You are on page 1of 5

Frequency of Success and Complications of

Coronary Angioplasty of a Stenosis at the
Ostium of a Branch Vessel
David W. Mathias, MD, Jodi Fishman Mooney, RN, MS, Helmut W. Lange, MD,
Irvin F. Goldenberg, MD, Fredarick L. Gobel, MD, and Michael R. Mooney, MD
The authors of this study hypothesixod that percu-
taneous transhuninal coronary angioptasty of a ste-
nosis at the ostlum of a branch vessel, whether iso-
lated or associated with a bifurcation stenosis, was
associated wlth reduced procedural success and in-
creased in-hospital compliitions. One hundred six
patients with 119 ostial branch stenoses were com-
parod with 1,166 patients who underwent angio-
plasty of nonostial branch stenoses. An ostial
branch stenosis was deftned as a stenosis in the
proximal 3 mm of a major branch vessel (diagonal
[n = 661, posterior descending [n = 211, obtuse
marginal [n = 341 and intermediate [n = 61). The
ostial branch stenosis was isolated in 61% of the
patients and associated with a bifurcation stenosis
in 39%. Despfte a balloon to artery ratio of 1.06~1,
angiographic success was 74% of ostial branch
stenoses versus 91% of nonostial stenoses (p
x0.01). Furthermore, angioplasty of ostial branch
stenoses resulted in a compliition rate of 13 ver-
sus 5% for angloplasty of nonostial branch steno-
ses(p <0.01).me!dore, angioplasty of ostial
branch &noses results in decreased procedural
success and dgnificant reshlual stenosis despite
adequate balloon sizing, suggesting arterial elastic
recoil and a significant increase in compliitions.
(Am JCardiol lSS1;67:491495)
From the Minneapolis Heart Institute, Abbott Northwestern Hospital,
Minneapolis, Minnesota. Manuscript received August 8, 1990; revised
manuscript received October 25, 1990, and accepted October 26.
Address for reprints: Michael R. Mooney, MD, Minneapolis Heart
Institute, 920 East 28th Street, Suite 300, Minneapolis, Minnesota
ercutaneous angioplasty for ostial lesions in the
right coronary artery,’ the left anterior descend-
ing2 and renal arteries3 have been associated with
low technical success rates and increased complications.
We have found that coronary angioplasty for a stenosis
at the ostium of a branch coronary artery can also pre-
sent technical difficulties. We therefore reviewed our
experience in this subgroup of patients and sought to
determine if angioplasty of a stenosis at the ostium of a
branch coronary artery, regardless of whether it repre-
sented an isolated ostial branch stenosis or a bifurcation
stenosis, was associated with increased procedural risks,
poorer overall results, and more frequent in-hospital
complications. Furthermore, although double-wire and
double-balloon techniques used for bifurcation stenoses
have been shown to preserve side branch patency,4-9
there is little information as to their effect on successful
dilation or prevention of angioplasty-related complica-
tions attributable to dilation of the ostial branch vessel.
Patients: Between November 1987 and January
1989, 1,274 patients underwent percutaneous translu-
minal coronary angioplasty (PTCA) at the Minneapolis
Heart Institute, Abbott Northwestern Hospital. Of
these 1,274 patients, 106 patients with 119 stenoses in-
volving the ostium of a branch coronary vessel were
retrospectively identified. All patients demonstrated a
X0% reduction in percent diameter within 3 mm of the
bifurcation of a large epicardial coronary artery. Isolat-
ed ostial branch stenoses (n = 65 patients) and bifurca-
tion stenoses (n = 41 patients) were included for analy-
Procedure: Angioplasty was performed using stan-
dard techniques in all patients. All patients were pre-
medicated with aspirin and a calcium antagonist. Angi-
oplasty was performed after 110,000 units of intrave-
nous heparin were administered to obtain an activated
clotting time of >300 seconds. The femoral approach
was used in nearly all patients. Identical angiographic
views, used for quantitative measurements, were ob-
tained before and after PICA, after the routine admin-
istration of 100 to 200 pg of intracoronary nitroglycerin.
The following coronary angioplasty techniques were
used depending on the coronary anatomy present: (1)
single-balloon and wire technique (n = 65), and (2)
double-balloon technique (n = 41), with successive or
simultaneous inflations.
AMI = acute myocardial Infarction; CABG = coronary artery bypass surgery; CAD = coronary artery disease.
