Ostial Stenosis Research Articles

Szabo versus provisional stenting of bifurcation coronary lesions

Highlights. This article presents a comparative analysis of the results of PCI of bifurcation coronary lesions using the Szabo technique and provisional stenting in patients with chronic coronary artery disease.Background. Coronary bifurcation and ostial stenosis are difficult to treat and require precise stent positioning in order to prevent restenosis and thrombosis.Aim. To perform a comparative analysis of the outocmes of percutaneous coronary interventions (PCI) of coronary bifurcation lesions using the Szabo technique and provisional stenting in patients with chronic coronary artery disease.Methods. The retrospective single-center observational study included 791 patients. In accordance with the performed bifurcation PCI technique, the patients were divided into two groups: 42 patients in the Szabo group and 749 in the provisional stenting group. Propensity score matching was performed for endpoint analysis, as a result of which 42 patients were selected out of 749 patients in the provisional stenting group, comparable in baseline characteristics with 42 patients in the Szabo group. Study endpoints were cardiac death, myocardial infarction, and repeat revascularization. A composite endpoint (MACE) including all of the above was also evaluated.Results. The median follow-up in the provisional stenting and Szabo groups was 1.3 and 1.4 years, respectively. There were no significant differences between the groups in terms of mortality, myocardial infarction, repeated revascularization and composite endpoint (MACE 23.80% provisional stenting and 19.04% Szabo, p = 0.594).Conclusion. Thus, Szabo is technically simple and safe technique for stenting coronary bifurcation lesions in patients with chronic coronary artery disease, which is not inferior in terms of efficiency to provisional stenting.

Left Main Coronary Artery Ostial Stenosis in a Pediatric Patient With Sudden Cardiac Arrest

Pediatric resuscitated sudden cardiac arrest may result from diverse conditions and, therefore, warrants a comprehensive work-up. Although rare, coronary artery abnormalities must be ruled out in these patients. We describe a case with congenital left main coronary artery ostial stenosis diagnosed using advanced imaging techniques. (Level of Difficulty: Advanced.)

Slučajni nalaz retke anomalije aurikule leve pretkomore - prikaz slučaja

Introduction. Congenital hypoplasia of the left atrial appendage (LAA) with stenotic ostium in an abnormal position is an extremely rare entity. We report an exceptional case of hypoplastic LAA with ostial stenosis in an abnormal location in the patient with mitral valve stenosis that was mistaken in the transesophageal echocardiography (TEE) for an intraluminal thrombus. Case report. A 43-year-old woman was admitted to our center with dyspnea on exertion. TEE revealed the presence of severe mitral stenosis and clot in the LAA. The patient underwent open cardiac surgery by cardiopulmonary bypass. Intraoperative inspection of the left atrium revealed hypoplasia of the LAA with stenotic and slit-like ostium. There was also a malposition of the LAA that was placed in a paravalvular location. The ostium of the LAA was not round and wide but narrowed and slit-like. Conclusion. The authors believe that this anomaly may have some physiologic consequences in patients with mild structural failure. Indeed, this anomaly may aggravate the severity of structural failure by pressure burden on the atrial wall and valve.

Delayed Coronary Ostial Stenosis after Surgical Aortic Valve Replacement and Root Enlargement Treated with Beating Heart On-Pump CABG

Delayed Coronary Ostial Stenosis after Surgical Aortic Valve Replacement and Root Enlargement Treated with Beating Heart On-Pump CABG

Toward More Granular Guidelines in AAOCA: Associating Anatomical Details With Specific Surgical Strategies.

Patients with anomalous aortic origin of a coronary artery (AAOCA) require imaging to clarify the multiple potential anatomic sites of obstruction (fixed or dynamic). Once repaired, the pathway of blood to the myocardium must not encounter: (1) intrinsic ostial stenosis, (2) obstruction from compression or distortion near the commissure or the intercoronary pillar, (3) stenosis where the artery exits the aortic wall (due to an acutely angled "take-off"), (4) compression due to a pathway between the great vessels, (5) stenosis or compression along an intramural course, or (6) compression due to an intramuscular (intraseptal/intraconal) course. Detailed anatomic evaluation of each of these locations allows the surgeon to select an appropriate repair strategy, and each of these abnormal anatomic features should be "matched" with a particular surgical correction. We speculate that the most common surgical repair, unroofing with or without tacking, is often inadequate, as in isolation, it may not allow for correction with a large orifice from the appropriate sinus, without an interarterial course. While the evidence base is insufficient to call these recommendations formal guidelines, these recommendations should serve as a basis for further validity testing, and ultimate evolution to more granular guidelines on AAOCA management.

