Heart India

CASE REPORT
Year
: 2020  |  Volume : 8  |  Issue : 2  |  Page : 111--115

Real time 3D-OCT predicts restenosis by identifying geographic miss between overlapping stents after complex multivessel percutaneous coronary intervention


Raghuram Palaparti, Gopala Krishna Koduru, Sudarshan Palaparti, PS S. Chowdary, Purnachandra Rao Kondru, Somasekhar Ghanta, Boochi Babu Mannuva, Prasad Maganti, Sasidhar Yendapalli 
 Department of Cardiology, Aayush Hospitals, Vijayawada, Andhra Pradesh, India

Correspondence Address:
Dr. Raghuram Palaparti
Department of Cardiology, Aayush Hospitals, Ramachandra Nagar, Vijayawada - 520 008, Andhra Pradesh
India

Abstract

A 78-year-old male patient with a history of cerebrovascular accident and left hemiparesis presented with evolved inferior wall myocardial infarction and preserved left ventricle (LV) function. Coronary angiogram revealed triple-vessel disease. After heart team discussion, he was advised multivessel percutaneous coronary intervention (PCI). He underwent PCI to right coronary artery (2× sirolimus-eluting stent) in the first stage with good result. After 4 weeks, he again presented to the emergency department with acute coronary syndrome (ACS). He underwent imaging-guided left main (LM) bifurcation PCI (mini-crush technique) with 2 ×× everolimus-eluting stent (EES) across LM to left anterior descending artery (LAD) and 2 ×× EES in left circumflex artery (LCX). Real-time three-dimensional optical coherence tomography (3D-OCT) identified 1 mm geographic miss between overlapping stents in heavily calcified LAD. Cine fluoroscopy and intravascular ultrasound (IVUS) did not identify the same. In view of elderly age, already high contrast load, mild renal impairment, and low-risk OCT features, he was managed conservatively. He was doing well until 10 months after PCI, when he presented again to the emergency department with ACS and LV dysfunction. CAG showed critical in-stent restenosis (ISR) at the LAD stent overlap area. Other stents were all patent with mild ISR in LCx. He underwent PCI to LAD with 1 ×× EES. He is in follow-up for the last 1 year without any complaints and improved LV function. The availability of real-time 3D-OCT machines allowed us to easily identify “geographic miss” which is sometimes difficult to detect with cine flouroscopy or IVUS, particularly in heavily calcified vessels. This newer technology adds another dimension to intravascular imaging-guided PCI and has shown great promise particularly in complex and bifurcation PCI.



How to cite this article:
Palaparti R, Koduru GK, Palaparti S, S. Chowdary P S, Kondru PR, Ghanta S, Mannuva BB, Maganti P, Yendapalli S. Real time 3D-OCT predicts restenosis by identifying geographic miss between overlapping stents after complex multivessel percutaneous coronary intervention.Heart India 2020;8:111-115


How to cite this URL:
Palaparti R, Koduru GK, Palaparti S, S. Chowdary P S, Kondru PR, Ghanta S, Mannuva BB, Maganti P, Yendapalli S. Real time 3D-OCT predicts restenosis by identifying geographic miss between overlapping stents after complex multivessel percutaneous coronary intervention. Heart India [serial online] 2020 [cited 2020 Oct 30 ];8:111-115
Available from: https://www.heartindia.net/text.asp?2020/8/2/111/291361


Full Text



 Introduction



With increasing rates of complex and high-risk percutaneous coronary intervention (PCI), intracoronary imaging plays an important role in optimization of PCI results on a daily basis in cardiac catheterization laboratory. Optical coherence tomography (OCT) scores over intravascular ultrasound (IVUS) as it offers clear, photographic-quality images, as opposed to grainy, lower-resolution IVUS images. Interventional cardiologists are “confounded” by the speckled IVUS images, which are sometimes difficult to interpret.[1] Fine details, such as stent strut apposition and thrombus, can be difficult to detect. Here, we report a case of complex multivessel (MV) PCI (LM bifurcation) in which OCT identified the geographic miss between overlapping left anterior descending artery (LAD) stents predicting the restenosis in follow-up.

