Impact of Optical Coherence Tomography-Based Post-PCI Physiology Assessment to Predict Clinical Outcomes

Figures

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  Figure 1. A graphical comparison of the capabilities of IVUS and OCT in guiding LM PCI (*where LM stent extends to ostium, proximal visualization superior with IVUS)

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  Figure 2. A composite Forrest plot of contemporary intracoronary imaging studies OPTIMAL,20 OCCUPI,23 OCTOBER22 & RENOVATE,10 assessing the impact of ICI on bifurcation PCI

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  Figure 3. Intravascular-ultrasound guided assessment of left main disease significance—the impact of catheter alignment on minimal lumen area measurement. Complete assessment requires IVUS evaluation of both limbs with the lowest value taken to determine significance. This case example, adapted from the EBC IVUS left main consensus,8 demonstrates significant differences in the lumen area between LAD and circumflex (LCx) pullback with the most severe MLA recorded from the LAD (red dot and dotted line)

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  Figure 4. Intravascular-ultrasound guided assessment of left main disease significance—absolute minimal lumen area thresholds for guiding revascularization. Adapted from the second EAPCI ICI consensus35 to include patient and ICI criteria to guide decision-making

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  Figure 5. Step-wise approach to maximizing the benefit of pre-PCI ICI. 1. Assessing the landing zones with particular attention to avoidance of plaque burden >50%. 2. Stent length selection should consider the need for proximal extension of the POT balloon to overcome significant calibre discrepancy3 between proximal and distal bifurcation segments. 4. Identification of significant calcification, especially arc >180°, length >5 mm and thickness >0.5 mm should trigger use of adjunctive technologies and repeated imaging is recommended to ensure adequate preparation before stenting. 5. In the presence of complex bifurcation disease affecting both limbs of the bifurcation, ICI of both the left anterior descending and circumflex arteries may inform procedural decision making

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  Figure 6. Stent optimization guidance for provisional LM crossover and 2-stent left main bifurcation PCI. Consideration of optimal stent areas and the equivalent lumen diameter is important to ensure that sizing of post-dilatation balloons is appropriate to the anatomy

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  Figure 7. Examples of unintended stent deformation detected by IVUS & OCT. GUIDE COLLISION—The proximal optimization technique (POT) ensures appropriate expansion and apposition of the left main stent segment, confirmed by angiographic stent optimization software and IVUS (red-dashed outline). However, withdrawal of the jailed guide wire (orange line) resulted in guide catheter collision and proximal stent distortion (strut malapposition and longitudinal shortening), confirmed by stent optimization software and IVUS (orange-dashed outline). Repeat POT corrected the distortion, confirmed by stent optimization software and IVUS (green-dashed outline). ABLUMINAL WIRING—Cross-sectional OCT imaging identifies the abluminal position of the catheter and wire in a segment of left main malapposition (lumen contour highlighted by red line & stent struts by white dashed line, with automated OCT software identifying strut malapposition >0.3 mm (yellow bar and 3D-strut reconstruction). 3D reconstruction with removal of tissue facilitates detection of the wire position in relation to stent contour, most evident viewing from outside the stent (viewpoint a) & from distal to proximal within the stent lumen…

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  Figure 8. Top 10 Key learning points from the Intracoronary Imaging for left main PCI consensus statement