Cardiac Optical Coherence Tomography (OCT): Difference between revisions

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== Overview ==
== Overview ==
Optical Coherence Tomography (OCT) is a medical imaging methodology that uses a specially designed catheter with an optical fiber at its distal end to emit near-infrared light. The proximal end of the catheter is connected to a computerized imaging console that detects the light backscattered from within the vessel wall. OCT allows high-resolution visualization of the coronary artery structure by generating cross-sectional images from inside the blood vessels. This technology enables highly detailed, real-time visualization of coronary morphology by capturing optical reflections of tissue microstructures, allowing precise assessment of the endothelium, plaque burden, thin-cap fibroatheromas (TCFA), thrombus, calcium, and stent positioning.[17-23]1.     {{cite journal|vauthors=Maehara A, Mintz GS, Witzenbichler B, Weisz G, Neumann FJ, Rinaldi MJ, Metzger DC, Henry TD, Cox DA, Duffy PL, Brodie BR, Stuckey TD, Mazzaferri EL, McAndrew T, Généreux P, Mehran R, Kirtane AJ, Stone GW|title=Relationship Between Intravascular Ultrasound Guidance and Clinical Outcomes After Drug-Eluting Stents|journal=Circ Cardiovasc Interv|volume=11|issue=11|pages=e006243|date=November 2018|pmid=30571206|doi=10.1161/CIRCINTERVENTIONS.117.006243|url=}} Compared to intravascular ultrasound (IVUS), OCT offers superior axial resolution (~10-20 µm vs. 100-150 µm for IVUS), though with shallower penetration depth (1-2 mm vs. 4-8 mm for IVUS).  
Optical Coherence Tomography (OCT) is a [[medical imaging]] methodology that uses a specially designed [[catheter]] with an optical fiber at its distal end to emit near-infrared light. The proximal end of the catheter is connected to a computerized imaging console that detects the light backscattered from within the vessel wall. OCT allows high-resolution visualization of the coronary artery structure by generating cross-sectional images from inside the [[Blood vessel|blood vessels]]. This technology enables highly detailed, real-time visualization of coronary morphology by capturing optical reflections of tissue microstructures, allowing precise assessment of the [[endothelium]], plaque burden, thin-cap fibroatheromas (TCFA), thrombus, calcium, and stent positioning.<ref name="pmid30571206">{{cite journal|vauthors=Maehara A, Mintz GS, Witzenbichler B, Weisz G, Neumann FJ, Rinaldi MJ, Metzger DC, Henry TD, Cox DA, Duffy PL, Brodie BR, Stuckey TD, Mazzaferri EL, McAndrew T, Généreux P, Mehran R, Kirtane AJ, Stone GW|title=Relationship Between Intravascular Ultrasound Guidance and Clinical Outcomes After Drug-Eluting Stents|journal=Circ Cardiovasc Interv|volume=11|issue=11|pages=e006243|date=November 2018|pmid=30571206|doi=10.1161/CIRCINTERVENTIONS.117.006243|url=}}</ref><ref name="pmid30025725">{{cite journal|vauthors=Jones DA, Rathod KS, Koganti S, Hamshere S, Astroulakis Z, Lim P, Sirker A, O'Mahony C, Jain AK, Knight CJ, Dalby MC, Malik IS, Mathur A, Rakhit R, Lockie T, Redwood S, MacCarthy PA, Desilva R, Weerackody R, Wragg A, Smith EJ, Bourantas CV|title=Angiography Alone Versus Angiography Plus Optical Coherence Tomography to Guide Percutaneous Coronary Intervention: Outcomes From the Pan-London PCI Cohort|journal=JACC Cardiovasc Interv|volume=11|issue=14|pages=1313–1321|date=July 2018|pmid=30025725|doi=10.1016/j.jcin.2018.01.274|url=}}</ref><ref name="pmid32473888">{{cite journal|vauthors=Park H, Ahn JM, Kang DY, Lee JB, Park S, Ko E, Cho SC, Lee PH, Park DW, Kang SJ, Lee SW, Kim YH, Lee CW, Park SW, Park SJ|title=Optimal Stenting Technique for Complex Coronary Lesions: Intracoronary Imaging-Guided Pre-Dilation, Stent Sizing, and Post-Dilation|journal=JACC Cardiovasc Interv|volume=13|issue=12|pages=1403–1413|date=June 2020|pmid=32473888|doi=10.1016/j.jcin.2020.03.023|url=}}</ref><ref name="pmid31918944">{{cite journal|vauthors=Hong SJ, Mintz GS, Ahn CM, Kim JS, Kim BK, Ko YG, Kang TS, Kang WC, Kim YH, Hur SH, Hong BK, Choi D, Kwon H, Jang Y, Hong MK|title=Effect of Intravascular Ultrasound-Guided Drug-Eluting Stent Implantation: 5-Year Follow-Up of the IVUS-XPL Randomized Trial|journal=JACC Cardiovasc Interv|volume=13|issue=1|pages=62–71|date=January 2020|pmid=31918944|doi=10.1016/j.jcin.2019.09.033|url=}}</ref><ref name="pmid30261237">{{cite journal|vauthors=Zhang J, Gao X, Kan J, Ge Z, Han L, Lu S, Tian N, Lin S, Lu Q, Wu X, Li Q, Liu Z, Chen Y, Qian X, Wang J, Chai D, Chen C, Li X, Gogas BD, Pan T, Shan S, Ye F, Chen SL|title=Intravascular Ultrasound Versus Angiography-Guided Drug-Eluting Stent Implantation: The ULTIMATE Trial|journal=J Am Coll Cardiol|volume=72|issue=24|pages=3126–3137|date=December 2018|pmid=30261237|doi=10.1016/j.jacc.2018.09.013|url=}}</ref><ref name="pmid30545452">{{cite journal|vauthors=di Mario C, Koskinas KC, Räber L|title=Clinical Benefit of IVUS Guidance for Coronary Stenting: The ULTIMATE Step Toward Definitive Evidence?|journal=J Am Coll Cardiol|volume=72|issue=24|pages=3138–3141|date=December 2018|pmid=30545452|doi=10.1016/j.jacc.2018.10.029|url=}}</ref><ref name="pmid31061353">{{cite journal|vauthors=Elgendy IY, Mahmoud AN, Elgendy AY, Mintz GS|title=Intravascular Ultrasound-Guidance Is Associated With Lower Cardiovascular Mortality and Myocardial Infarction for Drug-Eluting Stent Implantation　- Insights From an Updated Meta-Analysis of Randomized Trials|journal=Circ J|volume=83|issue=6|pages=1410–1413|date=May 2019|pmid=31061353|doi=10.1253/circj.CJ-19-0209|url=}}</ref> Compared to intravascular ultrasound (IVUS), OCT offers superior axial resolution (~10-20 µm vs. 100-150 µm for IVUS), though with shallower penetration depth (1-2 mm vs. 4-8 mm for IVUS).  


== Available Platforms ==
== Available Platforms ==
OCT imaging utilizes near-infrared light (typically ~1,300 nm) to detect backscattered signals from tissue, offering unmatched spatial resolution. OCT imaging quality can be compromised by structures that absorb infrared light, such as thrombus, lipid-rich necrotic core, or calcified plaques.[1] Additionally, because blood scatters infrared light and interferes with image clarity, it must be cleared from the vessel using radiocontrast or, in some cases, saline before acquiring OCT images.
OCT imaging utilizes '''near-infrared light''' (typically ~1,300 nm) to detect backscattered signals from tissue, offering unmatched spatial resolution. OCT imaging quality can be compromised by structures that absorb infrared light, such as thrombus, lipid-rich necrotic core, or calcified plaques.<ref name="pmid34110288">{{cite journal|vauthors=Ali ZA, Karimi Galougahi K, Mintz GS, Maehara A, Shlofmitz RA, Mattesini A|title=Intracoronary optical coherence tomography: state of the art and future directions|journal=EuroIntervention|volume=17|issue=2|pages=e105–e123|date=June 2021|pmid=34110288|pmc=9725016|doi=10.4244/EIJ-D-21-00089|url=}}</ref> Additionally, because blood scatters infrared light and interferes with image clarity, it must be cleared from the vessel using radiocontrast or, in some cases, saline before acquiring OCT images.


Two main systems dominate the OCT market:
Two main systems dominate the OCT market:
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* '''Time-domain OCT (TD-OCT)''': Obsolete in clinical settings.
* '''Time-domain OCT (TD-OCT)''': Obsolete in clinical settings.


Major commercial platforms include Abbott's Dragonfly catheter (used with the ILUMIEN system) and Terumo's LUNAWAVE system. Recent advancements in OCT technology have led to hybrid systems that integrate additional imaging modalities such as IVUS (e.g., Novasight Hybrid by Conavi Medical and Dual Sensor by Terumo), near-infrared spectroscopy (HyperVue by SpectraWave), and near-infrared fluorescence (Canon Medical). These combinations allow clinicians to harness the complementary strengths of each modality simultaneously. Furthermore, OCT-based vessel reconstructions are now being utilized to compute virtual fractional flow reserve (vFFR) through computational fluid dynamics, offering the potential to assess both the anatomical features and physiological significance of coronary lesions in a single imaging session.  
Major commercial platforms include '''Abbott's Dragonfly catheter''' (used with the ILUMIEN system) and '''Terumo's LUNAWAVE''' system. Recent advancements in OCT technology have led to hybrid systems that integrate additional imaging modalities such as IVUS (e.g., '''Novasight Hybrid''' by Conavi Medical and '''Dual Sensor''' by Terumo), near-infrared spectroscopy (HyperVue by SpectraWave), and near-infrared fluorescence (Canon Medical). These combinations allow clinicians to harness the complementary strengths of each modality simultaneously. Furthermore, OCT-based vessel reconstructions are now being utilized to compute '''virtual fractional flow reserve''' (vFFR) through computational fluid dynamics, offering the potential to assess both the anatomical features and physiological significance of coronary lesions in a single imaging session.  


== Assessment of Atherosclerosis ==
== Assessment of Atherosclerosis ==
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Arteries can either "positively remodel" or "negatively remodel".  If there is an outward expansion of the artery to accommodate the plaque, this is referred to as positive or outward, or expansive modeling. Until the plaque occupies 40 to 50% of the volume of the artery there is no luminal encroachment.in contrast, if the lumen is encroached upon this is called negative, and word or constrictive remodeling.
Arteries can either "positively remodel" or "negatively remodel".  If there is an outward expansion of the artery to accommodate the plaque, this is referred to as positive or outward, or expansive modeling. Until the plaque occupies 40 to 50% of the volume of the artery there is no luminal encroachment.in contrast, if the lumen is encroached upon this is called negative, and word or constrictive remodeling.


The characteristic bright-dark-bright trilaminar pattern seen in a normal coronary artery corresponds to light reflections from its three distinct layers: the intima, media, and adventitia.  
The characteristic '''bright-dark-bright trilaminar pattern''' seen in a normal coronary artery corresponds to light reflections from its three distinct layers: the intima, media, and adventitia. <ref name="pmid39064126">{{cite journal|vauthors=Mitsis A, Eftychiou C, Kadoglou NP, Theodoropoulos KC, Karagiannidis E, Nasoufidou A, Ziakas A, Tzikas S, Kassimis G|title=Innovations in Intracoronary Imaging: Present Clinical Practices and Future Outlooks|journal=J Clin Med|volume=13|issue=14|pages=|date=July 2024|pmid=39064126|pmc=11277956|doi=10.3390/jcm13144086|url=}}</ref>


In atherosclerotic vessels, the normal arterial architecture becomes disrupted, and OCT reveals distinct morphological patterns that correspond to various types of plaque. These vessel wall morphologies include signal-rich (bright) low-attenuating areas characteristic of fibrous plaques (figure 2A), signal-poor (dark), high-attenuation regions with an overlying fibrous cap indicative of lipid-rich plaques (figure 2B),  and well-defined, signal-poor low-attenuation zones representing calcific plaques (figure 2C).[3] Within the lumen, the most frequently observed pathologies include high-attenuation red thrombus, which produces shadowing on the vessel wall, and low-attenuation white thrombus.
In atherosclerotic vessels, the normal arterial architecture becomes disrupted, and OCT reveals distinct morphological patterns that correspond to various types of plaque. These vessel wall morphologies include '''signal-rich (bright) low-attenuating areas''' characteristic of '''fibrous plaques''' (figure 2A), '''signal-poor (dark), high-attenuation regions''' with an overlying fibrous cap indicative of '''lipid-rich plaques''' (figure 2B),  and '''well-defined, signal-poor low-attenuation zones''' representing '''calcific plaques''' (figure 2C).<ref name="pmid30166889">{{cite journal|vauthors=ElFaramawy A, Youssef M, Abdel Ghany M, Shokry K|title=Difference in plaque characteristics of coronary culprit lesions in a cohort of Egyptian patients presented with acute coronary syndrome and stable coronary artery disease: An optical coherence tomography study|journal=Egypt Heart J|volume=70|issue=2|pages=95–100|date=June 2018|pmid=30166889|pmc=6112336|doi=10.1016/j.ehj.2017.12.002|url=}}</ref> Within the lumen, the most frequently observed pathologies include high-attenuation red thrombus, which produces shadowing on the vessel wall, and low-attenuation white thrombus.(figure 3) <ref name="pmid19892716">{{cite journal|vauthors=Prati F, Regar E, Mintz GS, Arbustini E, Di Mario C, Jang IK, Akasaka T, Costa M, Guagliumi G, Grube E, Ozaki Y, Pinto F, Serruys PW|title=Expert review document on methodology, terminology, and clinical applications of optical coherence tomography: physical principles, methodology of image acquisition, and clinical application for assessment of coronary arteries and atherosclerosis|journal=Eur Heart J|volume=31|issue=4|pages=401–15|date=February 2010|pmid=19892716|doi=10.1093/eurheartj/ehp433|url=}}</ref>