TABLE I Demographic and Clinical Data
Age (mean)
Men/women (%)
Clinical presentation
Stable angina (%)
Unstable angina (%)
Recent AMI (%)
Class Ill or IV angina
Risk factors for CAD
Cigarette smoking (%)
Systemic hypertension
>150 mm Hg systolic (%)
Diabetes mellitus (%)
Serum total cholesterol >200 mg/dl
Family history (%)
Previous CABG (“IO)
Prior AMI (%)
Ostial Nonostial
Branch Stenosis Branch Stenosis*
(n = 106) (n = 1,168)
62 f 10.7 61 f 10.2
75 (71)/31(29) 864 (74)/304 (26)
36 (34)
467 W)
49 w 444 (38)
16(15) 327 (28)
82 (77) 1,016(87)
69 (65) 747 (64)
55 (52) 572 (49)
12 (11) 117 (10)
50 (47)
455 (39)
e-0 (38) 514(44)
ll(l0) 117 (10)
45 (42) 537 (46)
Data acquisition and analysis: Demographic, clini-
cal, angiographic and follow-up data were obtained in
all patients undergoing coronary angioplasty and were
included in a computerized coronary angioplasty data
Angiographic data obtained included the location of
all significant coronary artery stenoses, quantitative
measurements using a Hewlett-Packard electronic cali-
per in 12 identical orthogonal views (percent diameter
stenosis and balloon to artery ratio), lesion morphology,
and the presence or absence of localized or propagating
intimal dissection. An angiographically successful coro-
nary angioplasty was defined by residual diameter ste-
nosis <Xl%. In this study, if multivessel or bifurcation
angioplasty was performed, success was determined by
assessing residual stenosis in the ostial segment.
The following in-hospital complications were ana-
lyzed: abrupt closure, emergent coronary bypass, recur-
rent angina, delayed closure, periprocedural myocardial
infarction, delayed coronary bypass, repeat in-hospital
PTCA and death. Clinical success was defined as angio-
TABLE II Percutaneous Transluminal Coronary Angioplasty:
Procedure Data
Branch Stenosis
(n= 119)
Branch Stenosis
(n = 1,553)
Technical PTCA success
% diameter stenosis
Before PTCA
After PTCA
Number of dilations (mean)
Atmospheres (mean)
Duration (mean)
Balloon:artery ratio
Posterior descending
Obtuse marginal
88 (74%)’ 1.413(91%)9
100 seconds
58 (49%)
21 (18%)
34 (29%)
6 (4%)
134 seconds
1.08: 1
* p <O.Ol.
PTCA = percutaneous translumlnal coronary angioplasty
graphic success plus none of the above-mentioned major
complications occurring during the hospitalization, In
patients with multivessel coronary angioplasty or bifur-
cation lesions, complications were included in the analy-
sis if they were clearly related to the angioplasty of the
ostial branch stenosis. The data obtained from patients
who underwent coronary angioplasty of a stenosis at the
ostium of a branch vessel were compared with our gen-
eral cohort of patients who underwent angioplasty of a
lesion (or lesions) not localized at the ostium of a coro-
nary side branch.
Statisticcr: Continuous variables are expressed as
mean f standard deviation. Chi-square analysis or
Fisher exact tests were used to compare categorical
variables. Differences were accepted as significant if the
p value was <0.05. Analyses were performed on an
IBM computer using SAS statistical packages.
The clinical, demographic and procedure data for
the ostial and nonostial branch stenosis groups are listed
in Tables I and II. Despite a mean of 4 fully inflated
balloon dilations at 8 atm for 100 seconds each (balloon
to artery ratio of 1.05:1), angiographic angioplasty suc-
cess was obtained in 74% of the ostial versus 91% of the
nonostial branch stenosis groups (p <O.Ol). Further-
more, the complication rate (abrupt closure, emergency
coronary artery bypass surgery, myocardial infarction
or death-Table III) was 13% with angioplasty of ostial
branch stenoses versus 5% for PTCA of nonostial
branch stenoses (p <O.Ol).
