3D optical coherence tomography: new insights into the process of optimal rewiring of side branches during bifurcational stenting

Selected in EuroIntervention Journal by S. Brugaletta

References

Authors

Okamura T, Onuma Y, Yamada J, Iqbal J, Tateishi H, Nao T, Oda T, Maeda T, Nakamura T, Miura T, Yano M, Serruys PW

Reference

EuroIntervention. 2014 Dec 22;10(8):907-15

Published

December 2014

Link

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Aims

We describe three-dimensional optical coherence tomography (3D-OCT) guided bifurcation stenting and the clinical utility of 3D-OCT.

Methods and results

Twenty-two consecutive patients who underwent OCT examination to confirm the recrossing position after stent implantation in a bifurcation lesion were enrolled. Frequency domain OCT images were obtained to check the recrossing position and 3D reconstructions were performed off-line. The recrossing position was clearly visualised in 18/22 (81.8%) cases. In 13 cases, serial 3D-OCT could be assessed both before and after final kissing balloon post-dilation (FKBD). We divided these cases into two groups according to the presence of the link between hoops at the carina: free carina type (n=7) and connecting to carina type (n=6). All free carina types complied with the distal rewiring. The percentage of incomplete stent apposition (%ISA) of free carina type at the bifurcation segment after FKBD was significantly smaller than that of the connecting to carina type (0.7±0.9% vs. 12.2±6.5%, p=0.0074).

Conclusions

3D-OCT confirmation of the recrossing into the jailed side branch is feasible during PCI and may help to achieve distal rewiring and favourable stent positioning against the side branch ostium, leading to reduction in ISA and potentially better clinical outcomes.

My Comment

What is known 

Bifurcation lesions represent 15-20% of all percutaneous coronary interventions (PCI). Incomplete stent apposition (ISA) at the bifurcation segment can be a cause of stent thrombosis or target lesion revascularisation. The coronary guidewire re-crossing position before final kissing balloon post-dilation (FKBD) is important to reduce the incidence of ISA. Optical coherence tomography (OCT) can evaluate stent apposition and with 3D reconstruction may assess the spatial aspect of bifurcation stenting, potentially identifying the strut re-crossed by the wire before the FKBD. The aim of this paper was to describe a novel off-line software for 3D-OCT assessment of the re-crossing position during the procedure.

Major findings

  • Twenty-two consecutive patients who underwent OCT examination to confirm the re-crossing position after stent implantation in a bifurcation lesion were enrolled.
  • Frequency domain OCT images were obtained to check the re-crossing position and 3D reconstructions were performed off-line.
  • The re-crossing position was clearly visualised in 18/22 (81.8%) cases. In 13 cases, serial 3D-OCT could be assessed both before and after final kissing balloon post-dilation (FKBD).
  • The cases were divided into two groups according to the presence of the link between hoops at the carina: free carina type (n=7) and connecting to carina type (n=6).
  • All free carina types complied with the distal rewiring. The percentage of incomplete stent apposition (%ISA) of free carina type at the bifurcation segment after FKBD was significantly smaller than that of the connecting to carina type (0.7±0.9% vs. 12.2±6.5%, p=0.0074).

My comments 

The use of 3D-OCT for guiding the final kissing balloon in coronary bifurcation treatment is much appealing, as it helps to identify the favourable strut configuration, reducing incidence of incomplete struts apposition. This analysis represents a first attempt to evaluate the feasibility of this approach. Unfortunately informations about time needed for such 3D reconstruction, learning curve and intra and inter-operator variabilities are missing. A large study including outcome data would be also needed.

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