OCT : Basic understanding

1. MLD MAX PHYSICIAN PRESENTATION:
MLD MAX OCT Algorithm
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2. OCT Catheter and Modes
OCT Modes
• High res: 54 mm- 10 frames per mm
•
•
Survey: 75 mm- 5 frames per mm
Stationary
2.7F
™ Catheter
Monorail tip
Lens
Proximal marker
High res: 54 mm
Survey Mode: 75 mm
27 mm monorail
Refer to Instructions For Use (IFU) for additional information.
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3. Pullback Type
Survey-mode acquisition: 75 mm, 5 frames/mm - 2.1 Sec
High-resolution acquisition: 54 mm, 10 frames/mm - 3.0 Sec
Useful for:
• Bifurcation re-
crossing
Stent fracture
assessment
•
Refer to Instructions For Use (IFU) for additional information.
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4. User Interface
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5. Modern OCT Guided PCI Workflow | MLD MAX
Each OCT run serves a separate purpose. The pre-PCI run helps determine the
PCI strategy, and the post-PCI run allows for optimization of the stent as needed.
Pre-PCI OCT | Strategize
MORPHOLOGY LENGTH
Post-PCI OCT | Optimize
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MEDIAL DISSECTION APPOSITION
DIAMETER
EXPANSION

6. Pre-PCI OCT-Guidance
Pre-PCI OCT | Strategize
MORPHOLOGY
LENGTH
DIAMETER
Case courtesy of Dr. Ziad A. Ali
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7. SECTION 1
Morphology
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8. Normal Artery Morphology on OCT
• Intima = hard sponge
• IEL = rubber band
• Media = soft rope
• EEL = rubber band
• Adventitia = mesh
Shlofmitz, E. et al. Algorithmic Approach for OCT Guided Stent Implantation During PCI. Intervent Cardiol Clin 7 (2018) 329-344.
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9. OCT Image Interpretation
Can the EEL (rope) and Adventitia (mesh) be visualized?
Normal Artery
Fibrous Plaque Is the signal change in the lumen or the wall?
Wall
Lumen
Could you draw a line
NO
YES
Shlofmitz, E. et al. Algorithmic Approach for OCT Guided Stent
around the signal change?
Implantation During PCI. Intervent Cardiol Clin 7 (2018) 329-344.
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Low Attenuation
Calcium
High Attenuation
Lipid
Low Attenuation
(light refracted)
White Thrombus
High Attenuation
(light absorbed)
Red Thrombus

10. OCT Signal Attenuation
HIGH ATTENUATION
Courtesy of Dr. Ziad A. Ali
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LOW ATTENUATION
Light
Blocked
Light
refracted
(bent)

11. OCT Image Interpretation
Normal
Can the EEL and Adventitia be visualized?
Yes
Normal Artery
Fibrous Plaque
Courtesy of Dr. Ziad A. Ali
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12. OCT Image Interpretation
Can the EEL and Adventitia be visualized?
Yes
Normal Artery
Fibrous Plaque
Fibrous Plaque
Courtesy of Dr. Ziad A. Ali
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13. OCT Image Interpretation
Is the signal change in the lumen or the wall?
Fibro-fatty Plaque
Courtesy of Dr. Ziad A. Ali
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Wall
High
Attenuation
Lipid

14. OCT Image Interpretation
Is the signal change in the lumen or the wall?
Calcium
Courtesy of Dr. Ziad A. Ali
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Wall
Low
Attenuation
Calcium

15. OCT Image Interpretation
Is the signal change in the lumen or the wall?
Red Thrombus
Courtesy of Dr. Ziad A. Ali
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Lumen
High
Attenuation
Red
Thrombus

16. OCT Image Interpretation
Is the signal change in the lumen or the wall?
White Thrombus
Courtesy of Dr. Ziad A. Ali
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Lumen
Low
Attenuation
White
Thrombus

17. Morphology Guided Lesion Preparation
Lipidic
DIRECT STENTING1
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Fibrotic Mild/Moderate Ca2+ Severe Ca2+
COMPLIANT BALLOON2
NON-COMPLIANT BALLOON3
ATHERECTOMY OR IVL4
1. Taylor, A., et al. Efficacy and Safety of Direct Stenting in Coronary Angioplasty, J. Invasive Cardiology, 2000; 12(11); 2. Romagnoli, E., et al. Drug Eluting Stenting, JACC Cardiovascular Interventions, 2008;
1(1): 21-31; 3. Seyithanoglu, B., Compliant vs Non-compliant balloons. A Prospective Randomised Study, 1998; 39(1): 45-54; 4. Tomey, M., Current Status of Rotational Atherectomy, JACC Cardiovascular
Interventions, 2014; 7(4): 345-354.

