Korean Circ J.  2019 Sep;49(9):771-793. 10.4070/kcj.2019.0198.

Optimization of Percutaneous Coronary Intervention Using Optical Coherence Tomography

• Lee CH
• Hur SH

• KMID: 2455784
• DOI: http://doi.org/10.4070/kcj.2019.0198

Abstract

Compared to the luminogram obtained by angiography, intravascular modalities produce cross-sectional images of coronary arteries with a far greater spatial resolution. It is capable of accurately determining the vessel size and plaque morphology. It also eliminates some disadvantages such as contrast streaming, foreshortening, vessel overlap, and angle dependency inherent to angiography. Currently, the development of its system and the visualization of coronary arteries has shown significant advancement. Of those, optical coherence tomography (OCT) makes it possible to obtain high-resolution images of intraluminal and transmural coronary structures leading to navigation of the treatment strategy before and after stent implantations. The aim of this review is to summarize the published data on the clinical utility of OCT, focusing on the use of OCT in interventional cardiology practice to optimize percutaneous coronary intervention.

Keyword

Coronary artery disease; Percutaneous coronary intervention; Optical coherence tomography

MeSH Terms

Angiography
Cardiology
Coronary Artery Disease
Coronary Vessels
Percutaneous Coronary Intervention*
Rivers
Stents
Tomography, Optical Coherence*

Figure

• 

  Figure 1 A representative case demonstrating a discrepancy between coronary angiography and OCT. The right anterior oblique cranial projection of the left coronary angiogram showing mild stenosis at an LAD bifurcation lesion (A). However, OCT clearly demonstrates a focal (2 mm length) lotus root-like lesion consisting of multiple cavities with septation, which was not seen by coronary angiography (B). Modified from Korean J Intern Med 2016;31:807-808. LAD = left anterior descending; OCT = optical coherence tomography.

• 

  Figure 2 A representative case of an OCT-guided PCI (stent sizing and post-stent optimization). A 57-year old female patient with a non-ST segment myocardial infarction underwent CAG and an OCT examination before the intervention (panel I, A-E), after the stent implantation (panel II, F-K) and after additional balloon dilatation (panel III, L-Q). The baseline CAG revealed significant stenosis in the proximal right coronary artery (A). A longitudinal OCT image revealed a lesion length of 23.3 mm (B) and the cross-sectional OCT image revelaed a 1.66 mm2 lumen area with a red thrombus (C). Because the EEL contours were identifiable in both the proximal (C) and distal (D) reference segments, the mean EEL to EEL diameter was calculated. Of these, the lowest EEL to EEL diameter was 3.89 mm in the proximal reference segment (E). Thus a 3.5×28 mm Xience stent was chosen based on downsizing to the nearest stent diameter (3.5 mm) from the lowest EEL to EEL diameter (3.89 mm) and was implanted with a 12 atmospheric pressure. After the stent implantation, a CAG showed a mild residual stenosis at the proximal portion within the stented segments (F) and the longitudinal OCT image showed that the MSA was 4.24 mm2 and was located at the proximal one-third portion within the stented segments (G). Because a long stent (≥28 mm) was implanted in the proximal right coronary artery, the entire stented segments were divided by the stent length of 14 mm, half the stent length, and the reference bar was moved to each distal and proximal stented segment for an evaluation of the optimal relative stent expansion. Then, the residual AS was manually calculated by the OPTIS system: [[{1−(proximal (or distal) MSA/proximal (or distal) reference lumen area)}×100]=residual proximal (or distal) AS (%)]. The longitudinal and cross-sectional OCT images showed that the MSA in the distal half of the stented segments was 5.21 mm2, which calculated that the residual distal AS value was 17.4% relative to distal reference lumen area: [{1−(5.21/6.31)×100}=17.4% of AS] (I). Similarly, the MSA in the proximal half of the stented segments was 4.24 mm2, which calculated that the residual proximal AS value was 39.1% relative to proximal reference lumen area [{1−(4.24/6.96)×100}=39.1% of AS] (K). Stent underexpansion was confirmed by these AS results (an acceptable stent expansion is defined as an AS of at least <10% relative to each reference lumen area). The post-dilatation balloon size was determined by the EEL to EEL diameter of the proximal reference segment. Thus, post-dilatation was performed using a 3.75×8 mm non-compliant balloon throughout the stented segments. After additional balloon dilatation, a CAG showed no residual stenosis within the stented segments (L). The longitudinal and cross-sectional OCT images showed that the MSA in the distal half of the stented segments improved from 5.21 mm2 to 6.48 mm2, which calculated that the residual distal AS value had reduced from 17.4% to 1.2% relative to the distal reference lumen area [{1−(6.48/6.56)×100}=1.2% of AS] (O). Similarly, the MSA in the proximal half of the stented segments improved from 4.24 mm2 to 6.65 mm2, suggesting that the residual proximal AS value had decreased from 39.1% to 2.7% relative to the proximal reference lumen area [{1−(6.65/6.83)×100}=2.6% of AS] (Q). Based on the AS results post-dilatation, the stent optimization was confirmed without any complications. AS = area stenosis; CAG = coronary angiography; DS = diameter stenosis; EEL = external elastic lamina; Φ = diameter; MSA = minimal stent area; MLA = minimal lumen area; OCT = optical coherence tomography; PCI = percutaneous coronary intervention.