Furthermore, OCT’s superior resolution allows precise identification of culprit lesions in acute coronary syndrome (ACS), like plaque rupture, plaque erosion, and eruptive calcified nodules. (figure 4) [5] Recognizing the underlying causes of acute coronary syndrome (ACS) can contribute to more personalized and targeted treatment strategies. OCT is also valuable in assessing patients with spontaneous coronary artery dissection (SCAD) or myocardial infarction with non-obstructive coronary arteries (MINOCA), as it helps clarify the presence and nature of the culprit lesions in cases of non–ST-segment elevation MI (NSTEMI).[1] Finally, OCT is valuable in detecting high-risk vulnerable plaques, such as thin-cap fibroatheromas (TCFAs), that have a propensity to rupture and trigger acute coronary syndromes (ACS).  
Furthermore, OCT’s superior resolution allows precise identification of culprit lesions in '''acute coronary syndrome''' (ACS), like plaque rupture, plaque erosion, and eruptive calcified nodules.(figure 4)<ref name="pmid35907707">{{cite journal|vauthors=Yamamoto MH, Kondo S, Mizukami T, Yasuhara S, Wakabayashi K, Kobayashi N, Sambe T, Hibi K, Nanasato M, Sugiyama T, Kakuta T, Kondo T, Mitomo S, Nakamura S, Takano M, Yonetsu T, Ashikaga T, Dohi T, Yamamoto H, Kozuma K, Yamashita J, Yamaguchi J, Ohira H, Mitsumata K, Namiki A, Kimura S, Honye J, Kotoku N, Higuma T, Natsumeda M, Ikari Y, Sekimoto T, Mori H, Suzuki H, Otake H, Isomura N, Ochiai M, Suwa S, Shinke T|title=Rationale and design of the TACTICS registry: Optical coherence tomography guided primary percutaneous coronary intervention for patients with acute coronary syndrome|journal=J Cardiol|volume=80|issue=6|pages=505–510|date=December 2022|pmid=35907707|doi=10.1016/j.jjcc.2022.07.002|url=}}</ref> Recognizing the underlying causes of acute coronary syndrome (ACS) can contribute to more personalized and targeted treatment strategies. OCT is also valuable in assessing patients with spontaneous coronary artery dissection (SCAD) or myocardial infarction with non-obstructive coronary arteries (MINOCA), as it helps clarify the presence and nature of the culprit lesions in cases of non–ST-segment elevation MI (NSTEMI).<ref name="pmid341102882">{{cite journal|vauthors=Ali ZA, Karimi Galougahi K, Mintz GS, Maehara A, Shlofmitz RA, Mattesini A|title=Intracoronary optical coherence tomography: state of the art and future directions|journal=EuroIntervention|volume=17|issue=2|pages=e105–e123|date=June 2021|pmid=34110288|pmc=9725016|doi=10.4244/EIJ-D-21-00089|url=}}</ref> Finally, OCT is valuable in detecting high-risk vulnerable plaques, such as thin-cap fibroatheromas (TCFAs), that have a propensity to rupture and trigger acute coronary syndromes (ACS).(figure 5) <ref name="pmid21941666">{{cite journal|vauthors=Kubo T, Ino Y, Tanimoto T, Kitabata H, Tanaka A, Akasaka T|title=Optical coherence tomography imaging in acute coronary syndromes|journal=Cardiol Res Pract|volume=2011|issue=|pages=312978|date=2011|pmid=21941666|pmc=3177459|doi=10.4061/2011/312978|url=}}</ref>


In the interpretation of coronary Optical Coherence Tomography (OCT), the first step is to determine whether all three layers of the arterial wall—the intima, media, and adventitia—are clearly visualized. If all three layers are visible, the vessel is likely either a normal artery or one containing a fibrous plaque, both of which maintain relatively preserved architecture. However, if the layers cannot be fully visualized, the next step is to identify where the signal loss or attenuation is occurring.
In the interpretation of coronary Optical Coherence Tomography (OCT), the first step is to determine whether all three layers of the arterial wall—the intima, media, and adventitia—are clearly visualized. If all three layers are visible, the vessel is likely either a normal artery or one containing a fibrous plaque, both of which maintain relatively preserved architecture. However, if the layers cannot be fully visualized, the next step is to identify where the signal loss or attenuation is occurring.


If the signal change is located within the lumen, its characteristics help differentiate thrombus types. High attenuation in the lumen suggests the presence of red thrombus, which typically absorbs more light. Conversely, low attenuation in the lumen is indicative of a white thrombus, which is less optically dense.
If the signal change is located within the '''lumen''', its characteristics help differentiate thrombus types. High attenuation in the lumen suggests the presence of '''red thrombus''', which typically absorbs more light. Conversely, low attenuation in the lumen is indicative of a '''white thrombus''', which is less optically dense.


If the signal change occurs within the vessel wall, the pattern again provides diagnostic clues. High attenuation within the wall points toward a lipid-rich plaque, which scatters light significantly. On the other hand, low attenuation in the wall is characteristic of calcified plaque, which appears as a sharply delineated low-signal region with minimal backscatter.
If the signal change occurs within the vessel wall, the pattern again provides diagnostic clues. High attenuation within the wall points toward a lipid-rich plaque, which scatters light significantly. On the other hand, low attenuation in the wall is characteristic of calcified plaque, which appears as a sharply delineated low-signal region with minimal backscatter.


This stepwise assessment enables clinicians to classify plaques and thrombi with precision and guide decision-making during percutaneous coronary interventions.
This stepwise assessment enables clinicians to classify plaques and thrombi with precision and guide decision-making during percutaneous coronary interventions.(figure) <ref name="pmid341102883">{{cite journal|vauthors=Ali ZA, Karimi Galougahi K, Mintz GS, Maehara A, Shlofmitz RA, Mattesini A|title=Intracoronary optical coherence tomography: state of the art and future directions|journal=EuroIntervention|volume=17|issue=2|pages=e105–e123|date=June 2021|pmid=34110288|pmc=9725016|doi=10.4244/EIJ-D-21-00089|url=}}</ref>


== Indications ==
== Indications ==
Intravascular OCT is used to guide PCI in a standardized approach. This standardized method is often summarized using the mnemonic MLD-MAX, where the pre-PCI focus is on MLD: Morphology, Length, and Diameter, and the post-PCI evaluation centers on MAX: Medial dissection, Apposition, and eXpansion. Pre-procedural OCT imaging plays a key role in planning PCI by:  
Intravascular OCT is used to guide PCI in a standardized approach. This standardized method is often summarized using the mnemonic '''MLD-MAX''', where the pre-PCI focus is on '''MLD''': '''M'''orphology, '''L'''ength, and '''D'''iameter, and the post-PCI evaluation centers on '''MAX''': '''M'''edial dissection, '''A'''pposition, and e'''X'''pansion. Pre-procedural OCT imaging plays a key role in planning PCI by:  


(1) evaluating lesion morphology to guide optimal lesion preparation,  
(1) evaluating lesion morphology to guide optimal lesion preparation,  
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Angiography often underestimates the severity of lesions. The angiogram only evaluates the lumen and does not evaluate the plaque burden in an artery. If a lesion is present OCT will generally demonstrate that 50 to 60% of the volume of the artery is made up of plaque both proximal and distal to the lesion.
Angiography often underestimates the severity of lesions. The angiogram only evaluates the lumen and does not evaluate the plaque burden in an artery. If a lesion is present OCT will generally demonstrate that 50 to 60% of the volume of the artery is made up of plaque both proximal and distal to the lesion.


OCT has been related to defects on nuclear imaging and Doppler flow wire measurements of coronary flow reserve (CFR) and fractional flow reserve (FFR) to validate its accuracy.
OCT has been related to defects on nuclear imaging and Doppler flow wire measurements of [[coronary flow reserve]] ([[CFR]]) and [[fractional flow reserve]] ([[FFR]]) to validate its accuracy.


The consensus view is that any minimum lumen area (MLA) < 4 mm² in an artery that is > 3 mm on angiography (excluding the left main) is a significant stenosis.
The consensus view is that any minimum lumen area (MLA) < 4 mm² in an artery that is > 3 mm on angiography (excluding the left main) is a significant stenosis.
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'''To Assess the Underlying Morphology of Lesions'''
'''To Assess the Underlying Morphology of Lesions'''


OCT is more sensitive than angiography in the assessment of calcium, particularly the presence of calcium deep in the wall of the artery. The sensitivity of angiography is approximately 25% if there is one quadrant of calcium present, the sensitivity is 50% if there are two quadrants of calcium, the sensitivity is 60% if there are three quadrants of calcium and finally the sensitivity is 85% if there are for quadrants calcium. In lesions with predominantly fibrous or lipid-rich plaque, direct stenting or predilatation with an undersized balloon may be sufficient. However, for moderate to severe calcification, specialized plaque modification techniques, such as noncompliant, cutting, or scoring balloons, atherectomy, or intravascular lithotripsy (IVL), are often required. OCT is particularly valuable in these cases, as it provides a more precise evaluation of calcium burden compared to IVUS. An OCT-based calcium scoring system can help guide the need for advanced plaque modification.[15,16] (figure 10) Specifically, lesions with calcium arc >180° (i.e. 50% of circumference), thickness >0.5 mm, and length >5 mm (commonly referred to as the "rule of 5") are more likely to require atherectomy or IVL due to their association with suboptimal stent expansion.'''To Assess The Length Of Lesions'''
OCT is more sensitive than angiography in the '''assessment of calcium''', particularly the presence of calcium deep in the wall of the artery. The sensitivity of angiography is approximately 25% if there is one quadrant of calcium present, the sensitivity is 50% if there are two quadrants of calcium, the sensitivity is 60% if there are three quadrants of calcium and finally the sensitivity is 85% if there are for quadrants calcium. In lesions with predominantly fibrous or lipid-rich plaque, direct stenting or predilatation with an undersized balloon may be sufficient. However, for moderate to severe calcification, specialized plaque modification techniques, such as '''noncompliant, cutting, or scoring balloons, atherectomy, or intravascular lithotripsy (IVL)''', are often required. OCT is particularly valuable in these cases, as it provides a more precise evaluation of calcium burden compared to IVUS. An OCT-based calcium scoring system can help guide the need for advanced plaque modification.<ref name="pmid29400655">{{cite journal|vauthors=Fujino A, Mintz GS, Matsumura M, Lee T, Kim SY, Hoshino M, Usui E, Yonetsu T, Haag ES, Shlofmitz RA, Kakuta T, Maehara A|title=A new optical coherence tomography-based calcium scoring system to predict stent underexpansion|journal=EuroIntervention|volume=13|issue=18|pages=e2182–e2189|date=April 2018|pmid=29400655|doi=10.4244/EIJ-D-17-00962|url=}}</ref><ref name="pmid29624174">{{cite journal|vauthors=Ali ZA, Galougahi KK|title=Shining light on calcified lesions, plaque stabilisation and physiologic significance: new insights from intracoronary OCT|journal=EuroIntervention|volume=13|issue=18|pages=e2105–e2108|date=April 2018|pmid=29624174|doi=10.4244/EIJV13I18A346|url=}}</ref>(figure 10) Specifically, lesions with '''calcium arc >180°''' (i.e. 50% of circumference), '''thickness >0.5 mm''', and '''length >5 mm''' (commonly referred to as the '''"rule of 5"''') are more likely to require atherectomy or IVL due to their association with suboptimal stent expansion.


To accurately measure lesion length, it is essential to select proximal and distal reference segments that have minimal plaque burden and provide clear visualization of the vessel wall. The imaging software typically calculates the distance between these segments automatically, and the operator can adjust them to align with the length of an available drug-eluting stent. This approach helps reduce the risk of stent edge-related complications, such as inflow or outflow disease and the presence of TCFA at the stent margins, which are associated with poorer clinical outcomes. [28-33]
'''To Assess The Length Of Lesions'''
 
To accurately measure lesion length, it is essential to select proximal and distal reference segments that have minimal plaque burden and provide clear visualization of the vessel wall. The imaging software typically calculates the distance between these segments automatically, and the operator can adjust them to align with the length of an available drug-eluting stent. This approach helps reduce the risk of stent edge-related complications, such as inflow or outflow disease and the presence of TCFA at the stent margins, which are associated with poorer clinical outcomes.<ref name="pmid27688261">{{cite journal|vauthors=Ino Y, Kubo T, Matsuo Y, Yamaguchi T, Shiono Y, Shimamura K, Katayama Y, Nakamura T, Aoki H, Taruya A, Nishiguchi T, Satogami K, Yamano T, Kameyama T, Orii M, Ota S, Kuroi A, Kitabata H, Tanaka A, Hozumi T, Akasaka T|title=Optical Coherence Tomography Predictors for Edge Restenosis After Everolimus-Eluting Stent Implantation|journal=Circ Cardiovasc Interv|volume=9|issue=10|pages=|date=October 2016|pmid=27688261|doi=10.1161/CIRCINTERVENTIONS.116.004231|url=}}</ref><ref name="pmid27965297">{{cite journal|vauthors=Prati F, Romagnoli E, Gatto L, La Manna A, Burzotta F, Limbruno U, Versaci F, Fabbiocchi F, Di Giorgio A, Marco V, Ramazzotti V, Di Vito L, Trani C, Porto I, Boi A, Tavazzi L, Mintz GS|title=Clinical Impact of Suboptimal Stenting and Residual Intrastent Plaque/Thrombus Protrusion in Patients With Acute Coronary Syndrome: The CLI-OPCI ACS Substudy (Centro per la Lotta Contro L'Infarto-Optimization of Percutaneous Coronary Intervention in Acute Coronary Syndrome)|journal=Circ Cardiovasc Interv|volume=9|issue=12|pages=|date=December 2016|pmid=27965297|doi=10.1161/CIRCINTERVENTIONS.115.003726|url=}}</ref><ref name="pmid29633940">{{cite journal|vauthors=Prati F, Romagnoli E, La Manna A, Burzotta F, Gatto L, Marco V, Fineschi M, Fabbiocchi F, Versaci F, Trani C, Tamburino C, Alfonso F, Mintz GS|title=Long-term consequences of optical coherence tomography findings during percutaneous coronary intervention: the Centro Per La Lotta Contro L'infarto - Optimization Of Percutaneous Coronary Intervention (CLI-OPCI) LATE study|journal=EuroIntervention|volume=14|issue=4|pages=e443–e451|date=July 2018|pmid=29633940|doi=10.4244/EIJ-D-17-01111|url=}}</ref><ref name="pmid26563859">{{cite journal|vauthors=Prati F, Romagnoli E, Burzotta F, Limbruno U, Gatto L, La Manna A, Versaci F, Marco V, Di Vito L, Imola F, Paoletti G, Trani C, Tamburino C, Tavazzi L, Mintz GS|title=Clinical Impact of OCT Findings During PCI: The CLI-OPCI II Study|journal=JACC Cardiovasc Imaging|volume=8|issue=11|pages=1297–305|date=November 2015|pmid=26563859|doi=10.1016/j.jcmg.2015.08.013|url=}}</ref><ref name="pmid32089001">{{cite journal|vauthors=van Zandvoort LJ, Tomaniak M, Tovar Forero MN, Masdjedi K, Visseren L, Witberg K, Ligthart J, Kardys I, Lemmert ME, Diletti R, Wilschut J, de Jaegere P, Zijlstra F, Van Mieghem NM, Daemen J|title=Predictors for Clinical Outcome of Untreated Stent Edge Dissections as Detected by Optical Coherence Tomography|journal=Circ Cardiovasc Interv|volume=13|issue=3|pages=e008685|date=March 2020|pmid=32089001|doi=10.1161/CIRCINTERVENTIONS.119.008685|url=}}</ref>


