Optical coherence tomography-guided stent optimization for complex coronary lesions: the OCCUPI trial

Background and Aims This study evaluated the incidence, determinants, and clinical impact of stent optimization after optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) for complex lesions. Methods From the OCCUPI randomized trial investigating the impact of OCT guidance compared to angiography guidance in complex lesions, patients who underwent OCT-guided PCI with post-stenting OCT evaluations were enrolled and classified into two groups based on whether they met the OCCUPI-OCT criteria: OCT Optimization vs OCT Sub-Optimization. The primary endpoint was the cumulative incidence of cardiac death, myocardial infarction, stent thrombosis, or ischemia-driven target vessel revascularization during one year in the as-treated population. Results Among the 773 patients who underwent OCT-guided PCI, 549 (71.0%) met the optimization criteria (OCT Optimization), whereas 224 did not (OCT Sub-Optimization). On multivariable analysis, long lesions and small-vessel disease were significant independent predictors of OCT Sub-Optimization. The occurrence of the primary endpoint was significantly lower in the OCT Optimization (2.9%) than in the OCT Sub-Optimization [9.4%, hazard ratio (HR): 0.30, 95% confidence interval (CI): 0.16–0.58, P < .001] or angiography guidance [7.5%, HR: 0.38, 95% CI: 0.22–0.66, P < .001]. Each acceptable component of OCCUPI-OCT criteria assessing stent expansion (minimal stent area, ≥80% mean reference lumen or ≥100% distal reference lumen areas; > 4.5 mm2), apposition (malapposed distance, <400 μm), and absence of major edge dissection, was significantly associated with favourable outcomes (all P < .001). Conclusions The current study identifies long lesions or small-vessel disease as the determinants of stent optimization following OCT guidance, with the achievement of stent optimization significantly associated with improved clinical outcomes. Stent expansion, apposition, and edge dissection, the three key components of the OCCUPI-OCT criteria, were highly predictive of favourable clinical outcomes.