230 ANOMALOUS ORIGIN OF LEFT CIRCUMFLEX ARTERY FROM RIGHT SINUS OF VALSALVA: A RARE CASE BUT WITH GREAT CLINICAL RELEVANCE

Abstract Introduction The anomalous connection of the left circumflex artery (LCx) to the right coronary artery (RCA) or sinus is the most frequent coronary artery (CA) anomaly. Among them, only those with an interarterial course are regarded as hidden conditions at risk of myocardial ischemia (MI) and sudden cardiac death (SCD). We report an uncommon of anomalous origin of LCx from the right sinus of Valsalva and a retroaortic path causing MI. Case presentation A 61-year-old man presented to the emergency department complaining palpitations and chest discomfort for an hour. He only had history of hypertension. Physical examination was unremarkable. The ECG demonstrated atrial flutter with a 2:1 conduction ratio and a ventricular rate of 157 bpm and ST segment depression in leads V4-6. Transthoracic echocardiography did not reveal segmental kinetic anomalies but a five-chamber apical view showed a “RAC sign”, typical of anomalous retroaortic course of the left coronary artery. The patient was treated with intravenous infusion of amiodarone. He restored sinus rhythm and symptoms regressed completely, but the ECG taken after conversion showed flattened T waves in leads V5-6 and negative T waves in I and aVL. Cardiac enzymes had transient increase. After the acute episode ended the patient underwent cardiac computed tomography angiography (CTA) with evidence of anomalous origin of LCx from the right sinus with a retroaortic course. A coronary angiography excluded obstructive atherosclerotic coronary lesions. Nuclear myocardial perfusion imaging revealed reversible small subsegmental perfusion defects in mid inferolateral wall and apical lateral wall. We established a medical treatment with beta-blocker. Discussion Our patient had anomalous connection of the LCx branch to the right sinus of Valsalva with a retroaortic course. Although this anomaly is usually considered benign, cases of association with SCD and MI have been reported. The factor responsible for this pathogenicity could be high orifice, ostial stenosis, slit-like/fish-mouth-shaped orifice and acute-angle take-off. As cardiac CTA did not reveal any of these characteristics, we hypothesized that the increased cardiac output and expansion of the great vessels during tachycardia could cause compression of the retroaortic segment or angling at its origin and generate ischemia. Repolarization abnormalities at ECG are well documented during supraventricular tachycardia as a response to pacing-induced stress. These changes are usually diffused and disappear after conversion to sinus rhythm. In this case they appeared hours later, accompanied by cardiac enzyme buildup. As the epicardial coronary arteries did not show any pathology, we suggest that the patient had transient ischemia due to LCx anomaly. We confirmed it by myocardial perfusion imaging. As for the management of this anomaly in adults, surgery is recommended as class IC in patients with typical angina symptoms who present with evidence of stress-induced myocardial ischemia in a matching territory or high-risk anatomy. Our patient has never had clear manifestations of angina. All these elements together with the age of our patient motivated us to use a conservative approach. Conclusions We report a case of anomalous origin of LCx from right sinus of Valsalva causing transient myocardial ischemia in a patient that has always been asymptomatic. This anomaly has been and continues to be considered benign, nevertheless we suggest to judge the clinical significance of this kind of CA anomaly on a case-by-case integrated approach.

