Coronary Aorto-Ostial Lesion Interventions

Aorto-ostial lesions (AOLs), defined as a significant stenosis within 3 mm of the aortic orifice, are an uncommon but challenging lesion subset to manage. AOLs account for roughly 2.6% of interventions and frequently involve the right coronary artery. Risk factors for target lesion failure include treatment of bypass grafts, prior in-stent restenosis, direct stenting, and narrow postprocedure luminal diameter; all factors that can be influenced by the operator. Intravascular ultrasound (IVUS) is a key tool that provides a means of identifying the optimal landing zone and ensures optimal luminal gain and stent coverage after stent deployment. IVUS is strongly recommended for treatment of all AOLs. Additionally, appropriate lesion preparation with atherectomy or specialty angioplasty balloons is crucial in achieving maximal luminal gain. Although specialized AOL devices and techniques have been developed, the simple algorithm of adequate lesion preparation and heavy use of IVUS provides a robust and broadly applicable approach to AOLs. Successful long-term results can be obtained with AOLs involving the right coronary artery, left main, or the anastomosis of surgical bypass grafts.