Clinical Value of OCT. Guidance for Coronary Stenting. Giulio Guagliumi, MD

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1 Clinical Value of OCT Guidance for Coronary Stenting Giulio Guagliumi, MD

2 100 % Endovascular Imaging Indications of use 87.5 % 75 % 57.5 % 50 % 45 % 25 % 15 % 0 Lesion morphology Stent optimization Lesion Severity Scientific research Courtesy G. Musumeci, GISE Imaging Survey April 2012

3 IVUS can scan the wide area of vessel and assess plaque volume and distribution OCT can rapidly evaluate the entire vessel surface with fine images. 50 sec, microns axial resolution 3 sec, 10 microns axial resolution

4 Comparison of FD-OCT and IVUS Imaging Minimum Stent Area Mean Stent Area OCT mm 2 OCT mm 2 IVUS mm 2 IVUS mm 2 M. Habara et al. Circ Cardiovasc Interv 2012 published online March 27

5 FD-OCT vs. IVUS guidance PCI OCT Group (n=35) IVUS Group (n=35) p Value Minimum stent area (mm 2 ) 6.1 ± ± Stent expansion (%) 64.7 ± ± Stent deployment pressure (atm)* 9.8 ± ± 3.4 < Frequency of postballoon dilatation 60% 85.7% 0.03 Postballoon pressure (atm) 13.5 ± ± Angio guidance 91.4% 5.7% <0.001 * Stent deployment pressure and decision for performing postdilatation were based on vessel diameter at MLA. Habara M, et al. Circ Cardiovasc Interv. 2012;5: Letter by Garcia-Garcia HM, et al. Circ Cardiovasc Interv. 2012;5:e59.

6 Comparison of measurements among OCT, IVUS & QCA OPUS-CLASS study: 100 pts, 5 centers MLD 9% 5% MLA 10% 1.91± 0.69 mm 2.09± 0.60 mm 1.81± 0.72mm Kubo T, Akasaka T, et al, JACC Img in press 3.27±2.2 mm ±2.06mm 2 Wakayama Medical University

7 Measurements of MLA in Phantom Model FD-OCT (n=15) vs IVUS (n=15) Independent Corelab Courtesy of T. Kubo, T. Akasaka, J. Shite et al., JACC Imag in press 2012

8 OCT compared with IVUS: Lumen detection Good Lumen border visibility at OCT group N=35 IVUS group N=35 p value Proximal reference 100% 100% 0.99 MLA site 97.1 % 88,6 % 0.36 Distal reference 100% 100% 0.99 Habara Circ Cardiovasc Interv 2012 e pub

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10 Optical Coherence Tomography Assessment of gender diversity in primary Angioplasty 140 Age Matched STEMI pts

11 Assessing Manual Thrombectomy in STEMI Ospedali Riuniti di Bergamo

12 OCT allows quantification of residual atherothrombotic burden after stenting in AMI ATB low (Area < 4%) ATB high (Area 4%) (%) p= p= p= p=0.02 p= Slow flow No reflow Distal occlusion MBG 2/3 ST resolution Magro M, et al. Int J Cardiol 2012 Mar 27. Epub ahead of print.

13 Inferior STEMI after thrombus aspiration Ospedali Riuniti di Bergamo

14 4 mm Ospedali Riuniti di Bergamo

15 STEMI, 53 yrs Ospedali Riuniti di Bergamo

16 Less Plaque Burden in Young Women? \ G. Guagliumi Ospedali Riuniti di Bergamo

17 Stent length options mm mm mm

18 3D-OCT and multiple plaque rupture in the culprit lesion Kubo T, et al. Circ J 2012 Jul 31, Epub ahead of print.