• 

  Figure 3 Stepwise procedure for the stent optimization under OCT guidance. EEL = external elastic lamina; PCI = percutaneous coronary intervention; OCT = optical coherence tomography; Φ = diameter; MSA = minimal stent area; ref. = reference; LA = lumen area; NC = noncompliant.

• 

  Figure 4 A representative case of an OCT-angiography coregistration. Preinterventional OCT-angiography coregistration (panel I, A-C). Angiographic coregistration (A) shows diffuse significant disease in the proximal portion of the LAD. The red arrowheads indicate the proximal reference segment. The corresponding cross-sectional OCT image (B) demonstrates a fibrous plaque with a preserved lumen area at the proximal reference segment, and the longitudinal OCT image (C) also shows diffuse significant disease in the proximal portion of the LAD. Post-stenting OCT-angiography coregistration (panel II, D-F). In the angiographic coregistration (D), the 2nd red arrowhead and sky-blue arrowhead indicate the stented segments (1st DES 3.0×35 mm). The 1st red arrowhead indicates the location of the proximal edge dissection. The corresponding cross-sectional OCT image (E) and longitudinal OCT image (F) show a severe dissection with an intimal flap. Thus, a 2nd DES (3.5×15 mm) was implanted and the final OCT-angiography coregistration shows that the additional DES completely covered the prior proximal edge dissection (panel III, G-I). OCT = optical coherence tomography; DES = drug-eluting stent; GW = guide wire; LAD = left anterior descending.

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  Figure 5 A representative case demonstrating a stent malapposition viewed by OCT. Preinterventional angiography and OCT images (panel I, A-C). Interventional images of pre-dilatation and stent implantation (panel II, D-F). Pre-dilatation was performed using a 2.5×20 mm compliant balloon (D) followed by stent implantation in the LAD (1st DES 2.75×28 mm, 2nd DES 3.5×23 mm) (E-F). A post-PCI stent malapposition was detected by OCT images (panel III, G-I). Post-PCI angiography did not detect any stent malappositions (G). In the OCT cross-sectional view, the maximal stent to vessel wall distance was 1,050 µm (H). In the OCT longitudinal view, a critical stent malapposition (red line) was detected in the stent proximal segment and the stent malapposition length was approximately 5 mm (I). Additional high-pressure dilatation using a NC 4.5×8 mm balloon (J). Final angiography and OCT images after the NC ballooning (panel IV, K-M). Slight expansion of the stent proximal segment on angiography (K). No evidence of a stent malapposition in the OCT cross-sectional view (L). No visible automatic detected critical stent malappositions in the OCT longitudinal view (M). OCT = optical coherence tomography; DES = drug-eluting stent; LAD = left anterior descending; NC = noncompliant; PCI = percutaneous coronary intervention.

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  Figure 6 Acceptable criteria of stent optimization by OCT. LA = lumen area; LM = left main; OCT = optical coherence tomography; ref. = reference.

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