 Case Report



A 78-year-old male patient, diabetic for 20 years, hypertensive for 15 years, with previous history of ischemic cerebrovascular accident, left hemiparesis, and mild residual paralysis 10 years back, presented to the cardiology outpatient department with one episode of syncope 1 week back and rest angina. He was found to have electrocardiogram (ECG) changes suggestive of evolved inferior wall myocardial infarction, positive troponins, and preserved left ventricle (LV) function (ejection fraction [EF] = 0.50). Coronary angiogram (Feb 2018) showed triple-vessel disease with significant mid-LAD (80%) stenosis, critical diagonal (95%) disease, critical proximal (80-90) and distal LCX (80-90%) stenosis. Right coronary artery is dominant and is a subtotal (99%) occlusion [Videos 1-3].[MULTIMEDIA:1][MULTIMEDIA:2][MULTIMEDIA:3] After heart team discussion, he was decided to be at higher risk for coronary artery bypass graft and was given MV-PCI as an option. The patient also preferred to MV-PCI and underwent it in a staged manner.

First, he underwent PCI to RCA. Using JR 4.0, 6F guiding catheter, the RCA was cannulated and wired with Sion blue 0.014 inch wire, and the mid-RCA lesion was predilated with 2.5 × 18 noncompliant (NC) balloon at 14 atmospheric pressure (atm). A 2.75 × 28 sirolimus-eluting stent (SES) (PRONOVA XR, Vascular concepts) stent was deployed at 12 atm distally and 2.75 × 23 stent (PRONOVA XR, Vascular concepts) at 12 atm proximally. Stented area was postdilated with 3 × 20 NC TREK balloon at 18–22 atm achieving good result [Video 4].[MULTIMEDIA:4] He was planned for a staged intervention to left coronary system in view of mildly deranged renal parameters.

After 4 weeks in March 2018, he presented to the emergency department with multiple episodes of rest angina again, ST depressions in precordial leads, and positive troponins (non-ST elevation myocardial infarction [NSTEMI]). He underwent left main coronary artery (LMCA) bifurcation PCI (mini-crush technique) using intracoronary image guidance after stabilization. Left coronary artery was cannulated with 7F EBU 3.5 guide. LAD and LCX were wired with Sion blue and BMW 0.014 inch guidewires, respectively. Baseline IVUS through manual pullback using the OptiCross™ IVUS catheter was done for vessel sizing and to assess calcium burden. Moderate calcium burden was noted in mid-LAD. It was decided to proceed without debulking and to use high-pressure predilatation. LCX was predilated with 2.5 × 12 NC balloon at 18 atm. LAD was predilated with 3 × 15 NC balloon at 18 atm. A 2.5 × 28 Xience V everolimus-eluting stent (EES) stent (Abbott Vascular Company, Abbott Park, IL) was deployed in distal LCX and trumpeted with stent balloon. A 3 × 18 Xience V EES stent was deployed in proximal LCX overlapping with the distal stent and with one strut protruding into LM at 12 atm. A 3.5 × 18 mm Xience V EES stent was deployed across LMCA to LAD at 12 atm. Significant lesion was noted distal to the LAD stent. A 2.5 × 28 mm Xience V EES stent could not be negotiated through the proximal LAD stent even after multiple high-pressure balloon dilatations. Hence, this stent was delivered distally using GuideLiner catheter (Vascular Solutions Inc., Minneapolis, MN, USA) extension system and deployed at 12 atm. LCX was recrossed with wire and kissing inflation was done in LM bifurcation with 3.5 × 15 mm NC balloon in LAD and 3 × 12 mm NC in LCX at 10 atm each. OCT images were acquired with a commercially available frequency-domain OCT system (ILLUMIEN OPTIS OCT Imaging System, Abbott) after intracoronary administration of 200 μg of nitroglycerin through 7-F guiding catheter. OCT catheter (Dragonfly OPTIS, Abbott) was advanced over 0.014 inch angioplasty wire approximately 10 mm distal to the distal stent edge. The entire length of the stented region was scanned using an integrated automated motorized pullback device at a speed of 20 mm/s. Continuous flush of iodine contrast medium (10 ml) through hand injection was performed to create a virtually blood-free environment and to trigger image acquisition. OCT images showed suboptimal stent opposition in ostial LCX area. Final kissing inflation was repeated with 3.5 × 15 NC balloon in LCX and 3.5 × 15 NC balloon in LAD with good result [Video 5].[MULTIMEDIA:5] Manual pullback of IVUS and automated pullback with IVUS were repeated, confirming good strut opposition in all areas. Review of OCT pullback and three dimensional (3D) reconstruction images identified 1 mm bare area (geographic miss) at the overlap area of LAD stents which could not be detected while deployment of stent on cine fluoroscopy or on manual pullback IVUS images [Video 6 and [Figure 1] and [Figure 2].[MULTIMEDIA:6] It was managed conservatively. The patient did well postprocedure and was discharged on aspirin + ticagrelor, high-dose statin, optimal doses of beta blockers plus adverse cardiovascular event (ACE) inhibition, and antidiabetic medication.{Figure 1}{Figure 2}