19 To Avoid DES Failure: The Role of the Landing Zone Culprit Lesion Landing Zone Ospedali Riuniti di Bergamo

20 TFCA at the Landing Zone Ospedali Riuniti di Bergamo

21 Focal Edge Restenosis with Lipid-Laden Intima Ospedali Riuniti di Bergamo

22 A B B B A E C B E

23 To Avoid DES Failure: Ectasia at the Landing Zone Ospedali Riuniti di Bergamo

24 Ectasia at the Landing Zone Landing Zone Culprit Lesion Ospedali Riuniti di Bergamo

25 Large area of malapposed struts angiographically invisible Post DES implantation Ospedali Riuniti di Bergamo

26 Strut Appostion and Thrombus Formation after SES Implantation Presence and absence of thrombus 10 Months FU Well apposed (n=548) ISA (n=68) p Thrombus, n (%) 11 (2.0) 14 (20.6) <0.001 No thrombus, n (%) 537 (98.0) 54 (79.4) - Ozaki Y et al. Eur Heart J 2010; 31:

27 9 Months elective FU: Asymptomatic Ospedali Riuniti di Bergamo

28 Anterior MI: EES implantation vs 9 mos FU

29 The fate of distance of strut malapposition µm Number of malapposed strut at implant Courtesy Prof. J Shite Resolved malapposed struts at FU Persistent malapposed struts

30 % Patients with at least 1 strut > 300 µm of malapposition distance: 42% Which one should be tackled? Courtesy of OCTAVIA Investigators

31 STEMI DES, 3.5 HP postdil Ospedali Riuniti di Bergamo

32 Long stented segment embodies higher risk of malapposition Ospedali Riuniti di Bergamo

33 OCT guidance for stent optimization: 4.0 x 8mm balloon Ospedali Riuniti di Bergamo

34 Distal Mid Proximal Distal Mid Proximal CSA 3,96 mm Dissection 2 CSA 3,65 5,53 mm CSA 5,74 mm length < 2.17 mm 2 CSA 3,72 mm 2 CSA 5,40 mm 2 2

35 12 Months Baseline Natural History of OCT Detected Edge Dissections Following DES Implantation All not angiographically visible Median (IQR) Length, mm 2.9 ( ) Extended to media n, % 10 (50%) Detected by IVUS 8/16 (50%) 12 Month FU 90% completely healed Not healed: 4.3 mm longitudinally M. Radu et al. Featured Abstract TCT 2011 McouCCrtesy.D. Radu et al. JACC Vol 58(20) Suppl B; TCT-2011 Abstract 659

36 May.2005 June.2012

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38 Challenging Technical Cases: Stent Failure, ACS Sidebranch Stenting Courtesy Lino Patricio, MD Hospital de Santa Marta, Lisbon

39 1 st Diag SE Nitinol Stent 1 st Diagonal LAD Courtesy Lino Patricio, MD

40 LAD: accelerated atherosclerosis at bifurcation Mid LAD Prox LAD Courtesy Lino Patricio, MD

41 OCT for guidance of distal cell recrossing in bifurcation stenting 52 pts, provisional stent as default strategy Alegria-Barrero E, et al. EuroIntervention 2012;8:

42 OCT for guidance of distal cell recrossing in bifurcation stenting Alegria-Barrero E, et al. EuroIntervention 2012;8:

43 % malapposition % malapposition % malapposition OCT for guidance of distal cell recrossing in bifurcation stenting 50 Malapposition Bifurcation p< Malapposition Towards side branch p< Malapposition Opposite side branch p= Angio-guided OCT-guided Angio-guided OCT-guided Angio-guided OCT-guided D D D P P P Alegria-Barrero E, et al. EuroIntervention 2012;8:

44 3D-OCT: Left main bifurcation disease Kubo T, et al. Circ J 2012 Jul 31, Epub ahead of print.

45 OCT in PCI for in-stent restenosis Pre-PCI Cutting balloon Stent in stent Kubo T, et al. Circ J 2012 Jul 31, Epub ahead of print.

46 Vessel Toxicity: Cluster of Uncovered/Malapposed Struts 31 mos VLST, after thrombus aspiration Permanent Polimer DES Ospedali Riuniti di Bergamo

47 OCT is a new option to effectively guide stent implantation because lumen is leading the vast majority of stent implantations..and because angio is not longer the gold standard for optimization of PCI Full vessel assessment of type/extent of pathology with accurate measures in only few seconds (plus in unstable pts) Higly sensitive for thrombus (to optimize detection and removal: ACS, included ST) Accurate in assessing the landing zone before stent implantation (risky LCP, ectasia), to avoid stent failure (stable and unstable pts) Best ever stent results analysis, large malapposition (> 300 µm in distance) and edge dissection (> 4.5 mm) angiographically invisible, that need to be tackled Unique insights in guiding challenging stent cases (ie bifurcations) Key element for correct treatment of any stent failure, including LST: different causes = different treatment)