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OCT - few basic facts
1. OCT imaging provides high-resolution cross-sectional images of coronary arteries and stents to assess plaque, guide stent sizing and placement, and confirm procedural success. 2. The OCT catheter is advanced to the region of interest and an automated pullback acquires images as flush media clears blood from the field of view. Images can be used to characterize plaque, measure vessel and stent dimensions, check apposition and expansion, and detect complications. 3. OCT has advantages over IVUS like superior resolution and ability to identify details like thin-cap fibroatheroma, but it also has limitations such as limited tissue penetration and the need for flush media that adds contrast load.
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OCT - few basic facts
- 1. Dr Arindam Pande, ConsultantCardiologist, Academic Coordinator: DNB Cardiology and PGDCC Training Apollo Gleneagles Hospital, Kolkata “OCT- few basic facts you must know”
- 2. OCT Imaging Pre-Intervention Assessment Stent Deployment Complication andPost Procedural Assessments Intravascular OCT Imaging 1. How to acquire the image 2. Assess plaque composition 3. Identify reference segments 4. Choose stent size 5. Determine expansion/MSA 6. Determine apposition 7. Rule out geographical miss 8. Identify edge dissections 9. Identify tissue protrusion 10.Confirm procedural success
- 3. OCT Technology ConsoleIlumien, Ilumien Optis, OptisI integrated Rapid exchange (Rx) imaging catheter (Dragonfly) Flush Media Clearance Fast acquisition: 7.5 – 5.4cm pullback in 3.0 – 2.1sec
- 4. 1. Image acquisition:Outside the Body Imaging core Imaging sheath Optical Lens 1) Purge the catheter with flush media (3 drips) 2)Connect the catheter to the dock 3)Set flush media injection • Left coronary: 4cc/s, total 14 • Right coronary: 3cc/s, total 12 • Large vessel: 4cc/s, total 20 • Manual injection: 16cc in 20cc syringe *The key to adequate clearance is time not volume on automatic pullback. 4.Select pullback length and image acquisition method. *Manual pullback is useful in small vessels, tight stenoses or very large vessels.
- 5. High-resolution pullback: 54mm, 10 frames/mm 3.0 sec D1 LRP LRP Landing Zone Long pullback : 75 mm, 5 frames/mm 2.1 sec Pullback lengths
- 6. 1. Image acquisition:Inside the body 1) Advance OCT catheter to region of interest on “Standby” 2) Engage guide catheter • Avoid sideholes • Administer IC NTG 3) Enable “Live Image” and Inject flush media to deliver NTG and ensure adequate blood clearance *Do not waste contrast *Plan your angiographic view (avoid overlap) 4) Purge the OCT catheter *This minimizes signal dampening Distal Marker Lens Marker Proximal Marker
- 7. 1. Image acquisition:Inside the body 5) Press enable on the OCT dock or console to calibrate 6) Cine - Enable - Inject Proximal Marker Lens Marker Distal Marker Region of Interest – Vessel Segment Imaged During Pullback Markers 20 mm apart Pullback length: 5 cm Lens
- 8. 1. Co-registering 1) Selectco-register 2) Select a minimum of 3 points along the guidewire towards the guide. *The co-registration is dependent on the lens *Selecting more that 3 points is acceptable but not necessarily beneficial. *If co-registration fails, select points starting just below the lens towards the guide.
