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. 2021;28(6):831-841.
doi: 10.5603/CJ.a2021.0080. Epub 2021 Aug 6.

Optimal fluoroscopic viewing angles for stenting of the coronary aorto-ostial lesions

Radosław Targoński  1 , Jarosław Meyer-Szary  2 , Bartosz Baścik  3 , Edyta Szurowska  3 , Aleksandra Gąsecka  4 , Dariusz Jagielak  5 , Miłosz J Jaguszewski  6
Affiliations

Optimal fluoroscopic viewing angles for stenting of the coronary aorto-ostial lesions

Radosław Targoński et al. Cardiol J. 2021.

Abstract

Background: Long-term results after stenting aorto-coronary ostial lesions (AOL) are worse than those achieved in non-ostial locations. AOL interventions still pose a substantial challenge for interventional cardiologists. The aim of the study was to determine the optimal fluoroscopic viewing angles of the left and right coronary ostia, based on multislice computed tomography (MSCT) data.

Methods: Cardiac MSCT exams of 30 patients with clinical suspicion of coronary artery disease were analyzed. En face angles of both coronary ostia, as well as their optimal projection curves, were determined by 2 independent observers in a standard Dicom viewer, without any additional, specialized software add-ons, using a systematic, step-by-step approach. Spatial relations between the ostial plane and the aorta were also assessed.

Results: The average en face angle of the left coronary ostium was RAO 23°, CAU 45°; for the right coronary ostium RAO 18°, CRA 5°. The mean inter-observer differences for the en face angles of the left and right coronary arteries were 5° and 7°, respectively.

Conclusions: Multislice computed tomography data provide precise spatial information on the orientation of the coronary ostia and their relation to the aortic root. Their utilization for determining the patient-specific viewing angle may substantially facilitate percutaneous coronary interventions in AOL.

Keywords: aorto-ostial lesions; cardiovascular imaging; coronary intervention; multislice computed tomography; optimal projection curves.

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Conflict of interest statement

Conflict of interest: None declared

Figures

Figure 1
Figure 1
Systematic step-by-step approach for identifying the coronary aorto-ostial plane.
Figure 1
Figure 1
Systematic step-by-step approach for identifying the coronary aorto-ostial plane.
Figure 2
Figure 2
The optimal projection curve based on the determined en face angle; A. The optimal projection curve (red line) corresponding to the determined en face angle of the coronary ostium (red dot); B. The range of the optimal projection curve in which the coronary ostium does not overlap with the adjacent aorta. Because determining this range is based on the caudal/cranial (CAU/CRA) angulation, it is crucial to notice that two different points on the S-curve can have the same CAU/CRA angulation value (blue arrows). They can be identified by their relation to the maximal angulation of the curve (yellow arrows). Red dotted lines — “obstructed” view, green line — “unobstructed” view.
Figure 3
Figure 3
Finding the range of S-curve in which the ostium and the aorta do not overlap with each other.
Figure 4
Figure 4
En face angles of the right and left coronary ostia and their corresponding optimal projection curves (mean and 95% confidence interval). En face angle — blue dot. Optimal projection curve — blue line. The red area indicates the range in which the coronary ostium and the aortic root overlap. Central panel represents schematic illustration of coronary ostia plane in relation to the aortic root.
Figure 5
Figure 5
Individual optimal projection curves and en face angles in the study cohort. Optimal projection curves for the ostia of the left (A) and right coronary arteries (B). The range of the optimal projection curves in which neither the left (C) nor right coronary ostium (D) overlaps with the adjacent aorta. En face angles of left (E) and right coronary ostia (F).
Figure 6
Figure 6
Clinical examples of the suboptimal stent placement in the aorto-coronary ostial lesions. Geographic miss (arrow), stent in the right coronary artery (RCA) implanted too deeply (A); subsequent restenosis in the RCA (arrow) (B); stent protruding from left main into the aorta (arrow) (C); protruding stent crushed (arrow) by the calcified, widened aortic leaflet on postmortem examination (D); two stents protruding from the left coronary artery to the aorta (arrows) accidental finding in the patient admitted for transcatheter aortic valve replacement (E).
Figure 7
Figure 7
Examples of different aortic root configurations and their impact on the S-curve. Two examples of different aortic root configurations; A. A narrow “angiographic window” of the left coronary artery (LCA) ostium (green oval) with a very limited range of possible angulation (green arrow) of the X-ray source (yellow arrow) (adjacent aorta — red area); B. A wide “angiographic window” of the right coronary artery (RCA) ostium (green circle), offering a 360-degree view; C. The range of the corresponding S-curves in which the coronary ostium does not overlap with the adjacent aorta. In the case of the LCA (blue curve), angiographic viewing angles are limited, but are paradoxically “standard” and easy to achieve, while in the case of the RCA ostium (orange curve), its S-curve is quite atypical and, despite the full range, the degree of cranial angulation in standard left anterior oblique projections makes them unfeasible.
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