ABSTRACT
Overview Advances in angioplasty equipment and adjunctive medical therapy have been associated with improved immediate and long-term outcomes. However, the treatment of ostial and bifurcation lesions continues to be problematic, with reduced procedural success rates and an increased need for repeat procedures during long-term follow-up. With the exception of aorto-ostial disease, which presents its own unique challenges in terms of accurate visualization and precise instrumentation, these situations share a common pathologic basis, largely related to the likelihood of plaque shift with resultant axial redistribution, which results in the so-called ‘snow-plough’ effect.1,2 A systematic approach to management in these situations requires an understanding of the different possible ‘permutations’ of lesion morphologic type and the likely outcomes after intervention according to these anatomic subtypes. Ideally, a clear rationale for therapeutic decision-making will be based on this kind of information, indicating the need for side-branch protection, the appropriateness of debulking, and whether to deploy one, two (or more) stents. As well as requiring more attention to overall strategic considerations, bifurcation and aorto-ostial lesions commonly pose greater technical challenges, with the potential need to use two guidewires, balloons or stents demanding a higher degree of technical skill in the case of bifurcation disease, and difficulties in guide catheter manipulation
and stent positioning adding to the complexity of aorto-ostial intervention. The likelihood of a higher rate of in-hospital major adverse coronary events (MACE) and a higher restenosis rate when compared to non-bifurcation/ostial lesions must be taken into account if percutaneous intervention is chosen ahead of alternative treatment strategies.
