Percutaneous Treatment of Aorto-Ostial Coronary Lesions: Current Challenges and Future Directions

Flow-limiting aorto-ostial coronary lesions (AOL) are clinically important because they subtend a large myocardial territory and may induce extensive myocardial ischemia. Diagnosis and treatment of these lesions is challenging and procedural success and clinical outcomes are inferior to non-ostial lesions. AOL have a unique three-dimensional funnel-shaped morphology with a variable angle of takeoff of the coronary artery from the aorta. Diagnosis of AOL may be missed on coronary angiography when contrast media is injected distal to the lesion due to deep intubation of the catheter into the vessel. AOL are often severely calcified with increased lesion eccentricity and plaque burden, which may complicate stent deployment. Recent analysis of stented AOL by CT angiography revealed a high incidence of geographic miss with stents protruding into the aorta or placed distal to the lesion. The purpose of this review is to summarize current knowledge regarding aorto-ostial percutaneous coronary intervention and to suggest novel approaches for optimizing these procedures.