Intravascular ultrasound-guided percutaneous coronary intervention for syphilitic coronary ostial lesions: a single-center case series.

Objectives: This study aims to preliminarily explore the feasibility and safety of intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) for syphilitic coronary artery ostial lesions (SCAOL), providing hypothesis-generating insights for optimal stenting strategies in this distinct pathological entity. Background: Cardiovascular syphilis, a severe manifestation of tertiary syphilis, frequently leads to coronary ostial stenosis. While coronary artery bypass grafting (CABG) is the traditional revascularization modality, PCI has emerged as a minimally invasive alternative. Given the "borderless" inflammatory nature of syphilitic aortitis, the efficacy of the conventional "flush-alignment" stenting strategy lacks specific evidence. Methods: We retrospectively analyzed seven consecutive patients with confirmed SCAOL who underwent PCI at our center between January 2019 and February 2026 (follow-up through March 2026). All cases were diagnosed via syphilis serology, and IVUS was utilized for pre-procedural assessment and post-stenting optimization. The IVUS characteristics of SCAOL and PCI-related outcomes were analyzed to explore the potential impact of stent positioning strategies. The study received institutional ethical approval and written informed consent from all patients. Results: The cohort included four males and three females (mean age: 54.3 ± 3.4 years). Pre-procedural IVUS consistently revealed concentric fibrous hyperplasia and significant negative remodeling, lacking typical atherosclerotic plaque features. Second-generation drug-eluting stents (DES) were successfully implanted in all seven patients. Six patients, whose stents protruded variably into the aortic sinus (ranging from approximately 2-4 mm in most cases), remained free of major adverse cardiovascular events (MACE) over a median follow-up of 4 years (IQR: 3-6 years). Conversely, one patient (Case 6), who received a "flush-alignment" LM stent (protrusion <1 mm) and lacked standardized anti-syphilitic therapy, developed NSTEMI due to severe in-stent restenosis (ISR) 8 months post-procedure. A bailout PCI utilizing a protrusion of approximately 4-5 mm was performed, and the stent remained patent at the 13-month follow-up. Conclusions: IVUS-guided PCI was technically feasible in this small retrospective series of patients with suspected syphilitic coronary ostial lesions. Moderate aortic protrusion may help ensure ostial coverage, but the optimal protrusion length and its effect on restenosis require confirmation in larger multicenter studies. Furthermore, mechanical revascularization must be coupled with standardized systemic anti-syphilitic therapy and careful control of residual inflammatory activity to optimize long-term prognosis.