'''To Assess the Diameter Of Lesions'''
'''To Assess the Diameter Of Lesions'''


Device sizing during PCI can be guided using either the external elastic lamina (EEL) or lumen-based measurements. An external elastic lamina (EEL)-guided strategy is preferred over a lumen-guided approach when 2 measurements can be obtained at least one quadrant apart. This approach generally allows for the selection of a balloon or stent approximately 0.5 mm larger, resulting in a larger final lumen area without increasing the risk of complications.[24-26] To select the stent size, the mean EEL diameter of the distal reference segment is measured and then rounded down to the nearest available stent size.[27] If the EEL is not well visualized, often due to plaque-induced signal attenuation, the mean lumen diameter is used instead and rounded up to the next available stent size.[27] The same principles, based on the respective reference diameter measurements, apply when selecting the size of the post-dilation balloon.  
Device sizing during PCI can be guided using either the '''external elastic lamina (EEL)''' or '''lumen-based measurements'''. An external elastic lamina (EEL)-guided strategy is preferred over a lumen-guided approach when 2 measurements can be obtained at least one quadrant apart. This approach generally allows for the selection of a balloon or stent approximately 0.5 mm larger, resulting in a larger final lumen area without increasing the risk of complications.<ref name="pmid33167000">{{cite journal|vauthors=Shlofmitz E, Jeremias A, Parviz Y, Karimi Galougahi K, Redfors B, Petrossian G, Edens M, Matsumura M, Maehara A, Mintz GS, Stone GW, Shlofmitz RA, Ali ZA|title=External elastic lamina vs. luminal diameter measurement for determining stent diameter by optical coherence tomography: an ILUMIEN III substudy|journal=Eur Heart J Cardiovasc Imaging|volume=22|issue=7|pages=753–759|date=June 2021|pmid=33167000|doi=10.1093/ehjci/jeaa276|url=}}</ref><ref name="pmid27806900">{{cite journal|vauthors=Ali ZA, Maehara A, Généreux P, Shlofmitz RA, Fabbiocchi F, Nazif TM, Guagliumi G, Meraj PM, Alfonso F, Samady H, Akasaka T, Carlson EB, Leesar MA, Matsumura M, Ozan MO, Mintz GS, Ben-Yehuda O, Stone GW|title=Optical coherence tomography compared with intravascular ultrasound and with angiography to guide coronary stent implantation (ILUMIEN III: OPTIMIZE PCI): a randomised controlled trial|journal=Lancet|volume=388|issue=10060|pages=2618–2628|date=November 2016|pmid=27806900|doi=10.1016/S0140-6736(16)31922-5|url=}}</ref><ref name="pmid29121226">{{cite journal|vauthors=Kubo T, Shinke T, Okamura T, Hibi K, Nakazawa G, Morino Y, Shite J, Fusazaki T, Otake H, Kozuma K, Ioji T, Kaneda H, Serikawa T, Kataoka T, Okada H, Akasaka T|title=Optical frequency domain imaging vs. intravascular ultrasound in percutaneous coronary intervention (OPINION trial): one-year angiographic and clinical results|journal=Eur Heart J|volume=38|issue=42|pages=3139–3147|date=November 2017|pmid=29121226|pmc=5837511|doi=10.1093/eurheartj/ehx351|url=}}</ref> To select the stent size, the mean EEL diameter of the distal reference segment is measured and then rounded down to the nearest available stent size. If the EEL is not well visualized, often due to plaque-induced signal attenuation, the mean lumen diameter is used instead and rounded up to the next available stent size.<ref name="pmid32863246">{{cite journal|vauthors=Ali Z, Landmesser U, Karimi Galougahi K, Maehara A, Matsumura M, Shlofmitz RA, Guagliumi G, Price MJ, Hill JM, Akasaka T, Prati F, Bezerra HG, Wijns W, Mintz GS, Ben-Yehuda O, McGreevy RJ, Zhang Z, Rapoza RR, West NE, Stone GW|title=Optical coherence tomography-guided coronary stent implantation compared to angiography: a multicentre randomised trial in PCI - design and rationale of ILUMIEN IV: OPTIMAL PCI|journal=EuroIntervention|volume=16|issue=13|pages=1092–1099|date=January 2021|pmid=32863246|pmc=9725042|doi=10.4244/EIJ-D-20-00501|url=}}</ref> The same principles, based on the respective reference diameter measurements, apply when selecting the size of the post-dilation balloon. (figure 13)


Assessment of the left main is associated with the greatest amount of inter and intraobserver variability in angiography. The left main is short, and is often diseased with asymmetric lesions making its assessment on angiography difficult. There may be diffuse disease which may cause an underestimation of the extent of involvement on angiography. While luminal encroachment is defined as a minimum lumen area less than 4 mm² in the epicardial arteries, a minimum lumen area less than 6 mm² in the left main is considered to be significant. A minimum lumen area less than 6 mm² in the left main corresponds with a fractional flow reserve less than 0.75. A minimum lumen area less than 6 mm² also corresponds to a minimum lumen area less than 4 mm² in either the LAD or the circumflex arteries.
Assessment of the left main is associated with the greatest amount of inter and intraobserver variability in angiography. The left main is short, and is often diseased with asymmetric lesions making its assessment on angiography difficult. There may be diffuse disease which may cause an underestimation of the extent of involvement on angiography. While '''luminal encroachment''' is defined as a minimum lumen area less than 4 mm² in the epicardial arteries, a minimum lumen area less than 6 mm² in the left main is considered to be significant. A minimum lumen area less than 6 mm² in the left main corresponds with a fractional flow reserve less than 0.75. A minimum lumen area less than 6 mm² also corresponds to a minimum lumen area less than 4 mm² in either the LAD or the circumflex arteries.


Assessment of the diameter of the vessel is particularly useful in research studies such as those evaluating lipid lowering agents. Care must be taken to identify reproducible start and end points for the mechanical pullback to ensure that the same area of the segment is being interrogated.
Assessment of the diameter of the vessel is particularly useful in research studies such as those evaluating lipid lowering agents. Care must be taken to identify reproducible start and end points for the mechanical pullback to ensure that the same area of the segment is being interrogated.
Line 81: Line 83:
'''To Identify Complications Such as Dissection'''
'''To Identify Complications Such as Dissection'''


Following PCI, the proximal and distal reference segments should be evaluated for signs of medial dissection or intramural hematoma (Fig. 15).[35] Due to its high resolution, OCT can detect post-PCI edge dissections in up to 40% of cases.[36] However, most of these dissections are minor and tend to heal without causing significant clinical consequences.[37,38] That said, major edge dissections observed on OCT are associated with worse clinical outcomes.[39-42] It is generally advised to deploy an additional stent if a large dissection involves more than 60° of the vessel circumference and extends over 3 mm into the medial layer, provided that stenting is not limited by anatomical constraints.[43]
Following PCI, the proximal and distal reference segments should be evaluated for signs of '''medial dissection''' or intramural hematoma (Fig. 15).<ref name="pmid38304487">{{cite journal|vauthors=Nafee T, Shah A, Forsberg M, Zheng J, Ou J|title=State-of-art review: intravascular imaging in percutaneous coronary interventions|journal=Cardiol Plus|volume=8|issue=4|pages=227–246|date=2023|pmid=38304487|pmc=10829907|doi=10.1097/CP9.0000000000000069|url=}}</ref> Due to its high resolution, OCT can detect post-PCI edge dissections in up to 40% of cases.<ref name="pmid278069002">{{cite journal|vauthors=Ali ZA, Maehara A, Généreux P, Shlofmitz RA, Fabbiocchi F, Nazif TM, Guagliumi G, Meraj PM, Alfonso F, Samady H, Akasaka T, Carlson EB, Leesar MA, Matsumura M, Ozan MO, Mintz GS, Ben-Yehuda O, Stone GW|title=Optical coherence tomography compared with intravascular ultrasound and with angiography to guide coronary stent implantation (ILUMIEN III: OPTIMIZE PCI): a randomised controlled trial|journal=Lancet|volume=388|issue=10060|pages=2618–2628|date=November 2016|pmid=27806900|doi=10.1016/S0140-6736(16)31922-5|url=}}</ref> However, most of these dissections are minor and tend to heal without causing significant clinical consequences.<ref name="pmid320890012">{{cite journal|vauthors=van Zandvoort LJ, Tomaniak M, Tovar Forero MN, Masdjedi K, Visseren L, Witberg K, Ligthart J, Kardys I, Lemmert ME, Diletti R, Wilschut J, de Jaegere P, Zijlstra F, Van Mieghem NM, Daemen J|title=Predictors for Clinical Outcome of Untreated Stent Edge Dissections as Detected by Optical Coherence Tomography|journal=Circ Cardiovasc Interv|volume=13|issue=3|pages=e008685|date=March 2020|pmid=32089001|doi=10.1161/CIRCINTERVENTIONS.119.008685|url=}}</ref><ref name="pmid24064426">{{cite journal|vauthors=Radu MD, Räber L, Heo J, Gogas BD, Jørgensen E, Kelbæk H, Muramatsu T, Farooq V, Helqvist S, Garcia-Garcia HM, Windecker S, Saunamäki K, Serruys PW|title=Natural history of optical coherence tomography-detected non-flow-limiting edge dissections following drug-eluting stent implantation|journal=EuroIntervention|volume=9|issue=9|pages=1085–94|date=January 2014|pmid=24064426|doi=10.4244/EIJV9I9A183|url=}}</ref> That said, major edge dissections observed on OCT are associated with worse clinical outcomes.<ref name="pmid279652972">{{cite journal|vauthors=Prati F, Romagnoli E, Gatto L, La Manna A, Burzotta F, Limbruno U, Versaci F, Fabbiocchi F, Di Giorgio A, Marco V, Ramazzotti V, Di Vito L, Trani C, Porto I, Boi A, Tavazzi L, Mintz GS|title=Clinical Impact of Suboptimal Stenting and Residual Intrastent Plaque/Thrombus Protrusion in Patients With Acute Coronary Syndrome: The CLI-OPCI ACS Substudy (Centro per la Lotta Contro L'Infarto-Optimization of Percutaneous Coronary Intervention in Acute Coronary Syndrome)|journal=Circ Cardiovasc Interv|volume=9|issue=12|pages=|date=December 2016|pmid=27965297|doi=10.1161/CIRCINTERVENTIONS.115.003726|url=}}</ref><ref name="pmid296339402">{{cite journal|vauthors=Prati F, Romagnoli E, La Manna A, Burzotta F, Gatto L, Marco V, Fineschi M, Fabbiocchi F, Versaci F, Trani C, Tamburino C, Alfonso F, Mintz GS|title=Long-term consequences of optical coherence tomography findings during percutaneous coronary intervention: the Centro Per La Lotta Contro L'infarto - Optimization Of Percutaneous Coronary Intervention (CLI-OPCI) LATE study|journal=EuroIntervention|volume=14|issue=4|pages=e443–e451|date=July 2018|pmid=29633940|doi=10.4244/EIJ-D-17-01111|url=}}</ref><ref name="pmid265638592">{{cite journal|vauthors=Prati F, Romagnoli E, Burzotta F, Limbruno U, Gatto L, La Manna A, Versaci F, Marco V, Di Vito L, Imola F, Paoletti G, Trani C, Tamburino C, Tavazzi L, Mintz GS|title=Clinical Impact of OCT Findings During PCI: The CLI-OPCI II Study|journal=JACC Cardiovasc Imaging|volume=8|issue=11|pages=1297–305|date=November 2015|pmid=26563859|doi=10.1016/j.jcmg.2015.08.013|url=}}</ref><ref name="pmid320890013">{{cite journal|vauthors=van Zandvoort LJ, Tomaniak M, Tovar Forero MN, Masdjedi K, Visseren L, Witberg K, Ligthart J, Kardys I, Lemmert ME, Diletti R, Wilschut J, de Jaegere P, Zijlstra F, Van Mieghem NM, Daemen J|title=Predictors for Clinical Outcome of Untreated Stent Edge Dissections as Detected by Optical Coherence Tomography|journal=Circ Cardiovasc Interv|volume=13|issue=3|pages=e008685|date=March 2020|pmid=32089001|doi=10.1161/CIRCINTERVENTIONS.119.008685|url=}}</ref> It is generally advised to deploy an additional stent if a large dissection involves more than 60° of the vessel circumference and extends over 3 mm into the medial layer, provided that stenting is not limited by anatomical constraints.<ref name="pmid328632462">{{cite journal|vauthors=Ali Z, Landmesser U, Karimi Galougahi K, Maehara A, Matsumura M, Shlofmitz RA, Guagliumi G, Price MJ, Hill JM, Akasaka T, Prati F, Bezerra HG, Wijns W, Mintz GS, Ben-Yehuda O, McGreevy RJ, Zhang Z, Rapoza RR, West NE, Stone GW|title=Optical coherence tomography-guided coronary stent implantation compared to angiography: a multicentre randomised trial in PCI - design and rationale of ILUMIEN IV: OPTIMAL PCI|journal=EuroIntervention|volume=16|issue=13|pages=1092–1099|date=January 2021|pmid=32863246|pmc=9725042|doi=10.4244/EIJ-D-20-00501|url=}}</ref>


