2. Within the past 12 months, I or my spouse/partner have had a
financial interest, arrangement, or affiliation with the
organization(s) listed below:
Within the past 12 months, I or my spouse/partner have had a
financial interest, arrangement, or affiliation with the
organization(s) listed below:
Affiliation/Financial Relationship Company
Consultant, Proctor Boston Scientific,
Teleflex, Asahi intecc,
Cordis, Terumo
Disclosures
3. Ostial Lesions
Definition
Ostial disease is defined as a lesion
arising within 3 mm of the vessel origin
Classification
–Aorto-ostial – involving the ostia of the
RCA, LMS, and ACB grafts.
–Non-aorto-ostial – involving the ostia
of the major coronary arteries
not arising directly from the aorta; i.e.,
the LAD, Cx and RIM.
–Branch ostial – involving the ostia of
branches of the major coronary vessels;
(diagonals, marginals, PL and PD)
Percy Eurointerverntion2009
4. Ostial Lesions - Incidence
33%
12%
32%
18%
Overall Incidence around 3%
Patel CCI 2016
5. Ojeda et. al, 2020, DOI: 10.1016/j.rec.2020.01.008
Types of aorto-ostial CTOs
flush aorto-ostial occlusion (total absence of
a stump at the aortocoronary junction) aorto-ostial CTO with a minimal proximal cap
6. Success Rate?
Limited data
Euro CTO Registry 2012-2015
RCA Ostial
Other
Lesions
n 378 (4%) 9030 (96%)
lesion length(mm) 43,4 30,7
J CTO score (men) 3,2 2,3
antegrade only (%) 38 73
retrograde only (%) 37 11
antegradea and
retrograde (%)
25 16
stent length (mm) 78,4 62,3
procedural time 140,1 106,2
fluoro time 62,5 41,2
Contrast (ml) 317,5 292,2
Success rate (%) 78 87
7. Predictors of technical failure in ostial CTO
Ojeda et. al, 2020, DOI: 10.1016/j.rec.2020.01.008
8. Aorto - Ostial Lesion - Management
Non Ao-ostial Ao - ostial
+ +/-
++ +/-
++ ++
+++ -
+/- +/-
++ +++
How to predict the vessel origin in the absence of stump?
– Microchannels
– Bridging Collaterals
– Calcium in the vessel course
– Additional imaging modalities
• IVUS
• CT angio of CTO
– Utility of Retrograde Approach
9. Nicholson et. al. J Am Coll Cardiol Intv. 2016 Nov, 9 (22) 2356–2358
Retrograde Puncture into the Aorta
10. Nicholson et. al. J Am Coll Cardiol Intv. 2016 Nov, 9 (22) 2356–2358
Retrograde Puncture into the Aorta
E-CART (ElectroCautery-Assisted Re-enTry) of an Aorto-Ostial Right Coronary Artery Chronic
Total Occlusion:
11. Calcified ostial lesions
1 Consider imaging before stenting
(sufficient plaque modification?)
2 Use stents with high radial force
(better stent cross ability, due to thinner struts results in higher
recoil)
13. J-CTO Score 4, post CABG, EF 29%
CTO ostial RCA, Post CABG
14. J-CTO Score 4, post CABG, EF 29%
CTO ostial RCA, Post CABG
15. J-CTO Score 4, post CABG, EF 29%
CTO ostial RCA, Post CABG
16. CTO ostial LM- Post CABG
62y, CCS II, NYHA II, EF 20%, Post CABG, CTO LAD and CX, CTO PCI with Impella CP
17. 62y, CCS II, NYHA II, EF 20%, Post CABG, CTO LAD and CX, CTO PCI with Impella CP
CTO ostial LM- Post CABG
18. 62y, CCS II, NYHA II, EF 20%, Post CABG, CTO LAD and CX, CTO PCI with Impella CP
CTO ostial LM- Post CABG
19. 62y, CCS II, NYHA II, EF 20%, Post CABG, CTO LAD and CX, CTO PCI with Impella CP
CTO ostial LM- Post CABG
20. 62y, CCS II, NYHA II, EF 20%, Post CABG, CTO LAD and CX, CTO PCI with Impella CP
CTO ostial LM- Post CABG
21. 62y, CCS II, NYHA II, EF 20%, Post CABG, CTO LAD and CX, CTO PCI with Impella CP
CTO ostial LM- Post CABG
22. Take Home Message
Aorto-ostial CTO PCI
• Aorto-ostial occlusions represent a challenging subset for PCI
• The presence of interventional collaterals allowing the use of the retrograde
approach is key for achieving procedural success
• Use enough support
• Use IVUS for optimal Plaque Modification and stent Expansion
