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Application of Coronary OCT in Clinical Practice Imaging of the coronary arteries is a standard component of percutaneous coronary interventions (PCI) to guide optimal PCI strategies and stent deployment.1 Intravascular ultrasound (IVUS) is the most commonly used intracoronary imaging technique.2 IVUS has demonstrated a reduction in repeat revascularization and restenosis compared to PCI guided by angiography alone.2 Moreover, a recent metaanalysis of more than 19,000 patients showed that IVUS-guided coronary drug-eluting stent (DES) implantation was associated with a reduced incidence of death, major adverse cardiac events and stent thrombosis.3 OCT is a visual analog of IVUS in that it uses near-infrared light instead of sound waves to image the wall of the coronary artery. Both imaging modalities allow physicians to acquire images of diseased vessels from inside the artery, providing information on lesion length, vessel diameter, plaque morphology and stent-vessel wall apposition. OCT is capable of evaluating the cross-sectional and three-dimensional microstructure of blood vessels at a resolution of approximately 10 μm4 while the resolution afforded by IVUS is approximately 150 μm.5 The superior resolution of the OCT imaging allows physicians to better visualize important vessel characteristics and select the most appropriate treatment. Overall, OCT and IVUS demonstrate a strong correlation across the parameters most relevant to PCI guidance, i.e., lumen border, diameter and area measurements. Bezerra et al.6 reported equivalence between FD-OCT imaging and IVUS to determine coronary reference lumen dimensions, an important metric used in routine PCI. Yamaguchi T et al.7 performed a direct comparison of IVUS and OCT in the setting of PCI for coronary artery disease. The procedural success rates of OCT and IVUS, defined as successful acquisition of a pullback image, were not statistically different for the two techniques. There were no major complications with either technique. Some transient events, such as chest discomfort, brady- or tachycardia or ST-T changes were seen with both techniques, all of which resolved immediately after the procedure. Minimal lumen diameter and minimal lumen area measured by OCT were significantly correlated with the corresponding IVUS measurements, r = 0.91 and 0.95, respectively. Poor visibility of the lumen border was noted in 17 IVUS procedures (17.3%), compared to 6 OCT procedures (6.1%). The OCT technology has evolved from time-domain OCT (TD-OCT) to frequencydomain OCT (FD-OCT) with non-occlusive imaging. The main difference between TDOCT and FD-OCT systems is that FD-OCT systems are capable of much higher speeds, facilitating rapid, three-dimensional pullback imaging during the administration of a non-occlusive flush of an optically transparent media or radiocontrast. 4 This document and all applicable downloads are available at www.SJMprofessional.com/OCTreimbursement. OCT has been used for many years as a research tool and has accumulated more than 600 publications. This vast body of literature shows an acceptable safety profile with no significant safety issues reported.4 OCT has also been incorporated as an outcome measurement technique in multiple studies of new drug-eluting stents. However, FD-OCT with non-occlusive imaging is now being used routinely to guide PCI due to its ability to show precisely how the stent is positioned against the artery wall. This indication is not a research tool—physicians are routinely using FD-OCT for the same indications as IVUS, specifically to determine: Assessment of stent under expansion Need for additional stent Stent malapposition Presence of thrombus The following literature focuses on the specific clinical application of OCT for guiding PCI in the clinical catheterization lab: Stefano et al.8 described how OCT was incorporated into a US cardiac catheterization lab based on a specific quality initiative by participating hospitals. During a 3-month period, all patients undergoing PCI were expected to have OCT; a total of 150 patients (155 target vessels) participated. Outcomes included safety, OCT success and impact on management. OCT was performed either prior, during or after the intervention itself. OCT parameters recorded included luminal diameters and post-PCI edge dissection. No adverse events were reported, and successful imaging was reported in 85.7% of target vessels; failed imaging was related to the severity of stenosis, or inability of the catheter to reach the target legion. OCT prompted a change in patient management in 81.8% of the