'''To Guide Adequate Stent Apposition:'''
'''To Guide Adequate Stent Apposition:'''


Stent malapposition refers to the separation between the stent struts and the vessel wall. [1,44] Although malapposition is frequently observed on OCT following stent implantation (upto 50%),[45] it generally does not increase the risk of stent failure or thrombosis.[46-49] However, certain scenarios, such as proximal malapposition that may hinder future rewiring, extensive malapposition extending more than 3mm in length, or malapposition associated with stent underexpansion, warrants further optimization (Fig. 16).  Stent apposition refers to the stent touching the vessel wall while stent expansion refers to the size of the stent. Poor stent apposition is of a greater concern in an artery with a small minimum stent area than in a larger artery. Complete and position obviously may not be possible in aneurysmal segments or ectatic segments.
Stent malapposition refers to the separation between the stent struts and the vessel wall. <ref name="pmid29790954">{{cite journal|vauthors=Räber L, Mintz GS, Koskinas KC, Johnson TW, Holm NR, Onuma Y, Radu MD, Joner M, Yu B, Jia H, Meneveau N, de la Torre Hernandez JM, Escaned J, Hill J, Prati F, Colombo A, di Mario C, Regar E, Capodanno D, Wijns W, Byrne RA, Guagliumi G|title=Clinical use of intracoronary imaging. Part 1: guidance and optimization of coronary interventions. An expert consensus document of the European Association of Percutaneous Cardiovascular Interventions|journal=Eur Heart J|volume=39|issue=35|pages=3281–3300|date=September 2018|pmid=29790954|doi=10.1093/eurheartj/ehy285|url=}}</ref><ref name="pmid341102884">{{cite journal|vauthors=Ali ZA, Karimi Galougahi K, Mintz GS, Maehara A, Shlofmitz RA, Mattesini A|title=Intracoronary optical coherence tomography: state of the art and future directions|journal=EuroIntervention|volume=17|issue=2|pages=e105–e123|date=June 2021|pmid=34110288|pmc=9725016|doi=10.4244/EIJ-D-21-00089|url=}}</ref> Although '''malapposition''' is frequently observed on OCT following stent implantation (upto 50%),<ref name="pmid265638593">{{cite journal|vauthors=Prati F, Romagnoli E, Burzotta F, Limbruno U, Gatto L, La Manna A, Versaci F, Marco V, Di Vito L, Imola F, Paoletti G, Trani C, Tamburino C, Tavazzi L, Mintz GS|title=Clinical Impact of OCT Findings During PCI: The CLI-OPCI II Study|journal=JACC Cardiovasc Imaging|volume=8|issue=11|pages=1297–305|date=November 2015|pmid=26563859|doi=10.1016/j.jcmg.2015.08.013|url=}}</ref> it generally does not increase the risk of stent failure or thrombosis.<ref name="pmid296339403">{{cite journal|vauthors=Prati F, Romagnoli E, La Manna A, Burzotta F, Gatto L, Marco V, Fineschi M, Fabbiocchi F, Versaci F, Trani C, Tamburino C, Alfonso F, Mintz GS|title=Long-term consequences of optical coherence tomography findings during percutaneous coronary intervention: the Centro Per La Lotta Contro L'infarto - Optimization Of Percutaneous Coronary Intervention (CLI-OPCI) LATE study|journal=EuroIntervention|volume=14|issue=4|pages=e443–e451|date=July 2018|pmid=29633940|doi=10.4244/EIJ-D-17-01111|url=}}</ref><ref name="pmid28007741">{{cite journal|vauthors=Wang B, Mintz GS, Witzenbichler B, Souza CF, Metzger DC, Rinaldi MJ, Duffy PL, Weisz G, Stuckey TD, Brodie BR, Matsumura M, Yamamoto MH, Parvataneni R, Kirtane AJ, Stone GW, Maehara A|title=Predictors and Long-Term Clinical Impact of Acute Stent Malapposition: An Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents (ADAPT-DES) Intravascular Ultrasound Substudy|journal=J Am Heart Assoc|volume=5|issue=12|pages=|date=December 2016|pmid=28007741|pmc=5210413|doi=10.1161/JAHA.116.004438|url=}}</ref><ref name="pmid20488404">{{cite journal|vauthors=Steinberg DH, Mintz GS, Mandinov L, Yu A, Ellis SG, Grube E, Dawkins KD, Ormiston J, Turco MA, Stone GW, Weissman NJ|title=Long-term impact of routinely detected early and late incomplete stent apposition: an integrated intravascular ultrasound analysis of the TAXUS IV, V, and VI and TAXUS ATLAS workhorse, long lesion, and direct stent studies|journal=JACC Cardiovasc Interv|volume=3|issue=5|pages=486–94|date=May 2010|pmid=20488404|doi=10.1016/j.jcin.2010.03.007|url=}}</ref><ref name="pmid24425586">{{cite journal|vauthors=Im E, Kim BK, Ko YG, Shin DH, Kim JS, Choi D, Jang Y, Hong MK|title=Incidences, predictors, and clinical outcomes of acute and late stent malapposition detected by optical coherence tomography after drug-eluting stent implantation|journal=Circ Cardiovasc Interv|volume=7|issue=1|pages=88–96|date=February 2014|pmid=24425586|doi=10.1161/CIRCINTERVENTIONS.113.000797|url=}}</ref> However, certain scenarios, such as proximal malapposition that may hinder future rewiring, extensive malapposition extending more than 3mm in length, or malapposition associated with stent underexpansion, warrants further optimization (Fig. 16).  Stent apposition refers to the stent touching the vessel wall while stent expansion refers to the size of the stent. Poor stent apposition is of a greater concern in an artery with a small minimum stent area than in a larger artery. Complete and position obviously may not be possible in aneurysmal segments or ectatic segments.


'''To Guide Adequate Stent Expansion:'''
'''To Guide Adequate Stent Expansion:'''


Stent expansion is a key determinant of long-term stent success and can be evaluated using absolute measurements, such as minimum stent area (MSA), or relative metrics like the ratio of MSA to the reference lumen area.[44] According to current European guidelines, optimal stent deployment is defined by either: (1) an MSA > 4.5 mm² on OCT for non–left main lesions (absolute expansion), or (2) an MSA exceeding 80% of the average of the proximal and distal reference lumen areas (relative expansion).[50,60] While absolute MSA is generally a stronger predictor of adverse outcomes, achieving this threshold in smaller vessels may not be feasible, which highlights the clinical relevance of relative stent expansion.[44] Despite multiple criteria for defining adequate relative expansion, success is typically achieved in approximately 50% of cases.[51] (figure 17) An inadequate minimum stent area is associated with a higher risk of stent thrombosis. Insofar as OCT optimizes the minimum stented area, the use of OCT reduces the risk of stent restenosis.
Stent expansion is a key determinant of long-term stent success and can be evaluated using absolute measurements, such as minimum stent area (MSA), or relative metrics like the ratio of MSA to the reference lumen area.<ref name="pmid297909542">{{cite journal|vauthors=Räber L, Mintz GS, Koskinas KC, Johnson TW, Holm NR, Onuma Y, Radu MD, Joner M, Yu B, Jia H, Meneveau N, de la Torre Hernandez JM, Escaned J, Hill J, Prati F, Colombo A, di Mario C, Regar E, Capodanno D, Wijns W, Byrne RA, Guagliumi G|title=Clinical use of intracoronary imaging. Part 1: guidance and optimization of coronary interventions. An expert consensus document of the European Association of Percutaneous Cardiovascular Interventions|journal=Eur Heart J|volume=39|issue=35|pages=3281–3300|date=September 2018|pmid=29790954|doi=10.1093/eurheartj/ehy285|url=}}</ref> According to current European guidelines, optimal stent deployment is defined by either: (1) an '''MSA > 4.5 mm²''' on OCT for non–left main lesions ('''absolute expansion'''), or (2) an '''MSA exceeding 80% of the average''' of the proximal and distal reference lumen areas ('''relative expansion''').<ref name="pmid300257252">{{cite journal|vauthors=Jones DA, Rathod KS, Koganti S, Hamshere S, Astroulakis Z, Lim P, Sirker A, O'Mahony C, Jain AK, Knight CJ, Dalby MC, Malik IS, Mathur A, Rakhit R, Lockie T, Redwood S, MacCarthy PA, Desilva R, Weerackody R, Wragg A, Smith EJ, Bourantas CV|title=Angiography Alone Versus Angiography Plus Optical Coherence Tomography to Guide Percutaneous Coronary Intervention: Outcomes From the Pan-London PCI Cohort|journal=JACC Cardiovasc Interv|volume=11|issue=14|pages=1313–1321|date=July 2018|pmid=30025725|doi=10.1016/j.jcin.2018.01.274|url=}}</ref><ref name="pmid35656728">{{cite journal|vauthors=Kubo T, Nakazawa G|title=Optical coherence tomography criteria for stent optimisation|journal=EuroIntervention|volume=18|issue=2|pages=e99–e100|date=June 2022|pmid=35656728|pmc=9904381|doi=10.4244/EIJ-E-22-00010|url=}}</ref> While absolute MSA is generally a stronger predictor of adverse outcomes, achieving this threshold in smaller vessels may not be feasible, which highlights the clinical relevance of relative stent expansion.<ref name="pmid297909543">{{cite journal|vauthors=Räber L, Mintz GS, Koskinas KC, Johnson TW, Holm NR, Onuma Y, Radu MD, Joner M, Yu B, Jia H, Meneveau N, de la Torre Hernandez JM, Escaned J, Hill J, Prati F, Colombo A, di Mario C, Regar E, Capodanno D, Wijns W, Byrne RA, Guagliumi G|title=Clinical use of intracoronary imaging. Part 1: guidance and optimization of coronary interventions. An expert consensus document of the European Association of Percutaneous Cardiovascular Interventions|journal=Eur Heart J|volume=39|issue=35|pages=3281–3300|date=September 2018|pmid=29790954|doi=10.1093/eurheartj/ehy285|url=}}</ref> Despite multiple criteria for defining adequate relative expansion, success is typically achieved in approximately 50% of cases.<ref name="pmid37634188">{{cite journal|vauthors=Ali ZA, Landmesser U, Maehara A, Matsumura M, Shlofmitz RA, Guagliumi G, Price MJ, Hill JM, Akasaka T, Prati F, Bezerra HG, Wijns W, Leistner D, Canova P, Alfonso F, Fabbiocchi F, Dogan O, McGreevy RJ, McNutt RW, Nie H, Buccola J, West NE, Stone GW|title=Optical Coherence Tomography-Guided versus Angiography-Guided PCI|journal=N Engl J Med|volume=389|issue=16|pages=1466–1476|date=October 2023|pmid=37634188|doi=10.1056/NEJMoa2305861|url=}}</ref>(figure 17) An inadequate minimum stent area is associated with a higher risk of stent thrombosis. Insofar as OCT optimizes the minimum stented area, the use of OCT reduces the risk of '''stent restenosis.'''


== Advantages over Angiography ==
== Advantages over Angiography ==
Arguably the most valuable use of OCT is to visualize plaque, which cannot be seen by angiography. It has been increasingly used in research to better understand the behavior of the atherosclerosis process in living people. OCT enables accurately visualizing not only the lumen of the coronary arteries but also the atheroma (membrane/cholesterol loaded white blood cells) "hidden" within the wall. OCT has thus enabled advances in clinical research providing a more thorough perspective and better understanding.
Arguably the most valuable use of OCT is to visualize plaque, which cannot be seen by angiography. It has been increasingly used in research to better understand the behavior of the [[atherosclerosis]] process in living people. OCT enables accurately visualizing not only the lumen of the coronary arteries but also the atheroma (membrane/cholesterol loaded white blood cells) "hidden" within the wall. OCT has thus enabled advances in clinical research providing a more thorough perspective and better understanding.


Unlike angiography, which functions as a luminogram by displaying only the contrast-filled lumen, optical coherence tomography (OCT) offers a much more detailed assessment of the vessel wall and plaque characteristics. OCT can accurately differentiate between various types of plaque, including fibrous, lipid-rich, and calcific components. It is also highly sensitive in detecting thrombi, allowing identification of both red and white thrombus formations. In the context of stent deployment, OCT plays a crucial role by evaluating stent apposition, expansion, and detecting complications such as edge dissections or tissue prolapse. Importantly, OCT enables visualization of vulnerable plaques—particularly thin-cap fibroatheromas (TCFA)—which are defined by a fibrous cap measuring less than 65 µm and are often associated with acute coronary syndromes.
Unlike [[Angiography]], which functions as a luminogram by displaying only the contrast-filled lumen, optical coherence tomography (OCT) offers a much more detailed assessment of the vessel wall and plaque characteristics. OCT can accurately differentiate between various types of plaque, including fibrous, lipid-rich, and calcific components. It is also highly sensitive in detecting thrombi, allowing identification of both red and white thrombus formations. In the context of stent deployment, OCT plays a crucial role by evaluating stent apposition, expansion, and detecting complications such as edge dissections or tissue prolapse. Importantly, OCT enables visualization of vulnerable plaques—particularly thin-cap fibroatheromas (TCFA)—which are defined by a fibrous cap measuring less than 65 µm and are often associated with acute coronary syndromes.


