Optical coherence tomography in PCI, all you want to know

1. OCT in coronary artery disease
Your light in the dark tunnel
Ahmed ElBorae, MSc, MRCPUK (London), EAPCI
Assistant lecturer of Cardiology, Cairo University

2. Coronary angiography
“Lumen”
OCT
“Wall”
FFR
“flow”
A single modality rarely gives the whole truth

3. Agenda
• Basics
• How to perform an OCT study?
• Algorithmic approach
• Clinical application
• Limitations
• Future direction

4. Here we begin…
1992
Invitro
imaging
1
st
OCT
catheter
1
st
use
post
mortem
1
st
OCT
in
living
human
1995
1996
2002
OCT
concept
1991
Invitro Invivo dead Invivo alive Clinical
FDA
approval
2005
2021
Artificial
intelligence
AI

5. OCT concept
• Depends on a rotating near infra-red pulses and interferometer
• Generate picture according to the amplitude and time delay of the reflected
waves
Tissue
Interferometer
Image
Pulses of infrared light
Coherence
Represents “Optical biopsy”

6. Clinical Evidence
CLI-OPCI I and II:
OCT improves outcomes
vs. angiography
OPUS-Class Study
Reliability of OCT measurement
vs. IVUS and angiography
OCT Safety and Efficacy
Non-occlusive OCT study
Past
Present–2015
Future
ILUMIEN IV
OCT vs Angiography Randomized
Outcomes Trial
Other areas under
consideration:
 Non-contrast flush media
 BVS
 Virtual OFR
ILUMIEN I:
Define and evaluate OCT
stent guidance parameters
and determine impact on
physician decision making (84%)
ILUMIEN II
OCT vs. IVUS propensity
matched comparison of stent
expansion.
ILUMIEN III
OCT vs IVUS vs Angiography
prospective randomized trial to
evaluate OCT EEL-guided PCI
Courtesy of Ziad Ali

7. Percutaneous interventional cardiovascular medicine – The PCR-EAPCI Textbook
Francesco Prati1,2,3, Alessandro Sticchi1,2, Evelyn Regar4
OCT Vs IVUS
“Light vs. sound”
X 10

8. Agenda
• Basics
• How to perform an OCT study?
• Algorithmic approach
• Clinical application
• Limitations
• Future direction

9. 1- OCT Catheter preparation
B- Connect “Clockwise”
“DOC” Sterile cover
A- Flush 3 cc 100% contrast
Percutaneous interventional cardiovascular medicine – The PCR-EAPCI Textbook
Francesco Prati1,2,3, Alessandro Sticchi1,2, Evelyn Regar4

10. • Compatible with 6F guide catheter, vessel > 2 mm
• Advance till lens marker distal to area of interest
• Don’t forget nitroglycerin, full heparinization
• Remember blood is the enemy of infrared light
2- Advance the catheter
Percutaneous interventional cardiovascular medicine – The PCR-EAPCI Textbook
Francesco Prati1,2,3, Alessandro Sticchi1,2, Evelyn Regar4
Proximal marker
Lens marker
Pullback length

11. • A- Purge catheter& click on “Calibrate”
• B- Press “enable pullback”
• C- Inject either ( Contrast or Dextran or mix)
rate 3-4 ml/ s
• D- Revise run and remove catheter
3- Start pullback run
•Modes
•The 75 mm Survey Mode – fast but less frame rate
•The 54 mm High Resolution Mode – twice the frame rate
OCTaid,mount Sainai app

12. Capture
Measurement
display
View mode
Measurement
tool
Longitudinal mode
Lumen profile

13. Agenda
• Basics
• How to perform an OCT study?
• Algorithmic approach
• Clinical application
• Limitations
• Future direction

14. Before PCI
(MLD)

15. Normal vessel
Shlofmitz E, et al. Interven cardiology.2018

16. Common artifacts
Shadowing artifact
Sew-up artifact
Residual blood artifact

17. 1-Morphology
“Important terminology”
Backscattering =
Brightness due to light reflection
Attenuation=
Darkening of what behind due to light absorption
Low
Low
High
High
Fat Fibrous

18. Fibrous plaque Calcified lesion
Lipid rich plaque
High backscattering
Low attenuation
Low backscattering
High attenuation
“ill defined”
Intermediate backscattering
Low attenuation
“Well defined”
1- Morphology

19. Calcified lesion
IVUS
OCT advantage

20. Potential need for atherectomy
Score of ≥3 high risk of underexpansion
Consider plaque modification e.g. IVL, rotablation

21. Acute coronary syndrome
Red thrombus (RBCS) White thrombus (Platelets)
High attenuation Low attenuation

22. Summary of morphology assessment

23. • Plaque burden < 50 %
, no high lipid core at
the edges
• Co-registration feature
2- Length

24. Distal reference lumen
Upsize 0.25 mm
3- Diameter
Distal reference EEM if seen > 180°
Downsize 0.25 mm

25. After PCI
“MAX”

26. 1-Medial dissection
If > 60 °
Length > 2 mm
Depth to media
Need stenting esp. distal
edge
OCTaid,mount Sainai app

27. 2-Apposition
If distance > 0.4 mm
Length > 1 mm
Need optimization
OCTaid,mount Sainai app

28. 3- Expansion
Minim. Stent expansion > 80%
MSA/average ref. lumen area

29. MLD-MAX

30. Agenda
• Basics
• How to perform an OCT study?
• Algorithmic approach
• Clinical application
• Limitations
• Future direction

31. 1- Ambiguous culprit in ACS and MINOCA

32. Images courtesy of Mullasari Ajit Sankardas, MD, DM, FRCP.
Baseline
6 months
DAPT
MINOCA > Plaque erosion

33. Plaque rupture Plaque erosion
OCTaid,mount Sainai app
2- Tailor management in ACS
“EROSION study” showed safety of deferred stenting in plaque erosion and lesion < 70%

34. 27 % 49 %
Baseline
30 days

35. 3- Plaque vulnerability
“TCFA”
Thin capped fibro-atheroma:
• Fibrous cap < 65 micron
• High lipid core burden

36. Eur Heart J, Volume 42, Issue 45, 1 December 2021

37. 4- Stent failure
Stent fracture Stent underexpansion
Double layer

38. 5- Bifurcation
Benefits
• Optimization (MLD-MAX)
• SB assessment
• Accurate cell crossing
3D navigation

39. 6- Vascular healing after CTO PCI
High rate of late mal-apposition and delayed strut coverage
Prolonged DAPT

41. 7- BVS
Expectations
Reality

42. 8- SCAD and IMH

43. Agenda
• Basics
• How to perform an OCT study?
• Algorithmic approach
• Clinical application
• Limitations
• Future direction

44. OCT limitations
• Aorto-ostial lesions “Solution= Infra-red friendly guide extension”

45. OCT limitations
• Aorto-ostial lesions
• Ectatic tortuous vessels
• Live guidance in CTO
• Severe LV dysfunction
• Renal impairment

46. Agenda
• Basics
• How to perform an OCT study?
• Algorithmic approach
• Clinical application
• Limitations
• Future direction

47. OFR

49. Artificial intelligence

50. Hybrid OCT/IVUS catheter
Terumo hybrid

51. Further reading…

52. Thank You
James Fujimoto, MIT, USA
God father of OCT
Gary Tearney, MIT,USA
1st invivo OCT in human
David Huang, MIT, USA
1st OCT imaging invitro 1990