OCT for bifurcation stenting: what have we learned?

Abstract

Treatment of bifurcation lesions by percutaneous coronary intervention (PCI) shows major variation in complexity. Intravascular optical coherence tomography (OCT) provides high-resolution images of the pathoanatomy, thrombus, wires and stent positions during the procedure. This information may prove crucial in optimising PCI results and clinical outcomes after complex bifurcation treatment. Mounting evidence confirms the feasibility of OCT in bifurcations, and specific steps where OCT may be advantageous in guiding bifurcation PCI have been identified. Awaiting major clinical outcome trials, OCT has already entered the European guidelines for myocardial revascularisation. This paper aims to provide an overview of the potential clinical use of OCT in bifurcations.

Optical coherence tomography predictors of target vessel myocardial infarction after provisional stenting in patients with coronary bifurcation disease

“…Otherwise, we highly suggest that a systematic two‐stent strategy is preferable if a bifurcation lesion has a vulnerable plaque in the MV, particularly localizing at the POC area. Taken together, our results addressed the importance of routine assessment by OCT for bifurcation lesions before decision‐making 9,13,14,17‐19 …”

“…We found that vessels with vulnerable plaques had a wider distal bifurcation angle when measured by OCT but not by QCA. The presence of a wide bifurcation angle leads to a significant chance of restenosis after stent implantation and a disturbed flow pattern caused by the change in wall pressure between the main and bifurcated regions, with the presence of lower wall stress at bifurcations with a wider angle 7,16,17 . Therefore, a link between anatomical abnormality, presence of unstable plaque, and dynamic measurements would be important to guide bifurcation treatment 18‐20 …”

Optical coherence tomography assessment of a complex bifurcation lesion treated with double kissing Crush technique

“…[2] OCT can provide unique insights in this setting enabling detailed evaluation of coronary bifurcation pathology and facilitating procedural planning. [3] This is the first case in which we implemented OCT imaging to examine coronary artery pathology and use the DEFINITION classification to guide treatment of a bifurcation lesion. OCT imaging did not only permit detection of significant disease and thrombus at the ostium of the diagonal that was not seen by coronary angiography but also provided useful anatomical information and detailed assessment of the reference luminal dimensions and of the length of the lesions that facilitated selection of the appropriate balloon and stent size.…”

Optical coherence tomography: fundamentals and clinical utility

“…Bifurcation stenting, particularly the 2-stent techniques are associated with a high incidence of underexpansion and malapposition. OCT imaging with its stent rendering, apposition and expansion indicator functions facilitates identification of these abnormalities and hence appropriate corrective actions can be taken to avoid future adverse events (56)(57)(58)(59)(60)(61). Whether the use routine use of OCT to guide bifurcation PCI is associated with better outcomes is being tested in ongoing trials (62).…”