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Dr Arindam Pande, Consultant Cardiologist,
Academic Coordinator: DNB Cardiology and PGDCC Training
Apollo Gleneagles Hospital, Kolkata
“OCT- few basic facts you must know”
OCT Imaging
Pre-InterventionAssessment
Stent Deployment
Complication and Post Procedural
Assessments
Intravascular OCT Imaging
1. How to acquire the image
2. Assess plaque composition3. Identify reference segments4. Choose stent size
5. Determine expansion/MSA6. Determine apposition7. Rule out geographical miss
8. Identify edge dissections9. Identify tissue protrusion10.Confirm procedural success
OCT Technology Console Ilumien, 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
1. Image acquisition: Outside the Body
Imaging core
Imaging sheath
Optical Lens
1) Purge the catheter withflush media (3 drips)2)Connect the catheter tothe dock3)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.
High-resolution pullback: 54 mm, 10 frames/mm 3.0 sec D1
LRP
LRP
Landing Zone
Long pullback : 75 mm, 5 frames/mm 2.1 sec
Pullback lengths
1. Image acquisition: Inside the body
1) Advance OCT catheter to region of interest on “Standby”
2) Engage guide catheter• Avoid sideholes• Administer IC NTG3) Enable “Live Image” and Inject
flush media to deliver NTG and ensure adequate blood clearance
*Do not waste contrast*Plan your angiographic view (avoidoverlap)4) Purge the OCT catheter*This minimizes signal dampening
Distal Marker
Lens Marker
Proximal Marker
1. Image acquisition: Inside the body5) Press enable on the OCT dock
or console to calibrate6) Cine - Enable - Inject
Proximal Marker
Lens Marker
Distal Marker
Region of Interest – Vessel Segment Imaged During Pullback
Markers20 mm apart
Pullback length: 5 cm
Lens
1. Co-registering
1) Select co-register2) 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.
Calcific• Rotablator
•High Pressure
Necrotic Core• CuttingBalloon
• HighPressure
2. Assess Plaque CompositionFibrous Fibro-Fatty
•BAS • BAS
LCX
Dx
LM
MLA 1.95 mm2
Ø = 1.56 mm, AS = 76.5%
LLeseisoionnlelnenggthth2
826mmmm
Area 8.29 mm2
Ø = 3.12 mmArea 8.32 mm2
Ø = 3.04 mm
Area 8.79 mm2
Ø = 3.25 mm
3. Identify Reference Segments1) 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
Area 8.79 mm2 Ø = 3.55 mm
Lesion length 28 mm
LCX
LMDx
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
How Big?
LumenMLD 3.0mmMSA (r2) = 7.07mm2
Mid-wallMWD 3.1mmMSA (r2) = 7.55mm2
External Elastic LaminaEELD 3.2mmMSA (r2) = 8.04mm2
3. Choose StentDiameter
OCT vs IVUS vs Histology
Kubo et al. iJACC 2013;6(10):1095-1104
Size Matters
de Feyter et al. Circulation 1999;100:1777-83
Final Minimum Stent Area (mm2)
**
**
*
**
* ***
******
**
*****
**
*
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
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
Lumen Area, Stent Area, Strut-LumenDistance
Strut-Vessel Wall Distance
Protruding Covered
MalapposedEmbedded
6. Determine AppositionMalapposition
Alloy Strut Polymer Total Thickness Embedded Contact Malapposed
Cypher 140 7 154 <80 80-160 >160Taxus 97 15 127 <65 65-130 >130Zotarolimus 91 8 107 <55 55-110 >110Everolimus 81 7 88* <54 50-100 >108
6. Determine Apposition
Major
Strut
MinorStrut
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
OCT
7. Rule out geographic miss
1) Peruse OCT longitudinalimage for geographic miss
Stented Segment
8. Identify Edge Dissections
Major Category1) >60° / >3mm2)Flow limiting (TIMI)3)Inadequate MLA
8. Identify Edge Dissections
LCX-post BVS implantation
LCX-post BVS implantation
LCX – OCT run
9. Identify Tissue Protrusion
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
LAD – during BVS implantation
LAD – during BVS implantation
LAD – post aspiration
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)
OCT – ISR - BVS
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
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
Thank You