18. Influence of Ca2+ on Stent Expansion by OCT
Rule of 5’s
• 0.5 mm thickness
• 5.0 mm long
• 50% vessel arc
>50%
Length >5 mm
1. Fujino, A. et al. A new optical coherence tomography-based calcium scoring system to predict stent under expansion. EuroIntervention, April 2018; 13(18):e2182-e2189.
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OCT-Based Calcium Volume Index Score1
1. Maximum
Calcium Angle (o) ≤ 90o
90o < Angle ≤ 180o
> 180o
► 0 point
► 1 point
► 2 points
2. Maximum
Calcium Thickness
(mm)
≤ 0.5 mm
> 0.5 mm
► 0 point
► 1 point
3. Calcium Length
(mm)
≤ 5.0 mm
> 5.0 mm
► 0 point
► 1 point
Total score 0 to 4 points

19. Ca2+-Dependent Lesion Preparation
Area 2.06 mm2
Area 2.93 mm2
Area 5.08 mm2
Area 9.38 mm2
Pre-OCT
Atherectomy reduces
thickness
Ca2+ fracture at
point of thinning
Expansion >100%
Ali, Ziad A. Shining Light on Calcified Lesions, Plaque Stabilization and Physiologic Significance: New Insights from Intracoronary
OCT. EuroIntervention, vol. 13, no. 18, 2018, pp. 2105–2108.
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20. OCT-Guided Morphology Assessment
Identify:
• Normal or fibrous
edges
• Severe Ca2+
Case courtesy of Dr. Ziad A. Ali
Courtesy of Dr. Ziad A. Ali
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21. SECTION 2
Length
Courtesy of Dr. Ziad A. Ali
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22. Identify Landing Zones
Traditional 2-D Angiogram OCT 3-D Lumenogram
Courtesy of Dr. Ziad A. Ali
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23. Identify Landing Zones
“normal” OCT
lumenogram
“normal” OCT lumenogram
5) Adjust the length to
an available DES
size at the “more
normal” reference
4) Is this a safe place to land
the proximal stent edge?
The more visible the EEL
the safer your landing zone
Courtesy of Dr. Ziad A. Ali
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Lesion length 33 mm
The more visible the EEL
the safer your landing zone
1) Scroll reference vessel 2) Is this a safe place to land 3) Scroll reference vessel
markers to distal the distal stent edge? markers to proximal

24. SECTION 3
Diameter
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25. OCT Stent Sizing Algorithm
Can the EEL be identified at the distal
reference segment to allow vessel
diameter measurement?
PRE-PCI OCT
Stent diameter decided
by OCT measurement of
mean EEL to EEL
diameter rounded down
to nearest stent size1
Stent diameter decided
by OCT measurement of
mean lumen diameter
rounded up to nearest
stent size2
NO
YES
1. Ali, Z., et al., ILUMIEN III Study, Lancet Journal, 2016; 1-11. 2. Shlofmitz, E. et al. Algorithmic Approach
for OCT Guided Stent Implantation During PCI. Intervent Cardiol Clin 7 (2018) 329-344.
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26. OCT Post-Dilatation Balloon Sizing Algorithm
Can the EEL be identified at the proximal and
distal reference segment to allow vessel
diameter measurement?
YES NO
PRE-PCI OCT
Balloon diameter
decided by OCT
measurement of mean
EEL to EEL diameter
rounded down to
nearest balloon size1
Balloon diameter
decided by OCT
measurement of mean
lumen diameter
rounded up 0.25-0.50
mm2
1. Ali, Z., et al., ILUMIEN III Study, Lancet Journal, 2016; 1-11. 2. Shlofmitz, E. et al. Algorithmic Approach
for OCT Guided Stent Implantation During PCI. Intervent Cardiol Clin 7 (2018) 329-344.
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27. OCT Guided Stent / Balloon Sizing – Distal Reference
• At the LAD distal reference the vessel wall can be measured
• Mean EEL = 3.04 mm
• Round down to nearest stent size = 3.0 mm
Ali, Z., et al., ILUMIEN III Study, Lancet Journal, 2016.
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28. OCT Guided Post-Dilatation Balloon Sizing - Proximal
• At the LAD proximal reference the vessel wall can be measured. EEL = 4.36 mm
• Round down to nearest balloon size for post-dilation (if necessary) = 4.00 mm
• At the LAD proximal reference if the vessel wall can not be measured. MLD = 3.02 mm
• Round up to nearest balloon size for post-dilation (if necessary) = 3.50 mm
Ali, Z., et al., ILUMIEN III Study, Lancet Journal, 2016.
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29. Modern OCT Guided PCI Workflow | MLD MAX
Each OCT run serves a separate purpose. The pre-PCI run helps determine the
PCI strategy, and the post-PCI run allows for optimization of the stent as needed.
Pre-PCI OCT | Strategize
MORPHOLOGY LENGTH
Post-PCI OCT | Optimize
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MEDIAL DISSECTION APPOSITION
DIAMETER
EXPANSION