patients when used prior to PCI and in 54.8% when used post-intervention. Management changes when OCT was used prior to the PCI included the number of stents, stent length or diameter. Changes following PCI included further stenting, further dilation of an under expanded stent, or balloon dilation for stent malapposition. This study demonstrated that similar to IVUS, OCT provided information that directly impacts PCI procedures. As noted by the authors, “FD-OCT is safe, can successfully be incorporated into routine practice, and alters procedural strategy in a high proportion of patients undergoing PCI.” Prati F et al.9 compared PCI guidance using angiography and OCT (n=335) with matched patients undergoing PCI using angiographic guidance alone (n=335). The primary endpoint was the one year rate of cardiac death or myocardial infarction. Similar to the Stefano study above, this study demonstrated that OCT can be used to direct PCI decisions, specifically regarding the need for additional stents, stent underexpansion or stent malapposition. Findings from the OCT led to additional interventions in 34.7% of subjects. The authors concluded that OCT can be safely performed to guide routine PCI and that OCT identifies additional procedural interventions not recognized by angiography leading to additional interventions in one third of the patients. This document and all applicable downloads are available at www.SJMprofessional.com/OCTreimbursement. Viceconte N et al.10 reported on 108 consecutive patients who underwent OCT as an adjunct to PCI. Similar to the Stefano study, OCT was performed before or after the stenting itself. When performed prior to the stenting to evaluate candidacy for stenting an intermediate lesion, OCT resulted in a deferral of the procedure itself in 19.1%; when performed after dilation and just prior to stenting, OCT resulted in a change in management in 52.2% of patients. Finally, when performed after initial stent deployment, OCT suggested additional stenting in 14% of patients and further dilation in 30%. The authors concluded that repeated examinations with OCT can be safely used to guide stent selection and improve stent expansion and apposition. The published clinical evidence demonstrates the clinical utility of coronary OCT in PCI, and shows that OCT is a medically reasonable alternative to IVUS for intravascular imaging. Typically, PCI requiring intravascular imaging utilize only a single imaging modality and OCT would be utilized in lieu of IVUS, not in addition to IVUS. 1 2 3 4 5 6 7 8 9 10 Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. Circulation. 2011;124(23):2574-609. Agency for Healthcare research and Quality. Intravascular Diagnostic Procedures and Imaging Techniques Versus Angiography Alone in Coronary Artery Stenting: Comparative Effectiveness Review. February 26, 2013. Zhang Y, Farooq V, Garcia-Garcia HM, et al. Comparison of intravascular ultrasound versus angiography-guided drug-eluting stent implantation: a meta-analysis of one randomised trial and ten observational studies involving 19,619 patients. EuroIntervention. 2012;8(7):855-65. Tearney GJ, Regar E, Akasaka T, et al. Consensus standards for acquisition, measurement, and reporting of intravascular optical coherence tomography studies. J Am Coll Cardiol. 2012;59(12):1058-72. Nissen SE, Yock P. Intravascular ultrasound: Novel pathophysiological insights and current clinical applications. Circulation. 2001;103(4):604-16. Bezerra HG, Attizzani GF, Sirbu V, et al. Optical coherence tomography versus intravascular ultrasound to evaluate coronary artery disease and percutaneous coronary intervention. JACC Cardiovasc Intv. 2013;6(3):228-36. Yamaguchi T, Terashima M, Akasaka T, et al. Safety and feasibility of an intravascular optical coherence tomography image wire system in the clinical setting. Am J Cardiol. 2008;101(5):562-7. Stefano GT, Bezerra HG, Mehanna E, et al. Unrestricted utilization of frequency domain optical coherence tomography in coronary interventions. Int J Cardiovasc Imaging. 2013;29(4):741-52. Prati F, Di Vito L, Bionid-Zoccai G, et al. Angiography alone versus angiography plus optical coherence tomography to guide decision-making during percutaneous coronary intervention: The Centro Per la Lotta Control L-Infarto-Optimisation of Percutaneous Coronary Intervention (CLIOPCI) study. EuroIntervention. 2012;8(7):823-9. Viceconte N, Chan PH, Barrero EA, et al. Frequency domain optical coherence tomography for guidance of coronary stenting. Int J Cardiol. 2013;166(3):722-8. This document and all applicable downloads are available at www.SJMprofessional.com/OCTreimbursement.