery systems, for specific subsets of lesions will continually need to be compared to optimize long-term outcomes
The preceding article reports the outcome at 2 years of second-generation drug-eluting stents in the right coronary ostium. Now, fortunately or not, depending on one’s perspective, we are placing third-generation stents which are different in several ways, hopefully all even better than those reported. Be it platinum or cobalt chromium, stent strut thickness plays a more important role in ostial disease, while the polymer and drug delivery appear to be satisfactory at this point. The newer, third generation stents and struts are thinner, making them easier to deliver, but for an ostial lesion, this may have an adverse affect, although that remains to be determined. Stenting an ostial lesion is always something that brings out the best and worst of an interventional cardiologist. First, we must be certain that a lesion truly exists and is not related to catheter-induced spasm or an angiographic over read. Then after we predilate or not, we must place a true scaffold, knowing that we are now trying to keep a much thicker and elastic vessel, the aorta, open let alone prevent in-stent restenosis from intimal hyperplasia. In doing so, we know we must leave some of the stent in the aorta to assure that the ostium has been addressed and maximally dilated. All this typically requires closer attention, frequently with larger image intensification, more fluoroscopy, and perhaps one of the reported approaches to delivery [1–5]. C 2015 Wiley Periodicals, Inc. V
In the preceding article, the groups unfortunately were significantly different in other respects in that the “ostial” group had more stents placed, covered a longer area of the right coronary artery, and there were restenotic lesions more often, as well. All this would make one expect a higher rate of target lesion revascularization, which was the case, but a 7.5% rate is not too shabby given the drastic difference in the elastic membrane being strutted open. It would have been interesting to know how many of these restenoses were due to stent compression rather than intimal hyperplasia. If it is a question of intimal hyperplasia will we need “ostial-high-dose” stents that have higher drug concentrations owing to the thicker arterial layers of the aortic wall? Conversely, if stent compression is a significant culprit will we need “ostial-high-strength” stents, or maybe a combination for the “fourth generation” special use stent? Ostial stenting is always a non-routine time in the catheterization laboratory. With each new generation of stent delivery system that provides us with better features, we must also be vigilant that we are not giving up a feature we also valued. REFERENCES 1. Satler LF. Aorto-ostial disease and aorto-ostial in-stent restenosis: Poorly recognized but very complex lesion subsets. Catheter Cardiovasc Interv 2002;56:220–221. 2. Katoh O, Reifart N. New double wire technique to stent ostial lesions. Catheter Cardiovasc Interv 1997;40:400–402. 3. Dishmon DA, Elhaddi A, Packard K, et al. High incidence of inaccurate stent placement in the treatment of coronary aorta-istial disease. J Invasive Cardiol 2011;23:322–326. 4. Fischell TA, Saltiel FS, Foster MT, Wong SC, Dishman DA, Moses J. Initial clinical experience using an ostial stent positioning system (ostial pro) for the accurate placement of stents in the treatment of coronary aorto-ostial lesions. J Invasive Cardiol 2009;21:53–59. 5. Applegate RJ, Davis JM, Leonard JC. Treatment of ostial lesions using the Szabo technique: A case series. Catheter Cardiovasc Interv. 2008;72:823–828. Conflict of interest: Nothing to report. *Correspondence to: Samuel Butman, MD, HVCNA, 294 West Highway 89A, Cottonwood, AZ 86326. E-mail: [email protected] Received 12 January 2015; Revision accepted 16 January 2015 DOI: 10.1002/ccd.25845 Published online 19 February 2015 in Wiley Online Library (wileyonlinelibrary.com)
