Cath Lab Digest - March 2008 - (Page 64)

64 CASE REPORT MARCH 2008 The Ostial Pro™ Stent Positioning System: Perfecting Aorto-Ostial Stent Placement Frank S. Saltiel, MD, FACC, FSCAI, President, Illinois Heart & Vascular Foundation; Director, Interventional Cardiology Adventist Midwest Health, Lagrange, Illinois Tim A. Fischell, MD, FACC, FSCAI Director, Cardiovascular Research; Professor of Medicine, Michigan State University Borgess Heart Institute, Kalamazoo, Michigan Introduction As the field of interventional cardiology has continued to progress, the need for lesion-specific devices for complex and higher risk lesions has increased. Unfortunately, there has been relatively little improvement in devices to assist in the treatment of most complex lesion subtypes (e.g., CTOs, bifurcation lesions, etc.). However, a recently approved device shows promise to improve the results, and simplify the treatment of aortoostial lesions. Aorto-ostial lesions are technically more complicated due to the marked elastic recoil and heavy calcification associated with these lesions.1 As such, the standard treatment for these lesions involves compulsory stent implantation (occasionally with adjunctive debulking or cutting balloon angioplasty).2-5 However, stenting of the ostium poses additional challenges since extremely precise positioning is essential, and the use of standard angiographic landmarks is often misleading.6 Misplacement of the stent by even a few millimeters can result in adverse outcomes.6 Moreover, it is well documented that stented aorto-ostial lesions demonstrate worse long-term results as compared to lesions elsewhere in the arterial tree.2,4,5,7 This is likely due in part to misplacement of the stent, in not covering the true ostium of the vessel. In order to improve the accuracy of stent placement, several modifications of standard techniques have been proposed, but none have been widely applied.8,9 The Ostial Pro™ (Ostial Solutions, Inc., Kalamazoo, MI) is a new device designed specifically to aid in the precise placement of stents in aorto-ostial locations. The device consists of a nitinol wire with a distal cylinder which is slit, permitting removal of the device without compromising wire position. The device can be front or back-loaded. There are four thin, flexible, self-expanding legs arising from this cylindrical portion. Gold markers are located on the tip of the legs to allow for fluoroscopic visualization (Figure 1). After the ostial lesion has been wired and with the stent delivery system distal to the lesion, the Ostial Pro is advanced inside the guiding catheter over the stent delivery system until the gold plated legs “pop out” just beyond the tip of the guiding catheter. The guiding catheter is advanced until the legs abut the aortic wall surrounding the ostial lesion. This serves to not only mark the true plane of the ostium, but also prevents the guide from entering into the vessel and stabilizes the guide during the intervention. The stent delivery system is then simply withdrawn to a position just distal to the guide tip. Contrast injection at this point helps to even better define the precise position of the proximal stent struts. Once the exact position is confirmed, the stent is deployed at that location. The Ostial Pro device is then removed from the guiding catheter. A second inflation to “flare” the proximal stent struts at the true ostium is performed with the balloon withdrawn another 2-3 mm. This has been demonstrated by intravascular ultrasound (IVUS) imaging to result in highly accurate positioning of the stent, to within 0.1-0.2 mm of the true ostium. Figure 1. Photograph of the Ostial Pro™ stent positioning system. The panel on the left shows the Ostial Pro with the slit, cylindrical segment just distal to the guide tip. The right panel illustrates the proper position of the device in preparation for contact with the aortic wall. The thin, flexible nitinol legs are fully expanded. Gold markers on the tip of the legs allows for easy fluoroscopic visualization. Figure 2. Case #1: The pre-intervention angiogram utilizing a 6 French guiding catheter is on the left. There is no dye reflux into the aorta, confirming a significant ostial stenosis. The center panel shows the Ostial Pro deployed with the cylindrical portion inside the distal guide tip, and the legs expanded and in contact with the wall of the aorta. The stent delivery system has been withdrawn so that the proximal marker is just outside the tip of the guide. The stent was deployed in this location. The right panel shows the final angiogram. Note the free reflux of dye in the aorta, as well as the conus branch which was not visualized in the initial angiogram. This illustrates that the true ostium was several millimeters proximal to the perceived location from the initial angiogram. The position of the stent at the ostium was confirmed by intravascular ultrasound. We report two cases of right coronary ostial stenting using the Ostial Pro stent positioning system. The device can also be utilized in a similar fashion for stenting of saphenous vein grafts, left main, renal artery, as well as other anatomically suitable aortoostial stenoses. Case 1. A 67-year-old male with history of remote myocardial infarction with stenting of the left circumflex artery, hypertension, and hyperlipidemia presented with exertional angina. Nuclear stress imaging demonstrated the presence of inferior ischemia and cardiac catheterization was recommended. Coronary angiography Disclosure: Dr. Saltiel and Dr. Fischell hold a financial interest in Ostial Solutions, Inc., which owns the Ostial Pro.

Table of Contents Feed for the Digital Edition of Cath Lab Digest - March 2008

Cath Lab Digest - March 2008 Are You Being Paid Fair Market Value in 2008? A Cardiac Cath Lab Professionals Survey by Cath Lab Digest and the Society of Invasive Cardiovascular Professionals Saint Joseph’s Hospital Invasive Imaging Tools for Optimizing Coronary Stent Deployment Contents Clinical Editor’s Corner A Workflow Revolution in Cath Lab Reporting Advantages of a New Digital Lab at Baystate Medical Center Cardiac Computed Tomography: What Does it Mean for the Cath Lab? The Latest in Cardiac Magnetic Resonance Imaging (MRI) Cellular Cardiomyoplasty and Cardiac Regeneration Intravascular Ultrasound in the Cath Lab: A Powerful — and Underutilized — Tool to Improve Patient Outcomes The Stentplus™ Patient Success Program Cardiac Cath Lab Clutter — or, Spring into Action! Groin Bleeds and Other Hemorrhagic Complications of Cardiac Catheterization: A List of Relevant Issues Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab What Do You Think? Experience with a New Guidewire: The Terumo Runthrough NS The Ostial Pro™ Stent Positioning System: Perfecting Aorto-Ostial Stent Placement Precious Minutes The Ten-Minute Interview with…Mark Bowles, BSN, CCRN Vascular Care in the Cath Lab: Planning a Smooth Transition Cath Laughs CMS 2008 OPPS Final Rule Review An Extensive Set of Review Courses for the CCI Basic Science, Non-Invasive Echocardiography and Vascular, and ARDMS Ultrasound Exams Meetings Calendar CEU Education Center Clinical & Industry News STEMI Interventions Classifieds Advertisers Index

Cath Lab Digest - March 2008

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