For patients with bifurcation ostial branch stenosis,
a double-balloon technique was performed if the pri-
mary vessel had an associated significant stenosis at the
bifurcation. The outcome for the branch vessel was not
affected by the specific angioplasty technique per-
formed. Successful dilation of the ostial branch stenosis
was obtained in 74% of the patients when a single-wire
and balloon technique was used versus 78% when a dou-
ble-balloon technique was used (difference not signifi-
cant). The residual ostial stenosis in the bifurcation
loon technique was used (6.3 vs 6.6%). The success rate
cases was persistent throughout the procedure and did
for the primary vessel in these bifurcation cases was
not appear to be the result of “snow plowing” from dila-
91%. Complications in the primary vessel were 3%.
tion of the primary vessel. In addition, there was no dif-
Representative cases of coronary angioplasty of both
ference in in-hospital complications when a double-bal-
isolated ostial branch stenoses and ostial branch steno-
TABLE III In-Hospital Complications
Ostial Nonostial
Branch Stenosis Branch Stenosis
(n = 106) (n = 1.168)
Abrupt closure (“ID)
Emergent CABG (%)
AMI (%)
Death (%)
Complications (abrupt closure,
AMI. emergency CABG or death) (%)
10 (9) 47 (4)
4 (4) 25 (2)
0 (0)
2 (0.2)
58 (5)
* p <O.Ol.
CABG = coronary artery bypass graft surgery; AMI = acute myocardial infarction: PTCA = percutaneous transluminal coronary angoplasty
flGURE 1. A 64.year-old man with a pre-
vleus ante&r wall myocaruliil infarction
tl==Wi -ry artery) uwkment
pereutaneoucr transbminal comeuwy wgi-
oplasty (PTCA) of an ostial diagonal
branch stenosis (A). Balloons, 2.6,3.0
and 3.5 mm were used (6). Agam, despite
a balloon to artsiy ratio of 19:1, ths psr-
zgaN&N transluminal cor-
bih&ath !stemds invoking the kft anterior desfinding comuwy a&y and ostial diagonal branch (A). A
balkan in the kft anterior dcscen&ng artmy was simuftaneousiy Mated with a 2.5-mm fixed wire device in the diagonal branch
(B). Although the percent diameter stenosis in the Left anterior descending arby was reduced from 86 to 1396, the pertxnt
. . . . . . -.
ses associated with bifurcation lesions are shown in Fig-
ures 1 and 2.
Follow-up (mean 7.8 f 5.9 months) was available in
all patients. Of the 88 stenoses that were successfully
dilated, repeat coronary arteriography was performed in
19 patients (22%). A patent ostial segment was present
in 6 patients and restenosis was present in 13 patients.
Repeat coronary angioplasty was performed in 12 pa-
tients, with a technical success of 75%. Clinical follow-
up in this cohort of patients is difficult to evaluate ow-
ing to the presence of multivessel disease in 85% of the
patients. Nonetheless, chest pain was eliminated or im-
proved in 72% of the patients, 2 patients required coro-
nary bypass surgery, and only 2 patients had a myocar-
dial infarction during the follow-up period.
PTCA of stenoses at the ostium of a branch coro-
nary artery results in decreased procedural success de-
spite adequate balloon sizing and increased in-hospital
complications when compared with our general popula-
tion of patients undergoing PTCA. Our findings are
similar to those reported with ostial disease involving
the renal,‘O the right coronary,l and the left anterior
descending coronary arteries2 These studies have sug-
gested that angioplasty for ostial disease is associated
with decreased technical success, more complications
and increased restenosis. SOS et allo demonstrated that,
despite guidewire passage and adequate balloon sizing
and inflations, angioplasty of ostial renal artery stenoses
resulted in a 10 to 20% success rate versus 75% for non-
ostial disease. Topol et al1 showed that RICA of ostial
right coronary artery stenoses produced reduced success
rates and increased complications when compared with
nonostial lesions. Several studies have also suggested in-
creased restenosis in patients with coronary ostial dis-
ease.2,3 It would appear that an ostial stenosis, regard-
less of its location in the vascular system, has unique
properties that make it resistant to or unfavorable for
angioplasty. Previous reports have demonstrated that
side branch occlusion during coronary angioplasty oc-
curs in 14 to 17% of cases, particularly in branches with
preexisting ostial disease.’ l-l3 Because of this, various
techniques have been proposed for coronary angioplasty
of bifurcation stenoses such as double-wire and double-
balloon techniques with successive or simultaneous bal-
loon inflations.4-9 Angioplasty success in these studies
was determined by the outcome of the major epicardial
vessel and not the branch vessel. In fact, the percent
diameter stenosis before and after PTCA has not been
reported for the branch vessel in any of these studies.
Our data indicate that, although these techniques are
useful in preserving side branch patency, they do not
appear to improve the technical success of ostial branch
coronary angioplasty, nor do they prevent subsequent
ischemic complications of the branch vessel.