Left anterior descending artery at the overlap area

He was doing well until 10 months of follow-up, when he presented again with rest angina and dyspnea on exertion with ECG changes in December 2018. Echocardiography showed regional wall motion abnormality in LAD territory and depressed LV function (EF = 0.40). Check coronary angiogram showed focal 90% restenosis at the LAD stents overlap area and mild in-stent restenosis in the LCX stents. He underwent PCI to LAD using 3.0 × 15 mm XIENCE V EES at the overlap area and postdilatation with 3.5 × 12 mm NC TREK balloon at 14–16 atm with good result [Videos 7 and 8]. At 4 weeks of follow-up, he was symptom free and echocardiography showed improvement in LV function (EF = 0.50). He is under our regular follow-up since then and doing well.[MULTIMEDIA:7][MULTIMEDIA:8]

 Discussion



Intracoronary imaging has given a new dimension to the field of interventional cardiology. It immensely helps in accurate assessment of stent deployment and procedural complications in complex PCI. Stent optimization includes the assessment of stent expansion and malapposition. Intravascular imaging is useful in evaluating complications after stent implantation, including stent edge dissection, tissue protrusion, plaque shift, and coronary spasm. Additional applications of intravascular imaging include assessment of bifurcation stenting and bioresorbable vascular scaffold-treated lesions helping to optimize both procedural and long-term clinical outcomes.[2] When choosing the modality of intracoronary imaging, the anatomic location in the coronary tree appears to be a good discriminator. IVUS has better data when it comes to LMS-related lesions, whereas OCT seems to be superior in arteries with a minimal luminal area (MLA) of <3 mm2. When it comes to establishing diagnosis and optimizing stent deployment, OCT has the advantage of better resolution. However, when it comes to assessing the significance of intermediate coronary stenosis, physiological assessment with fractional flow reserve (FFR) should remain the first choice as IVUS and OCT-derived MLA cutoff values have at best moderate correlation and accuracy. In the hands of an experienced operator, imaging can be done rapidly with minimal or no complications. With advantages and limitations of one modality over the other, intracoronary imaging with IVUS and or OCT have the potential to complement each other.[3]

In ADAPT-DES study, a proximal reference segment plaque burden of >60% was associated with early stent thrombosis.[4] Similarly, in the HORIZONS-AMI IVUS substudy, a reference segment plaque burden of ≥70% and a lumen area of <4 mm2 was associated with early-stent thrombosis.[5] In CLI-OPCI II study, the reference lumen area of <4.5 mm2 in the presence of large plaque was an important predictor of major ACEs.[6] A recent review document recommends stent positioning in reference segments with <50% plaque burden on IVUS and absence of lipid-rich plaque on OCT imaging.[7] Angiographically detected persistent high-grade edge dissections (National Heart, Lung, and Blood Institute types B–F) have been associated with acute-stent thrombosis.[8] Intravascular imaging detects far more number of edge dissections that are angiographically invisible and clinically silent. In a study of systematic poststenting IVUS imaging, persistent edge dissections occurred in 9.2% of the patients and 39% of which were angiographically silent. Most of the IVUS-detected edge dissections are usually minor (angiographically silent and no lumen compromise by IVUS) and can be left alone safely.[9] In contrast, major dissections (IVUS lumen area narrowing <4 mm2 or dissection angle of ≥60°) have been associated with higher incidence of early-stent thrombosis and need additional stenting. Similarly, in ADAPT-DES IVUS substudy, residual stent edge dissection, especially with a smaller effective lumen area, was associated with target lesion revascularization during 1-year follow-up after drug-eluting stent implantation.[10] In a study by Chamie et al., high rates of stent edge dissections were detected by OCT, usually related to the presence of atherosclerosis at stent edges and to PCI technique. It occurred in 37.8% of the patients. Most of the edge dissections were minor, nonflow limiting, superficial (dissections with longitudinal length ≤1.75 mm, with <2 concomitant flaps, flap depth ≤0.52 mm, flap opening ≤0.33 mm, and not extending deeper than the media layer), and healed on follow-up.[11] According to ILLUMIEN III-Optimize PCI, a large multisite randomized trial evaluating the efficacy of OCT in optimizing PCI compared to IVUS, a major stent edge dissection was defined as ≥60° of the circumference of the vessel at site of dissection and/or ≥3 mm in length. A minor dissection was defined as any visible edge dissection <60° of the circumference of the vessel and <3 mm in length. The results showed that minor stent edge dissections are benign and can be managed conservatively.[12] From the above discussed clinical evidence, it shows that intravascular imaging (IVI) identifies the geographic miss, dissections early when compared to conventional angiography and allows us to treat the significant ones to prevent adverse outcomes.

