What is the best view for ostial Right Coronary Artery (RCA) stenting?

Best Angiographic View for Ostial RCA Stenting

For ostial right coronary artery (RCA) stenting, use the LAO (left anterior oblique) cranial view as your primary working projection, as it provides optimal visualization of the aorto-ostial junction in 98% of cases.

Primary Recommended View

• The LAO cranial view is the gold standard for ostial RCA visualization and stent placement, demonstrating adequate visualization of the RCA origin in 45 of 46 patients (98%) compared to only 33 of 46 (72%) with standard LAO views 1
• This angulated projection eliminates foreshortening and overlap that commonly obscures the aorto-ostial junction in standard views 1

Complementary Views for Confirmation

• Use RAO (right anterior oblique) views as secondary projections to confirm stent position, though these show the ostium adequately in only 37% of cases as a primary view 1
• Multiple angiographic views should be employed to assist in precise placement, as no single universal technique guarantees perfect ostial stent positioning 2
• RAO angled views (cranial or caudal) provide improved visualization of distal RCA segments but are of more limited utility for the ostium itself 1

Technical Considerations for Ostial RCA Lesions

Lesion Assessment

• IVUS guidance is reasonable (Class IIa) for assessment of angiographically indeterminate aorto-ostial disease, as conventional angiography can be misleading due to vessel overlap, aortic cusp opacification, and contrast streaming 3
• Aorto-ostial stenoses are most commonly atherosclerotic but can occur with congenital malformations, radiation exposure, or vasculitides 3

Stent Selection and Deployment

• Drug-eluting stents (DES) are reasonable (Class IIa, Level B) for aorto-ostial stenoses, as they reduce restenosis compared to bare metal stents 3
• Balloon angioplasty alone for ostial stenoses has lower procedural success rates, more frequent complications, and greater late restenosis 3

Calcification Management

• Rotational atherectomy is reasonable (Class IIa, Level C) for heavily calcified ostial lesions that cannot be crossed by a balloon catheter or adequately dilated before stenting 3
• Severely calcified lesions respond poorly to balloon angioplasty and may result in incomplete stent expansion 3
• When rotational atherectomy is not available, a buddy wire technique with focused-force angioplasty using slow incremental balloon inflation can be employed for plaque modification 4

Common Pitfalls and How to Avoid Them

Guiding Catheter Challenges

• Ostial RCA disease presents unique challenges with guiding catheter intubation, particularly when severe calcification creates a bar at the aorto-ostial junction 4
• Deep intubation should be avoided to prevent damaging the ostial lesion or causing dissection
• Coaxial alignment is critical for optimal stent delivery and deployment

Stent Positioning Errors

• Geographic miss (incomplete lesion coverage) is a major concern with ostial lesions - the stent must adequately cover the true ostium without excessive protrusion into the aorta 2
• Slight stent protrusion (1-2mm) into the aorta is generally acceptable and may be preferable to incomplete ostial coverage 2
• Verify final position in multiple views before post-dilation

Intracoronary Imaging Optimization

• Intracoronary imaging (IVUS or OCT) guidance is associated with lower risk of target vessel failure in complex lesions, though OCT has limitations for ostial left main disease due to contrast requirements 3
• IVUS allows assessment of minimum stent area, malapposition, underexpansion, and edge dissection after deployment 3
• A minimum stent area <4.5-5.0 mm² by OCT is an independent predictor of major adverse cardiac events 3