Ostial right coronary artery lesions: what to know and how to overcome

Percutaneous coronary intervention (PCI) for ostial right coronary artery (RCA) lesions remains challenging and is associated with higher rates of restenosis and target lesion revascularization, even in the contemporary drug-eluting stent era. These unfavorable outcomes are largely attributable to the unique anatomical and histological characteristics of the aorto-ostial junction, including severe calcification, limited vessel compliance, and hinge motion. Intravascular ultrasound (IVUS) studies have identified distinct morphological patterns of ostial RCA lesions, including isolated ostial lesions, diffuse atherosclerotic disease without calcified nodules, and lesions characterized by calcified nodules, which are associated with poorer clinical outcomes. Optimal management of ostial RCA lesions requires careful lesion assessment and tailored therapeutic strategies. For de novo lesions, adequate lesion preparation using high-pressure/scoring balloon dilation, rotational atherectomy (RA), or intravascular lithotripsy is essential to achieve optimal stent expansion. Precise ostial stent placement and intravascular imaging-guided optimization are critical procedural components, and drug-coated balloon (DCB) therapy may be considered in selected cases with a high risk of restenosis. In-stent restenosis (ISR) of the ostial RCA is frequently driven by mechanical factors such as stent underexpansion or fracture. DCBs are the preferred first-line treatment for ISR, while additional lesion modification using high-pressure balloons, RA may be required in cases with significant mechanical constraints. This review summarizes current evidence on the morphology, mechanisms, and contemporary treatment strategies for ostial RCA lesions, with a particular focus on intravascular imaging-guided intervention and practical considerations in clinical practice.