30. SECTION 4
Medial Dissection
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31. Dissections
1. Kubo, T. et al. Application of Optical Coherence Tomography in Percutaneous Coronary Intervention. Circulation Journal,
September 2012: Vol. 76, 2076-2083; 2. Ali, Z. et al. ILUMIEN III: Optimize PCI. Lancet 2016, 388:2618-2628.
Address Significant Dissection1
Dissection penetrates medial layer,
and is greater than 1 quadrant arc
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Intimal Medial Intramural Hematoma
Common Practice1,2
Place additional stent (particularly
for distal dissections)

32. SECTION 5
Apposition
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33. Apposition
If the stent struts are in contact with the artery wall, the stent is apposed
Address Gross Malapposition
• Longer than 3 mm,1 and
≥0.3 mm from wall2
Common Practice3
• Dilate with semi-compliant balloon at
low pressure
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MALAPPOSTION
1. Ali, Z. et al. ILUMIEN III: Optimize PCI. Lancet 2016, 388:2618-2628. 2. Souteyrand, G. et al. PESTO French Registry. European Heart Journal, 2016:37:1208-1216.
3. Kubo, T. et al. Application of Optical Coherence Tomography in Percutaneous Coronary Intervention. Circulation Journal, September 2012: Vol. 76, 2076-2083.

34. Apposition Indicator
OCT AUTOMATICALLY DETECTS MALAPPOSITION
Case courtesy of Dr. Ziad A. Ali
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35. SECTION 6
eXpansion
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36. eXpansion
If the stent is expanding the lumen, holding the lesion close to, or greater
than, the normal reference segment, the stent is expanded.
GOAL
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ACCEPTABLE = MSA ≥ 80% OF MEAN REFERENCE LUMEN AREA1
OPTIMAL = MSA ≥ 90% OF MEAN REFERENCE LUMEN AREA1
1. Kubo, T. et al. Application of Optical Coherence Tomography in Percutaneous Coronary Intervention. Circulation Journal, September 2012: Vol. 76, 2076-2083; Meneveau, N. et al.
DOCTORS Study. Circulation, September 2016, 134:906-917.; Zhang, J. et al. The ULTIMATE Trial. Journal of the American College of Cardiology, Dec 2018: Vol 72, No 24:3126- 37.;
Russo, R. et al. The AVID Trial. Circ Cardiovasc Intervent, April 2009; 2:113-123.; De Jaegere, P. et al. MUSICStudy. European Heart Journal, February 1998:19,1214-1223.

37. Determine Expansion / MSA - Dual
Fully automated
expansion display
• ROI automatically
detected
• Expansion
automatically
displayed Proximal Half
Distal Half
Case courtesy of Dr. Ziad A. Ali
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38. OCT Guided Optimization of Underexpansion
Measure:
• EEL-EEL, if
possible
• Mean lumen
diameter, if no
EEL-EEL
Case courtesy of Dr. Ziad A. Ali
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39. OCT Guided Optimization of Underexpansion
The post-PCI OCT is used to choose the balloon size for post-dilation in the
segment of stent with underexpansion
Mean EEL = 3.27, therefore a 3.25 mm balloon should be used for post-dilation
Case courtesy of Dr. Ziad A. Ali
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40. Optimized Expansion
The MSA is 6.17 mm2 and the distal reference 5.60 mm2, therefore the stent
is fully expanded distally >100%.
Case courtesy of Dr. Ziad A. Ali
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