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  • Editorial: Ostial left circumflex disease and the company it keeps

    Contemporary bifurcation stenting is challenging to master, encompassing decision making on various techniques that have multiple nuanced steps that continue to undergo refinement. The interest in this lesion subset stems from the prevalence, up to 1-of-5 percutaneous coronary interventions (PCI), and associated risk of adverse events including restenosis  . Of particular difficulty are lesions located at the ostium of major epicardial vessels due to their elastic fiber content, angulation, and calcium burden, which may raise recoil, increase wall rigidity, and lessen arterial distensibility, as is also seen with aorto-ostial lesions  . There are, however, differences in tackling an aorto-ostial lesion compared to ostial left anterior descending (LAD) and/or ostial left circumflex (LCx) artery bifurcation lesions  . Aorto-ostial lesions tend to cause operators difficulty due to limitations of traditional angiographic techniques for defining the coaxial plane to map the intervention and the incompatibility of the complex 3D anatomy with existing stent designs  . Furthermore, aorto-ostial lesions are notoriously associated with >50% rate of stent misplacement  . On the other hand, positioning stents at ostial LCx lesions is uniquely challenging due to the vessel often having steep angulation  . There is also risk of plaque or carina shift to the adjacent vessel during intervention, which is not encountered with aorto-ostial lesions  . A Medina 0,0,1 lesion is one that involves isolated ostial side branch disease with no disease in the proximal or distal main branch and is relatively uncommon, encountered in <5% of all bifurcations. The intervention of a Medina 0,0,1 lesion requires consideration of important factors such as lesion morphology and the degree of ischemia in the associated vessel territory. The majority of Medina 0,0,1 lesions do not supply >10% of the myocardium; however, in the case of ostial LCx lesions, the situation is often different  . The other major concern with intervening on a Medina 0,0,1 lesion is the possible compromise of the proximal main vessel, in the case of the ostial LCx, that would be referring to the left main coronary artery  .

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