The presence of significant residual stenosis in ostial
branch lesions after angioplasty despite adequate bal-
loon sizing suggests that the primary mechanism re-
sponsible for technical failure is elastic recoil. Clearly
defined regions of high and low wall shear stress are
created at the apex of bifurcations and in the proximal
branches.14 This increased shear stress at branch points
may lead to an increase in elastic tissue, and account for
elastic recoil after balloon inflations. To overcome this
elastic recoil, balloon oversizing has been used in the
hope of optimizing results of RICA. This strategy may
lead to an increase in complications. Specific revascu-
larization strategies for patients with ostial branch dis-
ease should take into account these findings. Finally,
newer therapeutic procedures such as coronary atherec-
tomy, stents and laser should be evaluated as a potential
measure to improve the treatment of ostial branch coro-
nary artery disease.
Acknowledgment: We thank Ellen Sawicki, RN,
BS, for data collection, Lori Kilber, BS, for data entry,
Howard Liang, MS, for statistical analysis, and Denise
Evans for her assistance in preparation of this manu-
1. Top01 EJ, Ellis Xi, Fishman J, Leimgrubcr P, Myler RK, Stertzer SH, O’Neill
WW, Douglas JS, Roubin GS, King SB. Multicenter study of percutaneous
transluminal angioplasty for right coronary artery ostial stenosis. J Am CON
Cardiol 1987;9:1214-1218.
2. Whitworth HB, Pilcher GS, Roubin GS, Gruentzig AR. Do proximal lesions
involving the origin of the left anterior descending artery have a higher restenosis
rate after coronary angioplasty? (abstr) Circularion 1985;72(suppl III):III-398.
3. Dangoisse V, Guiterasval P, David PR, Lesperance J, Crepeau J, Dyrda I,
Bourassa MG. Recurrence of stenosis after successful percutaneous transluminal
coronary angioplasty. Circulation 1982;66:33 1.
4. George B, Myler R, Stertzer S, Clark D, Cote G, Shaw R, Fishman-Rosen J,
Murphy M. Balloon angioplasty of coronary bifurcation lesions: the kissing bal-
loon technique. Co&f Cardioumc Diagn 1986;12:124-138.
5. O’Keefe JH, Holmes DR, Reeder GS, Bresnahan DR. A new approach for
dilation of bifurcation stenoses: the dual probe technique. Mayo Clin Proc
6. Zack PM, Ischinger T. Experience with a technique for coronary angioplasty of
bifurcation lesions. C&et Cardiomsc Diogn 1984;10:433-443.
7. Nath A, Vetrovcc GW, Cowley MJ, Newton M, Disciascio G, Mukharji J,
Lewis SA. Double-wire angioplasty of the right coronary artery bifurcation steno-
sis. Cathet Cardimmc Diagn 1988;14:37-40.
8. Myler RK, McConaway DR, Stertzer SH, Johnson W, Cumberland DC,
Boucher RA, Hidalgo B. Coronary bifurcation stenoses: the kissing balloon probe
technique via a single guiding catheter. Cathef Cardiwasc Diagn 1989;16:267-
9. Oesterle SN. Angioplasty techniques for stenoses involving coronary artery
bifurcations. Am / Cardiol 1988;61:299-329.
10. Sos TA, Pickering TG, Sniderman K, Saddekni S, Case DB, Silane MF,
Vaughan ED, Laragh JH. Percutaneous transluminal renal angioplasty in reno-
vascular hypertension due to atheroma or Iibromuscular dysplasia. N Engl JMed
11. Vetrovec GW, Cowley MJ, Wolfgang TC, Ducey KC. Effects of percutane-
ous transluminal coronary angioplasty on lesion-associated branches. Am Heart J
12. Boxt LM, Meyerovitz MF, Taus RH, Ganz P, Friedman PL, Levin DC. Side
branch occlusion complicating percutaneous transluminal coronary angioplasty.
Radiology 1986;161:681-683,
13. Meier B, Gruentzig AR, King SB, Douglas JS, Hollman J, Iscbinger T,
Aueron F, Galan K. Risk of side branch occlusion during coronary angioplasty.
Am J Cardiol 1984;53:10-14.
14. Salt&i S, WebbPeplce MM, Coltart DJ. Effect of variation in coronary
artery anatomy on distribution of stenotic lesions. Br Heart J 1979;42:186-191.