Doctor & Patient Education Cardiac Specialist Centre
8. RCA ostial lesion
Right Coronary Artery Ostial Lesion

Ostial lesion

  • Intervention of ostial lesions can sometimes be challenging
  • This is because the guiding catheter may not engage properly
  • During engagement, there may be damping of pressure
  • Optimum angle for angiogram may not be achieve making stent placement difficult
  • Movement of the heart with each beat and respiration may result in excessive to and fro movement of stent during inflation resulting in inaccurate placement position
  • This patient presented with anginal symptoms and positive stress test
  • The intervention was performed via the right radial route
  • Initial angiogram shows a very tight ostial lesion
  • Various guiding catheters could not engage the ostium to provide support
  • The final choice was a 6F AL 1 guide

The JR guide although could engage the RCA, it did not provide support for intervention

1 Base LAO


The AP cranial view shows the very ostial stenosis

2 Base Cran


AL1 guide could not engage at all
The Fielder wire search the aortic root and entered the RCA with the guide non-coaxially engaged

3 Non Coaxial wiring


Pre-dilatation with a 1.5 x 12 mm balloon

4 Balloon one point five


Even with the balloon seated in RCA the guide still could not be co-axially engaged

5 Still cannot get coaxial


  • To provide more support and to prevent the guide being kicked out, a buddy wire was used
  • The ostium was dilated with 2.5 x 15balloon
  • However, after dilatation with this balloon, a 3.0 x 15 balloon still could not be delivered due to poor guide support
6 double wire and balloon


  • To deliver the 3.0 balloon into the lesion, the 2.5 x 15 balloon was stationed in mRCA and inflated as anchor
  • The 30 x 15 balloon was then inflated to dilate the ostial lesion
  • However, after dilatation, the guide was still not able to engage ostium to enable adequate angiogram
7 double wire three mm balloon


  • To obtain an adequate ostial angiogram, the 3.0 x 15 balloon was inflated in the mRCA, the guide railroaded into position and the dye injected while the 3.0 x 15 balloon was still inflated
  • This allows the ostium to be visulised
8 Using balloon to obtain os angio


The stent can now be placed

9 stent placement


  • After deploying the stent, the stent balloon was pushed down to mRCA and again inflated while dye was injected
  • This allows visualisation of the ostium
10 Post stent balloon assisted pic


  • To see the whole of RCA, the deflated balloon is pulled back into the guide while dye is being injected
  • This maneuver sucks the guide into the RCA ostium thus allows adequate dye to flow down RCA
11 Deflated balloon shot


  • For the final shot, the wires and balloon have been removed
  • Thus the guide again cannot be coaxed to sit in proper co-axial position
  • The angiogram although adequate, is non-the-less not perfect
12 without wire is hard to see


  • Ostial lesion may be tricky to treat
  • But there are tricks to overcome the difficulties to facilitate satisfactory treatment
Know Your Cardiologists

I feel breathless when walking.

I feel a tightness over my chest.

Do I need to take my medicine for my blood pressure?

Do I need to take my medicine for my cholesterol?

Do I really need stents for my artery?

Do I really need to have a bypass operation?

When should I go for health screening?

I have heart problem, can I take Viagra?

I have heart problem, should I exercise?

Heart Disease
Learn about your heart Conditions

You may need an ultra sound scan of your heart to assess its function.

You may need a treadmill stress test.

You may need closer monitoring.

You may need a more thorough risk assessment and life style change.

You may only need to take your medicine.

You may get away with just stenting.

This generally should start at 40 years old.

Yes, but there are certain strict conditions to fulfill.

Yes, but you will need to find out the appropriate intensity.