Optimization Process After Angiography-Guided Stent Implantation: Pre-specified Analysis of the OCCUPI Randomized Trial

AIMS: Despite its benefits, the detailed process by which optical coherence tomography (OCT) improves stent optimization, and the role of pre-stenting OCT assessment, have not been fully investigated. We aimed (1) to assess the achievement of OCT-defined optimization criteria after angiography-guided stent implantation, and (2) to assess the role of pre-stenting OCT assessment. METHODS AND RESULTS: The first consecutive 200 patients in the OCT-guided arm of the OCCUPI trial were randomly assigned to the full OCT-guided or angiography-first-guided group. In the angiography-first-guided group, after achieving angiographically optimal stenting, OCT was performed to compare the achievement of OCT-defined optimization criteria between full OCT-guided PCI and angiography-first-guided PCI. After additional procedures in the angiography-first-guided group, the stent optimization rates and 1-year clinical outcomes were compared between the full OCT-guided and angiography-first-guided groups, both of which underwent stent optimization using OCT. The optimization rate was higher in the full OCT-guided group than in the angiography-first-guided group (63.3% vs. 44.4%; P = 0.012). After optimization with OCT, the optimization rate in the angiography-first-guided group increased to 60.6% with decrease of maximal malapposition distance and resolution of major edge dissections. Although the minimal stent area (MSA) increased after optimization with OCT in the angiography-first-guided group (MSA of OCT guidance without pre-stenting OCT), it remained smaller than that of the full OCT-guided group (MSA of OCT guidance with pre-stenting OCT). The clinical outcomes did not differ between groups. CONCLUSION: Angiography guidance achieved a lower optimization rate than OCT guidance. Furthermore, pre-stenting OCT may facilitate more robust stent expansion. STUDY REGISTRATION: ClinicalTrials.gov (ID: NCT03625908).