219 ISOLATED CORONARY OSTIAL STENOSIS DUE TO RECURRENT AORTIC WALL THROMBOSIS

Abstract Background Coronary ostial lesions are a rare entity and isolated coronary ostial stenosis is even less frequent. Diffuse coronary artery atherosclerosis is the main cause for the non-isolated stenosis, based on old post-mortem series and histological analysis of tissue removed during atherectomies. Case presentation A 49-year-old woman suffering from mild non-familial hypercholesterolemia reported to her family physician repeated episodes of chest pain related to exercise. During a cardiological outpatient evaluation, 12 lead electrocardiogram (ECG) and echocardiography turned out normal. During a stress test she had recurrent chest pain coupled with ECG ischemic changes (diffuse ST segment elevation). She was immediately referred to the emergency department where the ECG was back to normal and the troponin dosage within normal range. Coronary angiography was performed: non-selective cannulation revealed some irregularities of the aortic wall profile at the level of the right coronary ostium, with inability to visualize the right coronary artery. The selective cannulation of the left main coronary artery (LMCA), left anterior descending (LAD) and left circumflex branches showed a critical ostial stenosis at the origin of the LMCA without any other relevant lumen restriction, in a left-dominant pattern of coronary circulation. A suspicion of LAD dissection was raised when a laminar flux was observed at its origin. At the end of the procedure, the patient suddenly collapsed. The recorded rhythm was initially bradycardia, evolving to episodes of ventricular tachycardia for which multiple shocks were applied. Despite the resuscitation efforts, the patient never recovered. Autopsy was performed at the local hospital. At gross analysis, a non-uniform pale-tan thickening at the level of the sino-tubular junction was evident with involvement of both the right and left coronary ostia. Histological examination allowed to ascribe the thickening to recurrent thrombosis, without any underlying inflammatory process at the level of the aortic wall and with only minimal atherosclerotic plaques. No coronary artery dissection nor significant stenosis was present in all the coronary tree. Regarding the ventricular myocardium, one focus of replacement-type fibrosis was identified at subendocardial level in the infero-septal wall coupled with a small spot of loose connective tissue rich in hemosiderin-laden macrophages in the same region, consistent with an area of subacute ischemic damage. Conclusion Several series reported a higher frequency of isolated coronary ostial stenosis in women versus men. In fact, female sex along with hypertriglyceridemia have been recognized as independent risk factors for ostial lesions. The case herein reported highlights the diagnostic relevance of the autopsy investigation together with clinicopathological correlation, particularly in cases where the definite diagnosis can't be achieved in vivo.

278 A CASE OF ACCIDENTAL DIAGNOSIS OF ALCAPA SYNDROME IN ASYMPTOMATIC CHILD

Abstract A 7-year-old (y.o.) boy was referred to our center for a specialist evaluation due to alteration of the ventricular repolarization in the anterior and lateral lead on the electrocardiogram at medical evaluation for physical activity. The child was totally asymptomatic, with normal growth and unremarkable past medical history. The physical examination revealed only S4 and a minimal apical systolic murmur. Transthoracic echocardiogram demonstrated a mildly dilated left ventricle (LV) and normal left ventricular ejection fraction. Strain pattern of basal-medium segments of lateral wall was reduced. Right coronary artery (RCA) appeared dilatated and the left coronary artery (LCA) showed an inverse flow at Doppler evaluation. Findings were suspicious for ALCAPA diagnosis (Anomalous Left Coronary Artery Arising from the Pulmonary Artery); a rare congenital heart disease that, if not treated, leads to death in 90% of cases during first year of life. Adult type of ALCAPA (adolescence-60 y.o) is even more rare and can cause heart failure due to a dilatative cardiomyopathy, chronic cardiac ischemia and, in 80-90% of cases, sudden cardiac death. We performed a coronary angiography that confirmed the anomalous origin of LCA from the pulmonary artery. The RCA was dominant, enlarged and supplied an important collateral flow for LCA. Coronary angiography is indicated not only for diagnosis confirmation, but also for coronary tree demonstration, especially in adult type of ALCAPA, because of the presence of not rare anomalies or “adaptation” of peripheral coronary circulation. All these features are important positive prognostic factors that enable survival beyond infancy. LCA ostium stenosis or bronchial artery collateral vessels are also common but weren't seen in this case. In adult type of ALCAPA surgery is usually indicated at the time of diagnosis, so a coronary button transfer and pulmonary Valsalva sinus reconstruction with autologous pericardial patch were performed. This is the preferred surgical technique in adult patients as it is the most anatomic correction. Since before hospitalization heart failure therapy with betablocker was introduced and after surgery aspirin therapy was started too. Post-surgery transthoracic echocardiogram highlighted a moderate pericardial effusion without haemodynamic impact and a pleural effusion, so an anti-inflammatory therapy with ibuprofen, cortisone and then colchicine was started. After discharge anti-inflammatory therapy was under-titrated until suspension based on gradual reduction of pericardial and pleural effusion. Patient was always free of symptoms and with good performance status. ALCAPA or Bland–White–Garland syndrome is an uncommon congenital heart disease. The presence of adequate collateral circulation between RCA and LCA allows to survive beyond infancy (adult type). We described a case of early diagnosis of adult type of ALCAPA in asymptomatic child thanks to a careful examination of basal electrocardiogram for evaluation of non-competitive sport practice.