OCT also plays a significant role in evaluating restenosis and stent failure. In the past, angiographic appearances of “restenosis” after angioplasty often reflected not true luminal collapse, but rather the inadequate apposition or incomplete expansion of a stent. OCT enables precise assessment of stent geometry, measuring '''minimum stent area''', identifying '''tissue prolapse''', '''edge dissections''', and '''malapposition''', which angiography frequently misses. These details are pivotal in preventing stent thrombosis and ensuring long-term patency. [7,8]
OCT also plays a significant role in evaluating restenosis and stent failure. In the past, angiographic appearances of “restenosis” after angioplasty often reflected not true luminal collapse, but rather the inadequate apposition or incomplete expansion of a stent. OCT enables precise assessment of stent geometry, measuring '''minimum stent area''', identifying '''tissue prolapse''', '''edge dissections''', and '''malapposition''', which angiography frequently misses. These details are pivotal in preventing stent thrombosis and ensuring long-term patency.<ref name="pmid27573032">{{cite journal|vauthors=Meneveau N, Souteyrand G, Motreff P, Caussin C, Amabile N, Ohlmann P, Morel O, Lefrançois Y, Descotes-Genon V, Silvain J, Braik N, Chopard R, Chatot M, Ecarnot F, Tauzin H, Van Belle E, Belle L, Schiele F|title=Optical Coherence Tomography to Optimize Results of Percutaneous Coronary Intervention in Patients with Non-ST-Elevation Acute Coronary Syndrome: Results of the Multicenter, Randomized DOCTORS Study (Does Optical Coherence Tomography Optimize Results of Stenting)|journal=Circulation|volume=134|issue=13|pages=906–17|date=September 2016|pmid=27573032|doi=10.1161/CIRCULATIONAHA.116.024393|url=}}</ref><ref name="pmid278069003">{{cite journal|vauthors=Ali ZA, Maehara A, Généreux P, Shlofmitz RA, Fabbiocchi F, Nazif TM, Guagliumi G, Meraj PM, Alfonso F, Samady H, Akasaka T, Carlson EB, Leesar MA, Matsumura M, Ozan MO, Mintz GS, Ben-Yehuda O, Stone GW|title=Optical coherence tomography compared with intravascular ultrasound and with angiography to guide coronary stent implantation (ILUMIEN III: OPTIMIZE PCI): a randomised controlled trial|journal=Lancet|volume=388|issue=10060|pages=2618–2628|date=November 2016|pmid=27806900|doi=10.1016/S0140-6736(16)31922-5|url=}}</ref>


Furthermore, OCT imaging has advanced our understanding of coronary healing. For example, serial OCT studies have shown how neointimal coverage evolves over time after drug-eluting stent (DES) implantation, helping clinicians evaluate reendothelialization. [9]
Furthermore, OCT imaging has advanced our understanding of coronary healing. For example, serial OCT studies have shown how neointimal coverage evolves over time after drug-eluting stent (DES) implantation, helping clinicians evaluate reendothelialization.<ref name="pmid34357673">{{cite journal|vauthors=Noguchi M, Dohi T, Okazaki S, Matsumura M, Takeuchi M, Endo H, Kato Y, Okai I, Nishiyama H, Doi S, Iwata H, Isoda K, Usui E, Fujimura T, Seike F, Mintz GS, Miyauchi K, Daida H, Minamino T, Maehara A|title=Comparison of 6-month vascular healing response after bioresorbable polymer versus durable polymer drug-eluting stent implantation in patients with acute coronary syndromes: A randomized serial optical coherence tomography study|journal=Catheter Cardiovasc Interv|volume=98|issue=5|pages=E677–E686|date=November 2021|pmid=34357673|pmc=9292175|doi=10.1002/ccd.29892|url=}}</ref>


OCT's real-time, catheter-based imaging—paired with automated pullback and rapid acquisition—has enabled its integration into routine percutaneous coronary intervention (PCI), where it aids not only in lesion assessment but also in fine-tuning procedural outcomes. Most commercial OCT systems are now equipped with built-in tools for automated detection of stents and contouring of the lumen or external elastic membrane (EEM). Additionally, the use of deep learning algorithms for automated plaque and lesion characterization is an emerging area of ongoing research and development. (Figure 6) [10,13,14]
OCT's real-time, catheter-based imaging—paired with automated pullback and rapid acquisition—has enabled its integration into routine percutaneous coronary intervention (PCI), where it aids not only in lesion assessment but also in fine-tuning procedural outcomes. Most commercial OCT systems are now equipped with built-in tools for automated detection of stents and contouring of the lumen or external elastic membrane (EEM). Additionally, the use of deep learning algorithms for automated plaque and lesion characterization is an emerging area of ongoing research and development.<ref name="pmid34728349">{{cite journal|vauthors=Volleberg R, Mol JQ, van der Heijden D, Meuwissen M, van Leeuwen M, Escaned J, Holm N, Adriaenssens T, van Geuns RJ, Tu S, Crea F, Stone G, van Royen N|title=Optical coherence tomography and coronary revascularization: from indication to procedural optimization|journal=Trends Cardiovasc Med|volume=33|issue=2|pages=92–106|date=February 2023|pmid=34728349|doi=10.1016/j.tcm.2021.10.009|url=}}</ref><ref name="pmid31718998">{{cite journal|vauthors=Min HS, Yoo JH, Kang SJ, Lee JG, Cho H, Lee PH, Ahn JM, Park DW, Lee SW, Kim YH, Lee CW, Park SW, Park SJ|title=Detection of optical coherence tomography-defined thin-cap fibroatheroma in the coronary artery using deep learning|journal=EuroIntervention|volume=16|issue=5|pages=404–412|date=August 2020|pmid=31718998|doi=10.4244/EIJ-D-19-00487|url=}}</ref><ref name="pmid33528359">{{cite journal|vauthors=Chu M, Jia H, Gutiérrez-Chico JL, Maehara A, Ali ZA, Zeng X, He L, Zhao C, Matsumura M, Wu P, Zeng M, Kubo T, Xu B, Chen L, Yu B, Mintz GS, Wijns W, Holm NR, Tu S|title=Artificial intelligence and optical coherence tomography for the automatic characterisation of human atherosclerotic plaques|journal=EuroIntervention|volume=17|issue=1|pages=41–50|date=May 2021|pmid=33528359|pmc=9724931|doi=10.4244/EIJ-D-20-01355|url=}}</ref> (Figure 6)


== Disadvantages of OCT ==
== Disadvantages of OCT ==
'''Adoption Barriers Among Clinicians''':
'''Adoption Barriers Among Clinicians''':


A large survey [12] of interventional cardiologists cited the following as key barriers to routine OCT use:
A large survey<ref name="pmid29540631">{{cite journal|vauthors=Koskinas KC, Nakamura M, Räber L, Colleran R, Kadota K, Capodanno D, Wijns W, Akasaka T, Valgimigli M, Guagliumi G, Windecker S, Byrne RA|title=Current Use of Intracoronary Imaging in Interventional Practice　- Results of a European Association of Percutaneous Cardiovascular Interventions (EAPCI) and Japanese Association of Cardiovascular Interventions and Therapeutics (CVIT) Clinical Practice Survey|journal=Circ J|volume=82|issue=5|pages=1360–1368|date=April 2018|pmid=29540631|doi=10.1253/circj.CJ-17-1144|url=}}</ref> of interventional cardiologists cited the following as key barriers to routine OCT use:


* Higher procedural costs
* Higher procedural costs
Line 114: Line 116:
'''Cost Considerations''':
'''Cost Considerations''':


The FORZA trial reported that OCT-guided PCI incurs higher costs compared to FFR-guided PCI.[11] However, a head-to-head cost-effectiveness analysis between OCT, IVUS, and angiography has not yet been conducted.
The FORZA trial reported that OCT-guided PCI incurs higher costs compared to FFR-guided PCI.<ref name="pmid31918942">{{cite journal|vauthors=Burzotta F, Leone AM, Aurigemma C, Zambrano A, Zimbardo G, Arioti M, Vergallo R, De Maria GL, Cerracchio E, Romagnoli E, Trani C, Crea F|title=Fractional Flow Reserve or Optical Coherence Tomography to Guide Management of Angiographically Intermediate Coronary Stenosis: A Single-Center Trial|journal=JACC Cardiovasc Interv|volume=13|issue=1|pages=49–58|date=January 2020|pmid=31918942|doi=10.1016/j.jcin.2019.09.034|url=}}</ref> However, a head-to-head cost-effectiveness analysis between OCT, IVUS, and angiography has not yet been conducted.


'''Limited Penetration Depth''':
'''Limited Penetration Depth''':
Line 142: Line 144:
'''Imaging Artifacts'''
'''Imaging Artifacts'''


* OCT artifacts can be broadly classified into two categories: those arising from the interaction of light with the catheter, lumen, or vessel wall, and those resulting from the catheter’s position and movement within the vessel (Figure 11). Certain lumen contents or vessel components can significantly attenuate the OCT signal, creating shadowing effects that obscure the visualization of deeper arterial wall layers.
* OCT artifacts<ref name="pmid341102885">{{cite journal|vauthors=Ali ZA, Karimi Galougahi K, Mintz GS, Maehara A, Shlofmitz RA, Mattesini A|title=Intracoronary optical coherence tomography: state of the art and future directions|journal=EuroIntervention|volume=17|issue=2|pages=e105–e123|date=June 2021|pmid=34110288|pmc=9725016|doi=10.4244/EIJ-D-21-00089|url=}}</ref> can be broadly classified into two categories: those arising from the interaction of light with the catheter, lumen, or vessel wall, and those resulting from the catheter’s position and movement within the vessel (Figure 11). Certain lumen contents or vessel components can significantly attenuate the OCT signal, creating shadowing effects that obscure the visualization of deeper arterial wall layers.
* Inadequate clearance of blood from the imaging field can lead to signal-rich areas within the lumen, causing interference that reduces image clarity and diminishes the intensity of the OCT signal reaching the vessel wall (Figure 11A, 11B). Additionally, swirling blood, especially during the initiation or completion of the pullback, may mimic the appearance of thrombus or plaque erosion (Figure 11C, 11D). Red thrombus strongly attenuates OCT light, while metallic elements like stent struts and guidewires obstruct light propagation, casting shadows on the underlying tissue.
* Inadequate clearance of blood from the imaging field can lead to signal-rich areas within the lumen, causing interference that reduces image clarity and '''diminishes the intensity of the OCT signal''' reaching the vessel wall (Figure 11A, 11B). Additionally, swirling blood, especially during the initiation or completion of the pullback, may mimic the appearance of thrombus or plaque erosion (Figure 11C, 11D). Red thrombus strongly attenuates OCT light, while metallic elements like stent struts and guidewires obstruct light propagation, casting shadows on the underlying tissue.
* The catheter’s position within the vessel and the vessel’s diameter also influences image quality. Excessive force during insertion can lead to catheter prolapse, where the catheter bends or folds within the lumen (Figure 11E). Moreover, irregular catheter movement, whether due to inconsistent rotation or variable pullback speed, can distort images. One specific artifact, known as non-uniform rotational distortion (NURD), manifests as lateral blurring or smearing and is caused by variations in angular velocity of the rotating optical fiber. NURD commonly arises in tortuous or narrow vessels, or when there is resistance from tight hemostatic valves or crimped catheter sheaths (Figure 11F, 11G).
* The catheter’s position within the vessel and the vessel’s diameter also influences image quality. Excessive force during insertion can lead to catheter prolapse, where the '''catheter bends or folds''' within the lumen (Figure 11E). Moreover, irregular catheter movement, whether due to '''inconsistent rotation or variable pullback speed''', can distort images. One specific artifact, known as '''non-uniform rotational distortion''' (NURD), manifests as lateral blurring or smearing and is caused by variations in angular velocity of the rotating optical fiber. NURD commonly arises in tortuous or narrow vessels, or when there is resistance from tight hemostatic valves or crimped catheter sheaths (Figure 11F, 11G).
* Another artifact may occur when the OCT catheter is too close to the vessel wall. In such cases, the emitted light may travel nearly parallel to the tissue surface, reducing beam penetration. This can falsely appear as signal attenuation and may be misinterpreted as thin-cap fibroatheroma (TCFA) (Figure 4H). [34]
* Another artifact may occur when the OCT catheter is too close to the vessel wall. In such cases, the emitted light may travel nearly parallel to the tissue surface, reducing beam penetration. This can falsely appear as signal attenuation and may be misinterpreted as thin-cap fibroatheroma (TCFA) (Figure 4H).


== Method ==
== Method ==
Line 152: Line 154:
The OCT acquisition process follows a structured sequence: position, purge, puff, and pullback.
The OCT acquisition process follows a structured sequence: position, purge, puff, and pullback.


1.     Position: The OCT catheter is advanced approximately 10 mm distal to the lesion over a coronary guidewire.
1.     '''Position''': The OCT catheter is advanced approximately 10 mm distal to the lesion over a coronary guidewire.


2.     Purge: The catheter is purged again to eliminate residual air or bubbles.
2.     '''Purge''': The catheter is purged again to eliminate residual air or bubbles.


3.     Puff: A small puff of contrast is injected through the guide catheter to verify proper engagement and ensure adequate blood clearance. Occasionally, a guide catheter extension may be necessary to prevent backflow of the flushing agent into the aorta.
3.     '''Puff''': A small puff of contrast is injected through the guide catheter to verify proper engagement and ensure adequate blood clearance. Occasionally, a guide catheter extension may be necessary to prevent backflow of the flushing agent into the aorta.


4.     Pullback: The automated pullback mechanism is then activated. During this phase, contrast or saline is delivered either manually or via an automated injector.
4.     '''Pullback''': The automated pullback mechanism is then activated. During this phase, contrast or saline is delivered either manually or via an automated injector.


== Clinical Evidence ==
== Clinical Evidence ==
Early studies demonstrated that OCT imaging had a significant impact on procedural decision-making. In the CLI-OPCI study, for instance, post-PCI OCT identified suboptimal features requiring additional intervention in 35% of cases.[52] Moreover, OCT-guided PCI was associated with a lower incidence of myocardial infarction (MI) or cardiac death at one year after adjustment for confounding variables.
Early studies demonstrated that OCT imaging had a significant impact on procedural decision-making. In the CLI-OPCI study, for instance, post-PCI OCT identified suboptimal features requiring additional intervention in 35% of cases.<ref name="pmid23034247">{{cite journal|vauthors=Prati F, Di Vito L, Biondi-Zoccai G, Occhipinti M, La Manna A, Tamburino C, Burzotta F, Trani C, Porto I, Ramazzotti V, Imola F, Manzoli A, Materia L, Cremonesi A, Albertucci M|title=Angiography alone versus angiography plus optical coherence tomography to guide decision-making during percutaneous coronary intervention: the Centro per la Lotta contro l'Infarto-Optimisation of Percutaneous Coronary Intervention (CLI-OPCI) study|journal=EuroIntervention|volume=8|issue=7|pages=823–9|date=November 2012|pmid=23034247|doi=10.4244/EIJV8I7A125|url=}}</ref> Moreover, OCT-guided PCI was associated with a lower incidence of myocardial infarction (MI) or cardiac death at one year after adjustment for confounding variables.


