186
Images in CAD
Images in CAD Coronary Artery Disease 2015, 26:186–187
Stent position in ostial lesion: How can I be sure?
Percutaneous coronary intervention of an ostial lesion is a challenging procedure, even for experienced operators, especially if the angle between the bifurcating vessels is less than 75°, or if the lesion is 0, 0, 1, as per the Medina classification [1]. Various techniques have been described to achieve stable stent position in such lesions [2]. The intervention strategy for an ostial lesion of the left anterior descending artery (LAD) has to be decided upfront, either to aim for precise ostial stent position or to bring the stent back across the left circumflex (LCx) ostium into the left main stem.
Ashish Shaha, William J. Pennyb and Ashesh N. Buchc, aUniversity Health Network, Toronto, Ontario, Canada, bUniversity Hospital of Wales, Cardiff, UK and c East Carolina University Hospitals, Greenville, North Carolina, USA Correspondence to Ashish Shah, MD, MD-Research, MRCP, Department of Cardiology, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 Tel: + 1 416 835 2822; fax: + 1 416 340 3000; e-mail: [email protected] Received 28 October 2014 Revised 1 November 2014 Accepted 5 November 2014
Fig. 1
(b)
(a)
(d)
(c)
(f)
(e)
∗
m
10
20
30
40
10
20
30
40
0
20
30
40
(a) Coronary angiogram showing a diseased segment in the proximal LAD that has a narrow angle with LCx. (b) Stent position in the proximal/ostial LAD was secured using the Szabo technique, with a side branch wire in the LCx. (c) Final cine. OCT images showing stent position (d) in the lesion, (e) at the ostium of the LAD, and (f) across the ostium of the LCx, without any struts hanging across the side branch. (d–f) Position of the image detector is marked with an arrow on the longitudinal view of the vessel. LAD, left anterior descending artery; LCx, left circumflex; OCT, optical coherence tomography.
0954-6928 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/MCA.0000000000000199
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Stent position in ostial lesion Shah et al. 187
A 78-year-old man, known to have hypertension and high cholesterol and be an ex-smoker, presented to the hospital with acute coronary syndrome. Electrocardiography revealed ‘T’-wave inversion in V1–4, and echocardiography confirmed anterior wall hypokinesia. Coronary angiography revealed a culprit lesion in the ostial/proximal LAD (Fig. 1). The angle between the LAD and LCx was less than 30°, which is challenging to secure a stable stent position in the ostial LAD. We used the Szabo technique with an additional wire in the LCx. Maintaining forward push on the stent at the time of positioning and deployment helped us achieve satisfactory final angiographic results. Optical coherence tomography revealed excellent stent position in the LAD, with good apposition. There was only a single strut hanging proximal to the LAD ostium, probably the one through which the wire was passed into the LCx to anchor the stent. The Szabo technique is helpful in securing a precise stent position in the ostial lesions, especially the ones
with a narrow angle between the branches or in which branch separation cannot be easily seen. Stent movement can be nullified by maintaining forward push on the stent at the time of deployment. Intravascular ultrasound has been used to assess the efficacy of the Szabo technique [3], but to our knowledge this is the first case to demonstrate the precise stent position using the Szabo technique with optical coherence tomography.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2 3
Jokhi P, Curzen N. Percutaneous coronary intervention of ostial lesions. EuroIntervention 2009; 5:511–514. Kwan TW, James D, Huang Y, Liou M, Wong S, Coppola J. Perfection of precise ostial stent placement. J Invasive Cardiol 2012; 24:354–358. Yang S, Liu H-L. Safety and feasibility of Szabo technique in percutaneous coronary intervention of ostial lesions [abstract]. JACC Cardiovasc Imaging 2014; 64 (16, Suppl C):C151.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Images in CAD
Images in CAD Coronary Artery Disease 2015, 26:186–187
Stent position in ostial lesion: How can I be sure?
Percutaneous coronary intervention of an ostial lesion is a challenging procedure, even for experienced operators, especially if the angle between the bifurcating vessels is less than 75°, or if the lesion is 0, 0, 1, as per the Medina classification [1]. Various techniques have been described to achieve stable stent position in such lesions [2]. The intervention strategy for an ostial lesion of the left anterior descending artery (LAD) has to be decided upfront, either to aim for precise ostial stent position or to bring the stent back across the left circumflex (LCx) ostium into the left main stem.
Ashish Shaha, William J. Pennyb and Ashesh N. Buchc, aUniversity Health Network, Toronto, Ontario, Canada, bUniversity Hospital of Wales, Cardiff, UK and c East Carolina University Hospitals, Greenville, North Carolina, USA Correspondence to Ashish Shah, MD, MD-Research, MRCP, Department of Cardiology, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4 Tel: + 1 416 835 2822; fax: + 1 416 340 3000; e-mail: [email protected] Received 28 October 2014 Revised 1 November 2014 Accepted 5 November 2014
Fig. 1
(b)
(a)
(d)
(c)
(f)
(e)
∗
m
10
20
30
40
10
20
30
40
0
20
30
40
(a) Coronary angiogram showing a diseased segment in the proximal LAD that has a narrow angle with LCx. (b) Stent position in the proximal/ostial LAD was secured using the Szabo technique, with a side branch wire in the LCx. (c) Final cine. OCT images showing stent position (d) in the lesion, (e) at the ostium of the LAD, and (f) across the ostium of the LCx, without any struts hanging across the side branch. (d–f) Position of the image detector is marked with an arrow on the longitudinal view of the vessel. LAD, left anterior descending artery; LCx, left circumflex; OCT, optical coherence tomography.
0954-6928 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/MCA.0000000000000199
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Stent position in ostial lesion Shah et al. 187
A 78-year-old man, known to have hypertension and high cholesterol and be an ex-smoker, presented to the hospital with acute coronary syndrome. Electrocardiography revealed ‘T’-wave inversion in V1–4, and echocardiography confirmed anterior wall hypokinesia. Coronary angiography revealed a culprit lesion in the ostial/proximal LAD (Fig. 1). The angle between the LAD and LCx was less than 30°, which is challenging to secure a stable stent position in the ostial LAD. We used the Szabo technique with an additional wire in the LCx. Maintaining forward push on the stent at the time of positioning and deployment helped us achieve satisfactory final angiographic results. Optical coherence tomography revealed excellent stent position in the LAD, with good apposition. There was only a single strut hanging proximal to the LAD ostium, probably the one through which the wire was passed into the LCx to anchor the stent. The Szabo technique is helpful in securing a precise stent position in the ostial lesions, especially the ones
with a narrow angle between the branches or in which branch separation cannot be easily seen. Stent movement can be nullified by maintaining forward push on the stent at the time of deployment. Intravascular ultrasound has been used to assess the efficacy of the Szabo technique [3], but to our knowledge this is the first case to demonstrate the precise stent position using the Szabo technique with optical coherence tomography.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 2 3
Jokhi P, Curzen N. Percutaneous coronary intervention of ostial lesions. EuroIntervention 2009; 5:511–514. Kwan TW, James D, Huang Y, Liou M, Wong S, Coppola J. Perfection of precise ostial stent placement. J Invasive Cardiol 2012; 24:354–358. Yang S, Liu H-L. Safety and feasibility of Szabo technique in percutaneous coronary intervention of ostial lesions [abstract]. JACC Cardiovasc Imaging 2014; 64 (16, Suppl C):C151.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