A Case of Middle Aged Women with Isolated Left Coronary ostial stenosis with Non ST Elevation Myocardial Infarction

Background: The stenosis of the ostial left anterior descending artery represents one of the challenges for the interventional cardiologist. In contrast ostial stenosis of the left main trunk shows very good results after percutaneous interventions and implantation of drug-eluting stents. The indications for percutaneous transluminal coronary angioplasty (PTCA) of an ostial lesion correspond to the indications for treatment of all other lesions. Case: A-56-year-old woman was admitted to our hospital who was initially admitted in the intensive care unit for a severe acute chest pain. She had no coronary risk factors. No hormonal disorders were observed. Physical and laboratory examinations revealed that she had not suffered from syphilis or aortitis syndrome or any other inflammatory diseases. An electrocardiogram (ECG) was immediately performed and showed ST segment non elevation in the precordial leads (Figure 1) suggesting an acute anterior ST Non elevation myocardial infarction (NSTEMI). On coronary angiography, a 80% stenosis of the left coronary ostial stenosis was found, but no abnormality was found in other arterial trees. (Figure 2) The patient was diagnosed as having isolated coronary ostial stenosis. Conclusion: The patients are almost always middle aged woman with no coronary risk factors. , the involved coronary artery is the left main coronary artery, so its obstruction results in a serious condition. Therefore, though its pathogenesis remains to be determined, isolated left coronary ostial stenosis seems to be a distinct clinical entity.

Trends and Real-World Safety of Patients Undergoing Percutaneous Coronary Intervention for Symptomatic Stable Ischaemic Heart Disease in Australia

Percutaneous coronary intervention (PCI) in stable ischaemic heart disease (SIHD) has not been shown to improve prognosis but can alleviate symptoms and improve quality of life. Appropriately selected patients with symptoms refractory to medical therapy therefore stand to benefit, provided safety is proven. Consecutive patients undergoing PCI for SIHD between 2005-2018 in a prospective registry were included. Yearly comparisons evaluated trends, and a sub-analysis was performed comparing proximal left anterior descending artery (prox-LAD) to other-than-proximal LAD (non-pLAD) PCI. Outcomes included peri-procedural characteristics, in-hospital and 30-day event rates including MACE, and 5-year National Death Index (NDI) linked mortality. There were 9,421 procedures included. Over time, patients were increasingly co-morbid and had higher rates of AHA/ACC class B2/C lesions, ostial stenoses, bifurcation lesions, and chronic total occlusions (all p-for-trend ≤0.001). Over 14 years, major bleeding reduced (1.05% in 2005/06 vs 0.29% in 2017/18, p-for-trend <0.001), while other in-hospital and 30-day event rates were stably low. There were only seven (0.07%) in hospital deaths and 5-year mortality was 10.3%. No differences were found in outcomes between patients who underwent prox-LAD compared to non-pLAD PCI. Major independent predictors of NDI linked all-cause mortality included an eGFR <30 mL/min/1.73 m2 (HR 4.06, 95% CI 3.26-5.06), chronic obstructive pulmonary disease (COPD) (HR 2.25, 95% CI 1.89-2.67) and LVEF <30% (HR 2.13, 95% CI 1.57-2.89). Although patient and procedural complexity increased over time, a high degree of procedural success and safety was maintained, including in those undergoing prox-LAD PCI. These real-world data can enhance shared decision making discussions regarding whether PCI should be pursued in patients with symptomatic SIHD refractory to medical therapy.