The '''OPINION trial [53]''' was the first to directly compare outcomes between OCT- and IVUS-guided PCI. It found no significant difference in the primary endpoint of target vessel failure at one year, establishing the noninferiority of OCT guidance relative to IVUS. Similarly, the '''ILUMIEN III trial [54]''' demonstrated that OCT-guided PCI was noninferior to IVUS-guided PCI in terms of final minimum stent area (MSA), reinforcing OCT’s role as a viable alternative for intravascular imaging guidance. In the large-scale '''OCTIVUS trial''' (n = 1005 for OCT vs. 1003 for IVUS),[55] OCT-guided PCI was again shown to be noninferior to IVUS-guided PCI for the composite primary endpoint of cardiac death, target-vessel MI, or ischemia-driven target-vessel revascularization at one year.
The '''OPINION trial'''<ref name="pmid291212262">{{cite journal|vauthors=Kubo T, Shinke T, Okamura T, Hibi K, Nakazawa G, Morino Y, Shite J, Fusazaki T, Otake H, Kozuma K, Ioji T, Kaneda H, Serikawa T, Kataoka T, Okada H, Akasaka T|title=Optical frequency domain imaging vs. intravascular ultrasound in percutaneous coronary intervention (OPINION trial): one-year angiographic and clinical results|journal=Eur Heart J|volume=38|issue=42|pages=3139–3147|date=November 2017|pmid=29121226|pmc=5837511|doi=10.1093/eurheartj/ehx351|url=}}</ref> was the first to directly compare outcomes between OCT- and IVUS-guided PCI. It found no significant difference in the primary endpoint of target vessel failure at one year, establishing the noninferiority of OCT guidance relative to IVUS. Similarly, the '''ILUMIEN III trial'''<ref name="pmid278069004">{{cite journal|vauthors=Ali ZA, Maehara A, Généreux P, Shlofmitz RA, Fabbiocchi F, Nazif TM, Guagliumi G, Meraj PM, Alfonso F, Samady H, Akasaka T, Carlson EB, Leesar MA, Matsumura M, Ozan MO, Mintz GS, Ben-Yehuda O, Stone GW|title=Optical coherence tomography compared with intravascular ultrasound and with angiography to guide coronary stent implantation (ILUMIEN III: OPTIMIZE PCI): a randomised controlled trial|journal=Lancet|volume=388|issue=10060|pages=2618–2628|date=November 2016|pmid=27806900|doi=10.1016/S0140-6736(16)31922-5|url=}}</ref> demonstrated that OCT-guided PCI was noninferior to IVUS-guided PCI in terms of final minimum stent area (MSA), reinforcing OCT’s role as a viable alternative for intravascular imaging guidance. In the large-scale '''OCTIVUS trial'''<ref name="pmid37634092">{{cite journal|vauthors=Kang DY, Ahn JM, Yun SC, Hur SH, Cho YK, Lee CH, Hong SJ, Lim S, Kim SW, Won H, Oh JH, Choe JC, Hong YJ, Yoon YH, Kim H, Choi Y, Lee J, Yoon YW, Kim SJ, Bae JH, Park DW, Park SJ|title=Optical Coherence Tomography-Guided or Intravascular Ultrasound-Guided Percutaneous Coronary Intervention: The OCTIVUS Randomized Clinical Trial|journal=Circulation|volume=148|issue=16|pages=1195–1206|date=October 2023|pmid=37634092|doi=10.1161/CIRCULATIONAHA.123.066429|url=}}</ref> (n = 1005 for OCT vs. 1003 for IVUS), OCT-guided PCI was again shown to be noninferior to IVUS-guided PCI for the composite primary endpoint of cardiac death, target-vessel MI, or ischemia-driven target-vessel revascularization at one year.


The '''ILUMIEN IV trial [56]''', a global, multicenter randomized controlled study, compared OCT-guided versus angiography-guided PCI in high-risk patients or those with complex lesions (n = 1233 vs. 1254). OCT guidance resulted in significantly larger final MSA (5.72 ± 2.04 mm² vs. 5.36 ± 1.87 mm²; ''P'' < .001) and greater stent expansion, attributed to the selection of larger stents and more frequent high-pressure postdilation. While the trial showed no significant difference in the primary clinical endpoint of a composite of cardiac death, target-vessel MI, or ischemia-driven target-vessel revascularization at 2 years, it did report a notable reduction in stent thrombosis with OCT guidance. The '''OCTOBER trial''',[57] which enrolled patients with complex bifurcation lesions (n = 600 for OCT, 601 for angiography), found that OCT-guided PCI significantly reduced the composite outcome of cardiac death, target-lesion MI, or ischemia-driven target-vessel revascularization at two years compared to angiography guidance. In the '''RENOVATE-COMPLEX PCI trial''',[58] intravascular imaging guidance (both IVUS [74.5%] and OCT [25.5%]) led to a lower risk of the composite endpoint of cardiac death, target vessel-related MI, or clinically driven target vessel revascularization compared with angiography-guided PCI. Subgroup analysis confirmed consistent benefits across both IVUS and OCT modalities.
The '''ILUMIEN IV trial'''<ref name="pmid376341882">{{cite journal|vauthors=Ali ZA, Landmesser U, Maehara A, Matsumura M, Shlofmitz RA, Guagliumi G, Price MJ, Hill JM, Akasaka T, Prati F, Bezerra HG, Wijns W, Leistner D, Canova P, Alfonso F, Fabbiocchi F, Dogan O, McGreevy RJ, McNutt RW, Nie H, Buccola J, West NE, Stone GW|title=Optical Coherence Tomography-Guided versus Angiography-Guided PCI|journal=N Engl J Med|volume=389|issue=16|pages=1466–1476|date=October 2023|pmid=37634188|doi=10.1056/NEJMoa2305861|url=}}</ref>, a global, multicenter randomized controlled study, compared OCT-guided versus angiography-guided PCI in high-risk patients or those with complex lesions (n = 1233 vs. 1254). OCT guidance resulted in significantly larger final MSA (5.72 ± 2.04 mm² vs. 5.36 ± 1.87 mm²; ''P'' < .001) and greater stent expansion, attributed to the selection of larger stents and more frequent high-pressure postdilation. While the trial showed no significant difference in the primary clinical endpoint of a composite of cardiac death, target-vessel MI, or ischemia-driven target-vessel revascularization at 2 years, it did report a notable reduction in stent thrombosis with OCT guidance. The '''OCTOBER trial''',<ref name="pmid37634149">{{cite journal|vauthors=Holm NR, Andreasen LN, Neghabat O, Laanmets P, Kumsars I, Bennett J, Olsen NT, Odenstedt J, Hoffmann P, Dens J, Chowdhary S, O'Kane P, Bülow Rasmussen SH, Heigert M, Havndrup O, Van Kuijk JP, Biscaglia S, Mogensen LJ, Henareh L, Burzotta F, H Eek C, Mylotte D, Llinas MS, Koltowski L, Knaapen P, Calic S, Witt N, Santos-Pardo I, Watkins S, Lønborg J, Kristensen AT, Jensen LO, Calais F, Cockburn J, McNeice A, Kajander OA, Heestermans T, Kische S, Eftekhari A, Spratt JC, Christiansen EH|title=OCT or Angiography Guidance for PCI in Complex Bifurcation Lesions|journal=N Engl J Med|volume=389|issue=16|pages=1477–1487|date=October 2023|pmid=37634149|doi=10.1056/NEJMoa2307770|url=}}</ref> which enrolled patients with complex bifurcation lesions (n = 600 for OCT, 601 for angiography), found that OCT-guided PCI significantly reduced the composite outcome of cardiac death, target-lesion MI, or ischemia-driven target-vessel revascularization at two years compared to angiography guidance. In the '''RENOVATE-COMPLEX PCI trial,'''<ref name="pmid36876735">{{cite journal|vauthors=Lee JM, Choi KH, Song YB, Lee JY, Lee SJ, Lee SY, Kim SM, Yun KH, Cho JY, Kim CJ, Ahn HS, Nam CW, Yoon HJ, Park YH, Lee WS, Jeong JO, Song PS, Doh JH, Jo SH, Yoon CH, Kang MG, Koh JS, Lee KY, Lim YH, Cho YH, Cho JM, Jang WJ, Chun KJ, Hong D, Park TK, Yang JH, Choi SH, Gwon HC, Hahn JY|title=Intravascular Imaging-Guided or Angiography-Guided Complex PCI|journal=N Engl J Med|volume=388|issue=18|pages=1668–1679|date=May 2023|pmid=36876735|doi=10.1056/NEJMoa2216607|url=}}</ref> intravascular imaging guidance (both IVUS [74.5%] and OCT [25.5%]) led to a lower risk of the composite endpoint of cardiac death, target vessel-related MI, or clinically driven target vessel revascularization compared with angiography-guided PCI. Subgroup analysis confirmed consistent benefits across both IVUS and OCT modalities.


Multiple high-quality randomized trials support the use of OCT-guided PCI over angiography-guided strategies, particularly in high-risk patients or those with complex coronary lesions. Additionally, OCT has shown clinical equivalence to IVUS, making it a reliable alternative for intravascular imaging–guided intervention.
Multiple high-quality randomized trials support the use of OCT-guided PCI over angiography-guided strategies, particularly in high-risk patients or those with complex coronary lesions. Additionally, OCT has shown clinical equivalence to IVUS, making it a reliable alternative for intravascular imaging–guided intervention.


== Comparison with other imaging modalities ==
== Comparison with other imaging modalities ==
OCT offers the highest resolution among intravascular imaging modalities, providing excellent detection of fibrous cap and lipid core features, with good utility for identifying calcium and thrombus, making it uniquely suited for detailed plaque characterization. [59]
OCT offers the '''highest resolution''' among intravascular imaging modalities, providing excellent detection of fibrous cap and lipid core features, with good utility for identifying calcium and thrombus, making it uniquely suited for '''detailed plaque characterization'''.<ref name="pmid26879196">{{cite journal|vauthors=Batty JA, Subba S, Luke P, Gigi LW, Sinclair H, Kunadian V|title=Intracoronary Imaging in the Detection of Vulnerable Plaques|journal=Curr Cardiol Rep|volume=18|issue=3|pages=28|date=March 2016|pmid=26879196|pmc=4754333|doi=10.1007/s11886-016-0705-1|url=}}</ref>
{| class="wikitable"
{| class="wikitable" style="vertical-align:middle; background-color:#FFAB82;"
! colspan="5" |
|- style="font-weight:bold; text-align:center;"
! colspan="5" |'''Clinical utility in detection of vulnerable plaque feature'''
! colspan="5" |  
|-
! colspan="5" | '''Clinical utility in detection of vulnerable plaque feature'''
!'''Imaging Technique'''
|- style="font-weight:bold; text-align:center;"
!'''Technology'''
! '''Imaging Technique'''
!'''Wavelength (µm)'''
! '''Technology'''
!'''Penetration (mm)'''
! '''Wavelength (µm)'''
!'''Resolution (µm)'''
! '''Penetration (mm)'''
!'''Fibrous Cap'''
! '''Resolution (µm)'''
!'''Lipid Core'''
! '''Fibrous Cap'''
!'''Inflammation'''
! '''Lipid Core'''
!'''Calcium'''
! '''Inflammation'''
!'''Thrombus'''
! '''Calcium'''
|-
! '''Thrombus'''
!'''Coronary Angiography'''
|- style="background-color:#FFEAC1;"
|X-ray
| '''Coronary Angiography'''
|0.00001–0.01
| X-ray
|0.0
| 0.00001–0.01
|>500
| 0.0
|–
| >500
|–
| –
|–
| –
| –
| +
| +
| +++
| +++
|-
|-
!'''IVUS'''
| '''IVUS'''
|Ultrasound
| Ultrasound
|35–80
| 35–80
|10.0
| 10.0
|100–200
| 100–200
| +
| +
| ++
| ++
|–
| –
| +++
| +++
|–
| –
|-
|- style="background-color:#FFEAC1; color:#cb0000;"
!'''OCT'''
| '''OCT'''
|'''Infrared'''
| '''Infrared'''
|'''1.3'''
| '''1.3'''
|'''1.0–2.5'''
| '''1.0–2.5'''
|'''<10'''
| '''<10'''
|'''+++'''
| '''+++'''
|'''+++'''
| '''+++'''
|'''+'''
| '''+'''
|'''++'''
| '''++'''
|'''++'''
| '''++'''
|-
|-
!'''NIRS'''
| '''NIRS'''
|Near-infrared
| Near-infrared
|0.8–2.5
| 0.8–2.5
|1.0–2.0
| 1.0–2.0
|N/A
| N/A
|–
| –
| +++
| +++
|–
| –
|–
| –
|–
| –
|-
|- style="background-color:#FFEAC1;"
!'''Raman Spectroscopy'''
| '''Raman Spectroscopy'''
|Near-infrared
| Near-infrared
|0.75–1.0
| 0.75–1.0
|1.0–2.0
| 1.0–2.0
|N/A
| N/A
|–
| –
| +++
| +++
| -
| -
|–
| –
|–
| –
|-
|-
!'''IV-MRI'''
| '''IV-MRI'''
|MRI
| MRI
|N/A
| N/A
|0.25
| 0.25
|100
| 100
| +
| +
| ++
| ++
Line 251: Line 254:
| ++
| ++
| +
| +
|-
|- style="background-color:#FFEAC1;"
!'''Angioscopy'''
| '''Angioscopy'''
|Optical
| Optical
|0.4–0.7
| 0.4–0.7
|0.0
| 0.0
|10–50
| 10–50
| +
| +
| +
| +
| -
| -
|–
| –
| +++
| +++
|-
|-
!'''Thermography'''
| '''Thermography'''
|Infrared
| Infrared
|0.8–2.5
| 0.8–2.5
|1.0
| 1.0
|500
| 500
|–
| –
|–
| –
| +++
| +++
|–
| –
|–
| –
|}
|}
Legend:
Legend:
Line 280: Line 283:
== Guidelines and Recommendations ==
== Guidelines and Recommendations ==
The ACC/AHA 2022 and ESC 2024 guidelines both support the use of intravascular imaging for procedural guidance during PCI, particularly in complex lesions. While the U.S. gives a Class IIa recommendation for both IVUS and OCT, the European guidelines provide a stronger Class I recommendation with Level A evidence for using IVUS or OCT in left main, bifurcation, and long lesions.
The ACC/AHA 2022 and ESC 2024 guidelines both support the use of intravascular imaging for procedural guidance during PCI, particularly in complex lesions. While the U.S. gives a Class IIa recommendation for both IVUS and OCT, the European guidelines provide a stronger Class I recommendation with Level A evidence for using IVUS or OCT in left main, bifurcation, and long lesions.
{| class="wikitable"
| colspan="1" style="text-align:center; background:LightGreen" |[[European society of cardiology guidelines classification scheme|Class Ia]]
|-
| bgcolor="LightGreen" |"Intracoronary imaging guidance by IVUS or OCT is recommended for performing PCI on anatomically complex lesions, in particular left main stem, true bifurcations and long lesions.''([[European society of cardiology guidelines classification scheme|Level of Evidence: A]])'' <nowiki>"</nowiki>
|}
{| class="wikitable"
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.''' In patients undergoing coronary stent implantation, IVUS can be useful for procedural guidance, particularly in cases of '''left main''' or '''complex coronary artery stenting''', to reduce ischemic events.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''2.''' In patients undergoing coronary stent implan-tation, '''OCT is a reasonable alternative to IVUS''' for procedural guidance, except in ostial left main disease.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''3.''' [[IVUS|I]]<nowiki/>n patients with '''stent failure''', IVUS or OCT is reasonable to determine the '''mechanism of stent failure.'''''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''<nowiki>"</nowiki>
|}