- 9. Calcific • Rotablator •High Pressure Necrotic Core •Cutting Balloon • High Pressure 2. Assess Plaque CompositionFibrous Fibro-Fatty •BAS • BAS
- 10. LCX Dx LM MLA 1.95 mm2 Ø= 1.56 mm, AS = 76.5% LLeseisoionnlelnenggthth2 826mmmm Area 8.29 mm2 Ø = 3.12 mm Area 8.32 mm2 Ø = 3.04 mm Area 8.79 mm2 Ø = 3.25 mm 3. Identify Reference Segments 1) Scroll reference vessel markers to proximal and distal lesion edges. 2) Attempt to identify segment of vessel within 5mm with at least >180 degrees of visible EEL 3) Reposition reference scroll marker accordingly
- 11. Area 8.79 mm2Ø = 3.55 mm Lesion length 28 mm LCX LM Dx MLA 1.95 mm2 Ø = 1.56 mm, AS = 76.5% Area 8.32 mm2 Ø = 3.24 mm Increasingly aggressive •Largest reference lumen (prox or dist) •Mid-wall •Media-to-media (typically discounted) 3. Choose Stent Length
- 12. How Big? Lumen MLD 3.0mm MSA(πr2) = 7.07mm2 Mid-wall MWD 3.1mm MSA (πr2) = 7.55mm2 External Elastic Lamina EELD 3.2mm MSA (πr2) = 8.04mm2 3. Choose Stent Diameter
- 13. OCT vs IVUSvs Histology Kubo et al. iJACC 2013;6(10):1095-
- 14. Size Matters de Feyteret al. Circulation 1999;100:1777-83 Final Minimum Stent Area (mm2) * * * * * * * * * * * * * * * * * * * ** ** * * * *
- 15. 5. Determine Expansion/MSA 1)Scroll reference vessel markers to distal stent edge and midpoint of stent. 2) Identify “automated measures” yellow box to determine MSA. 3) Identify respective “automated measures” reference blue box to determine residual area stenosis. Distal Half
- 16. 5. Determine Expansion/MSA 1)Scroll reference vessel markers to distal stent edge and midpoint of stent. 2) Identify “automated measures” yellow box to determine MSA. 3) Identify respective “automated measures” reference blue box to determine residual area stenosis. Proximal Half
- 17. Lumen Area, StentArea, Strut-Lumen Distance Strut-Vessel Wall Distance Protruding Covered MalapposedEmbedded 6. Determine Apposition Malapposition Alloy Strut Polymer Total Thickness Embedded Contact Malapposed Cypher 140 7 154 <80 80-160 >160 Taxus 97 15 127 <65 65-130 >130 Zotarolimus 91 8 107 <55 55-110 >110 Everolimus 81 7 88* <54 50-100 >108
- 18. 6. Determine Apposition Major Strut Minor Strut Lumen Area;12.36mm2 Stent Area; 10.95mm2 Lumen Area; 5.47mm2 Stent Area; 4.32mm21mm 1mm • Associated with stent underexpansion • Not Associated with stent underexpansion
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- 20. 7. Rule outgeographic miss 1) Peruse OCT longitudinal image for geographic miss Stented Segment
- 21. 8. Identify EdgeDissections
- 22. Major Category 1) >60°/ >3mm 2)Flow limiting (TIMI) 3)Inadequate MLA 8. Identify Edge Dissections
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- 25. LCX – OCTrun
- 26. 9. Identify TissueProtrusion Major Minor • Effective MLA <5.5mm2 Effective Lumen Area; 2.70 mm2 Protrusion Area/Stent Area ≥ 10% Effective Lumen Area; 6.30 mm2 Protrusion Area/Stent Area < 10% Tissue protrusion Tissue protrusion 1mm 1mm Effective MLA >5.5mm2
- 27. LAD – duringBVS implantation
- 28. LAD – duringBVS implantation
- 29. LAD – postaspiration
- 30. 10. Confirm ProceduralSuccess Adequate stent expansion: The MSA within the stented segment must be ≥90% the mean proximal and distal reference lumen areas. Proximal Reference = 7.9mm2, Distal Reference = 7.1mm2 , mean = 7.45mm2 • Target =≥90% of 7.45mm2 = 6.70mm2 •Final MSA = 7.15mm2 (Adequate Stent Expansion Achieved)
- 31. OCT – ISR- BVS
- 32. Modality Advantages Disadvantages IVUS- High tissue penetration - Good imaging of fiber, calcium - Plaque burden - LMCA - No flush required - Large installed base - Outcomes data - Operator Experience - Cost - Slow - Inferior resolution - Difficult to resolve lipid, thrombus, stents, dissections - Apposition - Dissection - Calcium shadowing - Virtual histology reliability OCT - High resolution - < 3 second pullback - Non-occlusive - Follow-up for apposition, dissection - High sens/spec for lesion identification (lipid, calcium, fiber, thrombus) - Low crossing profile - Bioabsorbable stents - Lack of outcome data - LMCA - Poor tissue penetration - Ostial - Very tight lesions - Very large vessels - Adds contrast load IVUS versus OCT
- 33. Very Tight Lesions Pre-dilation with 1.5-2.0mm balloon Very Large Vessels Injection via Guideliner Contrast Load Obstacles to OCT Visipaque Dextran-40
- 34.