ASCENDING AORTIC ANEURYSMS: SURGERY, RMODELLING & AI

ASCENDING AORTIC ANEURYSMS: SURGERY, RMODELLING & AI

Analysis on the correlation between the occurrence of vertebral artery ostium stenosis and the severity of osteoporosis in elderly patients with atherosclerosis

To analyze the correlation between the occurrence of vertebral artery ostium stenosis (VAOS) and the severity of osteoporosis in elderly patients with atherosclerosis (AS), and disclose the physiopathologic mechanism of the correlation between VAOS and osteoporosis. 120 patients were divided into two groups. The baseline data of both groups were collected. The biochemical indicators of patients in both groups were collected. The EpiData database was established to enter all the data into the database for statistical analysis. There were significant differences in the incidence of dyslipidemia among risk factors of cardia-cerebrovascular disease (P<0.05). LDL-C, Apoa and Apob were significantly lower than the control group (P<0.05). BMD, T-value and Ca in the observation group were significantly lower than the control group, while BALP and serum phosphorus in the observation group were significantly higher than the control group (P<0.05). The more severe the VAOS stenosis, the higher the incidence of osteoporosis, and there was a statistical difference in the risk of osteoporosis among different VAOS stenosis degrees (P<0.05). Apolipoprotein A, B and LDL-C in blood lipids are important factors affecting the development of bone and artery diseases. There is a significant correlation between VAOS and the severity of osteoporosis. The pathological calcification process of VAOS has many similarities with the process of bone metabolism and osteogenesis, and shows preventable and reversible physiological characteristics.

Use of drug-eluting, balloon-expandable resolute onyx coronary stent as a novel treatment strategy for vertebral artery ostial stenosis: Case series.

Vertebral artery (VA) ostial stenosis is notoriously difficult to treat using bare-metal stents owing to high rates of restenosis and stent kinking and breakage. We investigated the safety and effectiveness of treatment with a drug-eluting, balloon-expandable coronary stent (Resolute Onyx, Medtronic). Our prospectively maintained database was retrospectively searched for consecutive patients diagnosed with VA ostial stenosis who underwent Resolute Onyx stenting with/without angioplasty between January 1, 2015 and January 1, 2022. Patient demographics and clinical and radiographic presentations were recorded. Occlusion location, stenosis severity, contralateral disease, devices used, and intraprocedural and postprocedural complications were noted. Outcomes were assessed based on new or recurrent stroke, transient ischemic attack (TIA), or intracranial hemorrhage (ICH). Patients were followed up clinically and with radiographic imaging for in-stent stenosis. Twenty-six patients were included in our study (21 men [80.8%]; mean age 70.3 ± 9.8 years). Symptomatic patients presented with TIA (11/26, 42.3%) and stroke (10/26; 38.5%). Mean stenosis in the study cohort was 74.9 ± 13.0%. One (3.8%) intraprocedural complication was encountered whereby the stent failed to open despite several attempts and was exchanged with a new one without issues. No in-hospital postprocedure stroke, TIA, or mortality was reported. During a mean 16.2 ± 13.6 months' follow up, two patients developed symptomatic in-stent restenosis that was treated with balloon angioplasty. We report the first case series of Resolute Onyx drug-eluting stenting including 30-day postprocedure stroke/TIA rates and clinical/radiographic follow up and demonstrate safe and effective treatment of symptomatic and asymptomatic VA ostial stenosis.

Abstract 12089: Right Coronary Artery Aneurysm in Takayasu Arteritis

Background: Takayasu arteritis (TA) is a large vessel vasculitis that affects the aorta and its primary branches. The coronary arteries are uncommonly involved. Case Presentation: A 52-year-old man, with a history of TA not on immune suppressants due to recurrent active miliary tuberculosis, was scheduled for open abdominal repair of a multilobulated saccular thoracoabdominal aneurysm. Cardiology was consulted for pre-operative evaluation. His physical exam and EKG were unremarkable. Imaging of his coronaries with CT angiography showed proximal and distal right coronary artery dilation (14 mm) and a intraluminal thrombus. Revascularization surgically or percutaneously was not advised. Additional vascular interventions were postponed until the patient received adequate treatment for his tuberculosis and uncontrolled TA. The patient was started on ASA and warfarin for the intraluminal thrombus and coronary aneurysm. Discussion: Coronary artery aneurysms are rare in TA. When coronaries are involved, ostial stenosis or occlusion is the most common lesion. Invasive coronary angiography is difficult due to diffuse vascular disease and involvement of the aorta. The imaging modality of choice remains a debate. CT angiograms remain a reasonable option for the assessment of coronary involvement. There is no established guideline for the treatment of coronary thrombus in patients with TA. Because coronary aneurysms promote thrombus formation by stasis and abnormal flow conditions, it is reasonable to treat with ASA combined with warfarin as they do in Kawasaki disease. Conclusion: Although rare in TA, coronary aneurysm formation is possible. A coronary angiogram is technically difficult in this group of patients, and CT angiograms remains a safe option to define coronary anatomy. The treatment guidelines are lacking, and ASA combined with warfarin is a reasonable option to reduce myocardial infarction and death.