== Conclusion ==
== Conclusion ==

Latest revision as of 13:56, 29 April 2025

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor-In-Chief: Parth Vikram Singh, MBBS[2]

Overview

Optical Coherence Tomography (OCT) is a medical imaging methodology that uses a specially designed catheter with an optical fiber at its distal end to emit near-infrared light. The proximal end of the catheter is connected to a computerized imaging console that detects the light backscattered from within the vessel wall. OCT allows high-resolution visualization of the coronary artery structure by generating cross-sectional images from inside the blood vessels. This technology enables highly detailed, real-time visualization of coronary morphology by capturing optical reflections of tissue microstructures, allowing precise assessment of the endothelium, plaque burden, thin-cap fibroatheromas (TCFA), thrombus, calcium, and stent positioning.[1][2][3][4][5][6][7] Compared to intravascular ultrasound (IVUS), OCT offers superior axial resolution (~10-20 µm vs. 100-150 µm for IVUS), though with shallower penetration depth (1-2 mm vs. 4-8 mm for IVUS).  

Available Platforms

OCT imaging utilizes near-infrared light (typically ~1,300 nm) to detect backscattered signals from tissue, offering unmatched spatial resolution. OCT imaging quality can be compromised by structures that absorb infrared light, such as thrombus, lipid-rich necrotic core, or calcified plaques.[8] Additionally, because blood scatters infrared light and interferes with image clarity, it must be cleared from the vessel using radiocontrast or, in some cases, saline before acquiring OCT images.

Two main systems dominate the OCT market:

  • Frequency-domain OCT (FD-OCT): Most commonly used, faster, and allows real-time imaging.
  • Time-domain OCT (TD-OCT): Obsolete in clinical settings.

Major commercial platforms include Abbott's Dragonfly catheter (used with the ILUMIEN system) and Terumo's LUNAWAVE system. Recent advancements in OCT technology have led to hybrid systems that integrate additional imaging modalities such as IVUS (e.g., Novasight Hybrid by Conavi Medical and Dual Sensor by Terumo), near-infrared spectroscopy (HyperVue by SpectraWave), and near-infrared fluorescence (Canon Medical). These combinations allow clinicians to harness the complementary strengths of each modality simultaneously. Furthermore, OCT-based vessel reconstructions are now being utilized to compute virtual fractional flow reserve (vFFR) through computational fluid dynamics, offering the potential to assess both the anatomical features and physiological significance of coronary lesions in a single imaging session.  

Assessment of Atherosclerosis

The arteries of the heart (the coronary arteries) are the most frequent imaging target for OCT. OCT is used in the coronary arteries to determine the amount of atheromatous plaque built up at any particular point in the epicardial coronary artery. The progressive accumulation of plaque within the artery wall over decades is the setup for vulnerable plaque which, in turn, leads to myocardial infarction and stenosis (narrowing) of the artery (known as coronary artery lesions). OCT is of use to determine both plaque volume within the wall of the artery and/or the degree of stenosis of the artery lumen. It can be especially useful in situations in which angiographic imaging is considered unreliable; such as for the lumen of ostial lesions or where angiographic images do not visualize lumen segments adequately, such as regions with multiple overlapping arterial segments. It is also used to assess the effects of treatments of stenosis such as with hydraulic angioplasty expansion of the artery, with or without stents, and the results of medical therapy over time.

Arteries can either "positively remodel" or "negatively remodel". If there is an outward expansion of the artery to accommodate the plaque, this is referred to as positive or outward, or expansive modeling. Until the plaque occupies 40 to 50% of the volume of the artery there is no luminal encroachment.in contrast, if the lumen is encroached upon this is called negative, and word or constrictive remodeling.

The characteristic bright-dark-bright trilaminar pattern seen in a normal coronary artery corresponds to light reflections from its three distinct layers: the intima, media, and adventitia. [9]

In atherosclerotic vessels, the normal arterial architecture becomes disrupted, and OCT reveals distinct morphological patterns that correspond to various types of plaque. These vessel wall morphologies include signal-rich (bright) low-attenuating areas characteristic of fibrous plaques (figure 2A), signal-poor (dark), high-attenuation regions with an overlying fibrous cap indicative of lipid-rich plaques (figure 2B),  and well-defined, signal-poor low-attenuation zones representing calcific plaques (figure 2C).[10] Within the lumen, the most frequently observed pathologies include high-attenuation red thrombus, which produces shadowing on the vessel wall, and low-attenuation white thrombus.(figure 3) [11]

Furthermore, OCT’s superior resolution allows precise identification of culprit lesions in acute coronary syndrome (ACS), like plaque rupture, plaque erosion, and eruptive calcified nodules.(figure 4)[12] Recognizing the underlying causes of acute coronary syndrome (ACS) can contribute to more personalized and targeted treatment strategies. OCT is also valuable in assessing patients with spontaneous coronary artery dissection (SCAD) or myocardial infarction with non-obstructive coronary arteries (MINOCA), as it helps clarify the presence and nature of the culprit lesions in cases of non–ST-segment elevation MI (NSTEMI).[13] Finally, OCT is valuable in detecting high-risk vulnerable plaques, such as thin-cap fibroatheromas (TCFAs), that have a propensity to rupture and trigger acute coronary syndromes (ACS).(figure 5) [14]

In the interpretation of coronary Optical Coherence Tomography (OCT), the first step is to determine whether all three layers of the arterial wall—the intima, media, and adventitia—are clearly visualized. If all three layers are visible, the vessel is likely either a normal artery or one containing a fibrous plaque, both of which maintain relatively preserved architecture. However, if the layers cannot be fully visualized, the next step is to identify where the signal loss or attenuation is occurring.

If the signal change is located within the lumen, its characteristics help differentiate thrombus types. High attenuation in the lumen suggests the presence of red thrombus, which typically absorbs more light. Conversely, low attenuation in the lumen is indicative of a white thrombus, which is less optically dense.

If the signal change occurs within the vessel wall, the pattern again provides diagnostic clues. High attenuation within the wall points toward a lipid-rich plaque, which scatters light significantly. On the other hand, low attenuation in the wall is characteristic of calcified plaque, which appears as a sharply delineated low-signal region with minimal backscatter.

This stepwise assessment enables clinicians to classify plaques and thrombi with precision and guide decision-making during percutaneous coronary interventions.(figure) [15]

Indications

Intravascular OCT is used to guide PCI in a standardized approach. This standardized method is often summarized using the mnemonic MLD-MAX, where the pre-PCI focus is on MLD: Morphology, Length, and Diameter, and the post-PCI evaluation centers on MAX: Medial dissection, Apposition, and eXpansion. Pre-procedural OCT imaging plays a key role in planning PCI by:

(1) evaluating lesion morphology to guide optimal lesion preparation,

(2) identifying suitable proximal and distal landing zones with minimal disease for stent placement,

(3) accurately measuring vessel diameter to select appropriate balloon and stent sizes.

Following PCI, OCT imaging is instrumental in optimizing stent outcomes by detecting

(1) edge dissections at the stent margins that may necessitate additional stenting,

(2) areas of stent malapposition, and

(3) stent underexpansion that may require further post-dilation.

Pre-PCI lesion assessment:

To Assess the Severity of Lesions

Angiography often underestimates the severity of lesions. The angiogram only evaluates the lumen and does not evaluate the plaque burden in an artery. If a lesion is present OCT will generally demonstrate that 50 to 60% of the volume of the artery is made up of plaque both proximal and distal to the lesion.

OCT has been related to defects on nuclear imaging and Doppler flow wire measurements of coronary flow reserve (CFR) and fractional flow reserve (FFR) to validate its accuracy.

The consensus view is that any minimum lumen area (MLA) < 4 mm² in an artery that is > 3 mm on angiography (excluding the left main) is a significant stenosis.

To Assess the Underlying Morphology of Lesions

OCT is more sensitive than angiography in the assessment of calcium, particularly the presence of calcium deep in the wall of the artery. The sensitivity of angiography is approximately 25% if there is one quadrant of calcium present, the sensitivity is 50% if there are two quadrants of calcium, the sensitivity is 60% if there are three quadrants of calcium and finally the sensitivity is 85% if there are for quadrants calcium. In lesions with predominantly fibrous or lipid-rich plaque, direct stenting or predilatation with an undersized balloon may be sufficient. However, for moderate to severe calcification, specialized plaque modification techniques, such as noncompliant, cutting, or scoring balloons, atherectomy, or intravascular lithotripsy (IVL), are often required. OCT is particularly valuable in these cases, as it provides a more precise evaluation of calcium burden compared to IVUS. An OCT-based calcium scoring system can help guide the need for advanced plaque modification.[16][17](figure 10) Specifically, lesions with calcium arc >180° (i.e. 50% of circumference), thickness >0.5 mm, and length >5 mm (commonly referred to as the "rule of 5") are more likely to require atherectomy or IVL due to their association with suboptimal stent expansion.

To Assess The Length Of Lesions

To accurately measure lesion length, it is essential to select proximal and distal reference segments that have minimal plaque burden and provide clear visualization of the vessel wall. The imaging software typically calculates the distance between these segments automatically, and the operator can adjust them to align with the length of an available drug-eluting stent. This approach helps reduce the risk of stent edge-related complications, such as inflow or outflow disease and the presence of TCFA at the stent margins, which are associated with poorer clinical outcomes.[18][19][20][21][22]

To Assess the Diameter Of Lesions

Device sizing during PCI can be guided using either the external elastic lamina (EEL) or lumen-based measurements. An external elastic lamina (EEL)-guided strategy is preferred over a lumen-guided approach when 2 measurements can be obtained at least one quadrant apart. This approach generally allows for the selection of a balloon or stent approximately 0.5 mm larger, resulting in a larger final lumen area without increasing the risk of complications.[23][24][25] To select the stent size, the mean EEL diameter of the distal reference segment is measured and then rounded down to the nearest available stent size. If the EEL is not well visualized, often due to plaque-induced signal attenuation, the mean lumen diameter is used instead and rounded up to the next available stent size.[26] The same principles, based on the respective reference diameter measurements, apply when selecting the size of the post-dilation balloon. (figure 13)

Assessment of the left main is associated with the greatest amount of inter and intraobserver variability in angiography. The left main is short, and is often diseased with asymmetric lesions making its assessment on angiography difficult. There may be diffuse disease which may cause an underestimation of the extent of involvement on angiography. While luminal encroachment is defined as a minimum lumen area less than 4 mm² in the epicardial arteries, a minimum lumen area less than 6 mm² in the left main is considered to be significant. A minimum lumen area less than 6 mm² in the left main corresponds with a fractional flow reserve less than 0.75. A minimum lumen area less than 6 mm² also corresponds to a minimum lumen area less than 4 mm² in either the LAD or the circumflex arteries.

Assessment of the diameter of the vessel is particularly useful in research studies such as those evaluating lipid lowering agents. Care must be taken to identify reproducible start and end points for the mechanical pullback to ensure that the same area of the segment is being interrogated.

Post-PCI lesion optimization

To Identify Complications Such as Dissection

Following PCI, the proximal and distal reference segments should be evaluated for signs of medial dissection or intramural hematoma (Fig. 15).[27] Due to its high resolution, OCT can detect post-PCI edge dissections in up to 40% of cases.[28] However, most of these dissections are minor and tend to heal without causing significant clinical consequences.[29][30] That said, major edge dissections observed on OCT are associated with worse clinical outcomes.[31][32][33][34] It is generally advised to deploy an additional stent if a large dissection involves more than 60° of the vessel circumference and extends over 3 mm into the medial layer, provided that stenting is not limited by anatomical constraints.[35]

To Guide Adequate Stent Apposition:

Stent malapposition refers to the separation between the stent struts and the vessel wall. [36][37] Although malapposition is frequently observed on OCT following stent implantation (upto 50%),[38] it generally does not increase the risk of stent failure or thrombosis.[39][40][41][42] However, certain scenarios, such as proximal malapposition that may hinder future rewiring, extensive malapposition extending more than 3mm in length, or malapposition associated with stent underexpansion, warrants further optimization (Fig. 16).  Stent apposition refers to the stent touching the vessel wall while stent expansion refers to the size of the stent. Poor stent apposition is of a greater concern in an artery with a small minimum stent area than in a larger artery. Complete and position obviously may not be possible in aneurysmal segments or ectatic segments.