OCT-guided PCI is now unanimously considered “appropriate” in stent thrombosis, guidance in PCI, especially in distal left main coronary artery and proximal left anterior descending coronary artery, unexplained angiographic abnormalities, and use of bioresorbable vascular scaffold.[13] In OCT acute coronary syndrome trial, OCT-guided PCI in patients with NSTEMI showed that the percentage of acutely malapposed struts was substantially lower in the OCT-guided group (P < 0.01). At 6-month follow-up, the OCT-guided group had a significantly lower proportion of uncovered struts. Furthermore, OCT-guided patients had significantly more completely covered stents. The investigators concluded that OCT-guided stent implantation improves strut coverage at 6-month follow-up in comparison with angiographic guidance alone.[14] Similarly in the multicenter, randomized DOCTORS study, OCT-guided PCI is associated with higher postprocedure FFR than PCI guided by angiography alone. OCT did not increase periprocedural complications, type 4a myocardial infarction, or acute kidney injury.[15]

Our patient had 1 mm geographic miss between the overlapping stents in the LAD which was easily identified by real-time 3D-OCT. There was no evidence of edge dissection, luminal narrowing, or thrombus. Considering high contrast load, prolonged procedure, elderly age and mild renal impairment, we opted not to treat it. OCT also did not reveal high-risk features like dissection flap, flow comprise, luminal narrowing or thrombus. The patient was also stable without angina or ECG changes. Hence, our decision of managing the geographic miss conservatively appears reasonable.

Frequency-domain OCT (FD-OCT) enables better 3D reconstruction of coronary vessels and stent struts because of faster frame rate. After the first application of 3D reconstruction of the human coronary artery, 3D-OCT reconstruction technology has promptly developed its clinical utility, such as for bifurcation lesion treatment, assessment of jailed side branches, and AMI management. With the advance of OCT technology, 3D reconstruction based on the OCT has become feasible. In bifurcation lesions, 3D-OCT may guide positioning of the wire through the appropriate (distal) cells. Some studies have suggested that such a guidance strategy could reduce the incidence of malapposition in bifurcation lesions.[16] In contrast, the 3D reconstruction of IVUS was first described in 1995, but has not shown an obvious, useful clinical application yet. Moreover, it is time-consuming, cumbersome, and sometimes will have to be done in an imaging core lab which is not routinely available in all centers. Newer technologies such as high-resolution IVUS and OCT 3D reconstruction will hopefully provide further clinical implications of intravascular imaging-guided PCI.[17]

Learning objective

Real-time 3D-OCT imaging available in present-generation FD-OCT machines allowed us to identify the geographic miss between overlapping stents in a heavily calcified LAD. Thereby, it predicted the restenosis in follow-up. This could not be identified on simultaneous cine fluoroscopy or IVUS. This newer technology adds another dimension to intravascular imaging-guided PCI and has shown great promise particularly in complex and bifurcation PCI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical Approval

Ethical clearance in the form of informed written and verbal consent has been obtained from the patient. Ethical committee approval is not required for the case report.

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