Evaluation of Long-Term Outcomes of Crossover or Focal Ostial Stenting of Left Anterior Descending Artery Ostial Stenosis

Optimal management of patients with ostial left anterior descending artery stenosis remains an unresolved issue. Patients with ostial left anterior descending stenosis who underwent stent implantation were included in this study. Coronary records of all patients were monitored, and long-term clinical outcomes were recorded. The patients were divided into 2 groups according to the stenting method: focal left anterior descending stenting [ostial stenting group] and stenting from the left main coronary artery to the left anterior descending [crossover stenting group]. Of the 97 eligible consecutive patients, 56 were treated with ostial stenting and 41 with crossover stenting. At a mean follow-up of 23.6 ± 12.6 months, non-fatal myocardial infarction (3.9% vs. 12.8%, P=.118), target lesion revascularization (5.9% vs. 12.8%, P=.252), and all-cause death (2.0% vs. 7.7%, P=.191) rates were not statistically significant. However, the rate of major adverse cardiovascular events defined as a composite of non-fatal myocardial infarction, target lesion revascularization, or all-cause death was significantly higher in the crossover stenting group (8.2% vs. 28.2%, P = .013). In the multiple regression analysis, left main coronary artery diameter (odds ratio = 4.506; 95% CI: 1.225-16.582, P = .024) and application of the crossover stenting technique (odds ratio = 5.126; 95% CI: 1.325-19.833, P = .018) were found to be the most effective predictors of major adverse cardiovascular events. In our study, the ostial stenting group was associated with better clinical outcomes in the treatment of ostial left anterior descending stenosis. However, it is notappropriate to apply a single method to all patients with such lesions.

A balloon-supported embolism protection technique during vertebral/subclavian artery angioplasty stenting.

A balloon-supported embolism protection technique during vertebral/subclavian artery angioplasty stenting.

Cardiovascular Disease Prevention in Patients With Atherosclerotic Renovascular Disease-Induced Resistant Hypertension: Further Considerations for 24-Hour BloodPressure Profiles.

Cardiovascular Disease Prevention in Patients With Atherosclerotic Renovascular Disease-Induced Resistant Hypertension: Further Considerations for 24-Hour BloodPressure Profiles.

Surgical Ostioplasty of the Left Main Coronary Artery: An Alternative to Coronary Artery Bypass Grafting in the Treatment of Left Main Stem Isolated Ostial Stenosis—A Case Series

This study aims to demonstrate the use of surgical ostioplasty of the left main coronary artery as an alternative technique to the conventional use of coronary artery bypass grafting for the treatment of left main stem-isolated ostial stenosis. From 2002 to 2021, five patients—three women (60%) and two men (40%)—presented with a history of angina pectoris and were diagnosed with isolated stenosis of the coronary ostia associated with normal distal coronary arteries. Pre-operative cardiac catheterization and echocardiography were performed to aid in the diagnosis. The patients were submitted to surgical ostioplasty with a posterior approach using a saphenous patch. There were no hospital deaths or myocardial infarctions during the post-operative period. The mean cardiopulmonary bypass time was 82 min (range, 70–95 min), and the mean aortic-clamp time was 62 min (range, 55–75 min). The average time of hospitalization was 6.2 days (range, 4–18 days). Patients with isolated stenosis of the coronary ostia associated with normal distal coronary arteries may be submitted to left main coronary artery ostioplasty as an alternative to coronary artery bypass grafting, the traditional surgical technique for this pathology.

Simultaneous angiographic and instantaneous wave-free ratio co-registration assisted with intravascular ultrasound for optimal assessment of left main coronary artery ostial stenosis and optimization of the angioplasty effect.

Simultaneous angiographic and instantaneous wave-free ratio co-registration assisted with intravascular ultrasound for optimal assessment of left main coronary artery ostial stenosis and optimization of the angioplasty effect.

Reply to Letter to the Editor: "Management of Coronary Ostial Stenosis with Drug Coated Balloons: Technicaland Clinical Aspects".

Reply to Letter to the Editor: "Management of Coronary Ostial Stenosis with Drug Coated Balloons: Technicaland Clinical Aspects".