To Guide Adequate Stent Expansion:

Stent expansion is a key determinant of long-term stent success and can be evaluated using absolute measurements, such as minimum stent area (MSA), or relative metrics like the ratio of MSA to the reference lumen area.[43] According to current European guidelines, optimal stent deployment is defined by either: (1) an MSA > 4.5 mm² on OCT for non–left main lesions (absolute expansion), or (2) an MSA exceeding 80% of the average of the proximal and distal reference lumen areas (relative expansion).[44][45] While absolute MSA is generally a stronger predictor of adverse outcomes, achieving this threshold in smaller vessels may not be feasible, which highlights the clinical relevance of relative stent expansion.[46] Despite multiple criteria for defining adequate relative expansion, success is typically achieved in approximately 50% of cases.[47](figure 17) An inadequate minimum stent area is associated with a higher risk of stent thrombosis. Insofar as OCT optimizes the minimum stented area, the use of OCT reduces the risk of stent restenosis.

Advantages over Angiography

Arguably the most valuable use of OCT is to visualize plaque, which cannot be seen by angiography. It has been increasingly used in research to better understand the behavior of the atherosclerosis process in living people. OCT enables accurately visualizing not only the lumen of the coronary arteries but also the atheroma (membrane/cholesterol loaded white blood cells) "hidden" within the wall. OCT has thus enabled advances in clinical research providing a more thorough perspective and better understanding.

Unlike Angiography, which functions as a luminogram by displaying only the contrast-filled lumen, optical coherence tomography (OCT) offers a much more detailed assessment of the vessel wall and plaque characteristics. OCT can accurately differentiate between various types of plaque, including fibrous, lipid-rich, and calcific components. It is also highly sensitive in detecting thrombi, allowing identification of both red and white thrombus formations. In the context of stent deployment, OCT plays a crucial role by evaluating stent apposition, expansion, and detecting complications such as edge dissections or tissue prolapse. Importantly, OCT enables visualization of vulnerable plaques—particularly thin-cap fibroatheromas (TCFA)—which are defined by a fibrous cap measuring less than 65 µm and are often associated with acute coronary syndromes.

OCT also plays a significant role in evaluating restenosis and stent failure. In the past, angiographic appearances of “restenosis” after angioplasty often reflected not true luminal collapse, but rather the inadequate apposition or incomplete expansion of a stent. OCT enables precise assessment of stent geometry, measuring minimum stent area, identifying tissue prolapse, edge dissections, and malapposition, which angiography frequently misses. These details are pivotal in preventing stent thrombosis and ensuring long-term patency.[48][49]

Furthermore, OCT imaging has advanced our understanding of coronary healing. For example, serial OCT studies have shown how neointimal coverage evolves over time after drug-eluting stent (DES) implantation, helping clinicians evaluate reendothelialization.[50]

OCT's real-time, catheter-based imaging—paired with automated pullback and rapid acquisition—has enabled its integration into routine percutaneous coronary intervention (PCI), where it aids not only in lesion assessment but also in fine-tuning procedural outcomes. Most commercial OCT systems are now equipped with built-in tools for automated detection of stents and contouring of the lumen or external elastic membrane (EEM). Additionally, the use of deep learning algorithms for automated plaque and lesion characterization is an emerging area of ongoing research and development.[51][52][53] (Figure 6)

Disadvantages of OCT

Adoption Barriers Among Clinicians:

A large survey[54] of interventional cardiologists cited the following as key barriers to routine OCT use:

  • Higher procedural costs
  • Increased procedure time (~15 minutes longer)
  • Lack of formal training
  • Absence of standardized interpretation guidelines

Cost Considerations:

The FORZA trial reported that OCT-guided PCI incurs higher costs compared to FFR-guided PCI.[55] However, a head-to-head cost-effectiveness analysis between OCT, IVUS, and angiography has not yet been conducted.

Limited Penetration Depth:

Despite its superior resolution, OCT has shallower tissue penetration than IVUS, which can restrict its ability to assess deeper structures.

Need for Blood Clearance:

OCT requires temporary displacement of blood from the imaging field, usually through contrast injection. This makes imaging difficult in:

  • Ostial coronary segments since it is difficult to clear the blood from the coronary ostia.
  • Caliber of the left  main coronary artery may prohibit it from adequate flush clearance.
  • Hemodynamically unstable patients where high contrast load may be undesirable.
  • Individuals with advanced chronic kidney disease, where contrast use is contraindicated

Challenges in Certain Anatomies:

  • Difficulty imaging the aorto-ostial regions due to poor clearance
  • Suboptimal results in large-caliber vessels (e.g., left main)
  • Limitations in tortuous or ectatic coronary arteries
  • Not validated for chronic total occlusion (CTO) revascularization guidance

Flushing Agent Issues:

While alternative agents like normal saline have been explored, they may still result in blood mixing and carry a risk of arrhythmia.

Imaging Artifacts

  • OCT artifacts[56] can be broadly classified into two categories: those arising from the interaction of light with the catheter, lumen, or vessel wall, and those resulting from the catheter’s position and movement within the vessel (Figure 11). Certain lumen contents or vessel components can significantly attenuate the OCT signal, creating shadowing effects that obscure the visualization of deeper arterial wall layers.
  • Inadequate clearance of blood from the imaging field can lead to signal-rich areas within the lumen, causing interference that reduces image clarity and diminishes the intensity of the OCT signal reaching the vessel wall (Figure 11A, 11B). Additionally, swirling blood, especially during the initiation or completion of the pullback, may mimic the appearance of thrombus or plaque erosion (Figure 11C, 11D). Red thrombus strongly attenuates OCT light, while metallic elements like stent struts and guidewires obstruct light propagation, casting shadows on the underlying tissue.
  • The catheter’s position within the vessel and the vessel’s diameter also influences image quality. Excessive force during insertion can lead to catheter prolapse, where the catheter bends or folds within the lumen (Figure 11E). Moreover, irregular catheter movement, whether due to inconsistent rotation or variable pullback speed, can distort images. One specific artifact, known as non-uniform rotational distortion (NURD), manifests as lateral blurring or smearing and is caused by variations in angular velocity of the rotating optical fiber. NURD commonly arises in tortuous or narrow vessels, or when there is resistance from tight hemostatic valves or crimped catheter sheaths (Figure 11F, 11G).
  • Another artifact may occur when the OCT catheter is too close to the vessel wall. In such cases, the emitted light may travel nearly parallel to the tissue surface, reducing beam penetration. This can falsely appear as signal attenuation and may be misinterpreted as thin-cap fibroatheroma (TCFA) (Figure 4H).

Method

An OCT system is composed of three main components: the imaging catheter, a motorized drive unit, and dedicated imaging software. Before the procedure, the catheter must be flushed with the same fluid intended for coronary artery flushing—typically radiographic contrast, though saline is occasionally used. Proper engagement of the guide catheter is essential to ensure effective flushing and to prevent catheter disengagement during image acquisition. To enhance image quality and reduce the risk of catheter-induced vasospasm, intracoronary nitroglycerin is typically administered before imaging.

The OCT acquisition process follows a structured sequence: position, purge, puff, and pullback.

1.     Position: The OCT catheter is advanced approximately 10 mm distal to the lesion over a coronary guidewire.

2.     Purge: The catheter is purged again to eliminate residual air or bubbles.

3.     Puff: A small puff of contrast is injected through the guide catheter to verify proper engagement and ensure adequate blood clearance. Occasionally, a guide catheter extension may be necessary to prevent backflow of the flushing agent into the aorta.

4.     Pullback: The automated pullback mechanism is then activated. During this phase, contrast or saline is delivered either manually or via an automated injector.

Clinical Evidence

Early studies demonstrated that OCT imaging had a significant impact on procedural decision-making. In the CLI-OPCI study, for instance, post-PCI OCT identified suboptimal features requiring additional intervention in 35% of cases.[57] Moreover, OCT-guided PCI was associated with a lower incidence of myocardial infarction (MI) or cardiac death at one year after adjustment for confounding variables.

The OPINION trial[58] was the first to directly compare outcomes between OCT- and IVUS-guided PCI. It found no significant difference in the primary endpoint of target vessel failure at one year, establishing the noninferiority of OCT guidance relative to IVUS. Similarly, the ILUMIEN III trial[59] demonstrated that OCT-guided PCI was noninferior to IVUS-guided PCI in terms of final minimum stent area (MSA), reinforcing OCT’s role as a viable alternative for intravascular imaging guidance. In the large-scale OCTIVUS trial[60] (n = 1005 for OCT vs. 1003 for IVUS), OCT-guided PCI was again shown to be noninferior to IVUS-guided PCI for the composite primary endpoint of cardiac death, target-vessel MI, or ischemia-driven target-vessel revascularization at one year.

The ILUMIEN IV trial[61], a global, multicenter randomized controlled study, compared OCT-guided versus angiography-guided PCI in high-risk patients or those with complex lesions (n = 1233 vs. 1254). OCT guidance resulted in significantly larger final MSA (5.72 ± 2.04 mm² vs. 5.36 ± 1.87 mm²; P < .001) and greater stent expansion, attributed to the selection of larger stents and more frequent high-pressure postdilation. While the trial showed no significant difference in the primary clinical endpoint of a composite of cardiac death, target-vessel MI, or ischemia-driven target-vessel revascularization at 2 years, it did report a notable reduction in stent thrombosis with OCT guidance. The OCTOBER trial,[62] which enrolled patients with complex bifurcation lesions (n = 600 for OCT, 601 for angiography), found that OCT-guided PCI significantly reduced the composite outcome of cardiac death, target-lesion MI, or ischemia-driven target-vessel revascularization at two years compared to angiography guidance. In the RENOVATE-COMPLEX PCI trial,[63] intravascular imaging guidance (both IVUS [74.5%] and OCT [25.5%]) led to a lower risk of the composite endpoint of cardiac death, target vessel-related MI, or clinically driven target vessel revascularization compared with angiography-guided PCI. Subgroup analysis confirmed consistent benefits across both IVUS and OCT modalities.

Multiple high-quality randomized trials support the use of OCT-guided PCI over angiography-guided strategies, particularly in high-risk patients or those with complex coronary lesions. Additionally, OCT has shown clinical equivalence to IVUS, making it a reliable alternative for intravascular imaging–guided intervention.

Comparison with other imaging modalities

OCT offers the highest resolution among intravascular imaging modalities, providing excellent detection of fibrous cap and lipid core features, with good utility for identifying calcium and thrombus, making it uniquely suited for detailed plaque characterization.[64]

Clinical utility in detection of vulnerable plaque feature
Imaging Technique Technology Wavelength (µm) Penetration (mm) Resolution (µm) Fibrous Cap Lipid Core Inflammation Calcium Thrombus
Coronary Angiography X-ray 0.00001–0.01 0.0 >500 – – – + +++
IVUS Ultrasound 35–80 10.0 100–200 + ++ – +++ –
OCT Infrared 1.3 1.0–2.5 <10 +++ +++ + ++ ++
NIRS Near-infrared 0.8–2.5 1.0–2.0 N/A – +++ – – –
Raman Spectroscopy Near-infrared 0.75–1.0 1.0–2.0 N/A – +++ - – –
IV-MRI MRI N/A 0.25 100 + ++ ++ ++ +
Angioscopy Optical 0.4–0.7 0.0 10–50 + + - – +++
Thermography Infrared 0.8–2.5 1.0 500 – – +++ – –

Legend:

– = Not possible   + = Adequate   ++ = Good   +++ = Excellent

Guidelines and Recommendations

The ACC/AHA 2022 and ESC 2024 guidelines both support the use of intravascular imaging for procedural guidance during PCI, particularly in complex lesions. While the U.S. gives a Class IIa recommendation for both IVUS and OCT, the European guidelines provide a stronger Class I recommendation with Level A evidence for using IVUS or OCT in left main, bifurcation, and long lesions.

Class Ia
"Intracoronary imaging guidance by IVUS or OCT is recommended for performing PCI on anatomically complex lesions, in particular left main stem, true bifurcations and long lesions.(Level of Evidence: A) "
Class IIa
"1. In patients undergoing coronary stent implantation, IVUS can be useful for procedural guidance, particularly in cases of left main or complex coronary artery stenting, to reduce ischemic events.(Level of Evidence: B-R)"
"2. In patients undergoing coronary stent implan-tation, OCT is a reasonable alternative to IVUS for procedural guidance, except in ostial left main disease.(Level of Evidence: B-R)"
"3. In patients with stent failure, IVUS or OCT is reasonable to determine the mechanism of stent failure.(Level of Evidence: C-LD)"

Conclusion

OCT is an advanced imaging modality offering unparalleled resolution for intracoronary imaging. It complements angiography and IVUS in guiding PCI, particularly in stent optimization and high-risk plaque detection. Its limitations are offset by its precision and evolving evidence base.


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  4. ↑ Hong SJ, Mintz GS, Ahn CM, Kim JS, Kim BK, Ko YG, Kang TS, Kang WC, Kim YH, Hur SH, Hong BK, Choi D, Kwon H, Jang Y, Hong MK (January 2020). "Effect of Intravascular Ultrasound-Guided Drug-Eluting Stent Implantation: 5-Year Follow-Up of the IVUS-XPL Randomized Trial". JACC Cardiovasc Interv. 13 (1): 62–71. doi:10.1016/j.jcin.2019.09.033. PMID 31918944.
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  9. ↑ Mitsis A, Eftychiou C, Kadoglou NP, Theodoropoulos KC, Karagiannidis E, Nasoufidou A, Ziakas A, Tzikas S, Kassimis G (July 2024). "Innovations in Intracoronary Imaging: Present Clinical Practices and Future Outlooks". J Clin Med. 13 (14). doi:10.3390/jcm13144086. PMC 11277956 Check |pmc= value (help). PMID 39064126 Check |pmid= value (help).
  10. ↑ ElFaramawy A, Youssef M, Abdel Ghany M, Shokry K (June 2018). "Difference in plaque characteristics of coronary culprit lesions in a cohort of Egyptian patients presented with acute coronary syndrome and stable coronary artery disease: An optical coherence tomography study". Egypt Heart J. 70 (2): 95–100. doi:10.1016/j.ehj.2017.12.002. PMC 6112336. PMID 30166889.
  11. ↑ Prati F, Regar E, Mintz GS, Arbustini E, Di Mario C, Jang IK, Akasaka T, Costa M, Guagliumi G, Grube E, Ozaki Y, Pinto F, Serruys PW (February 2010). "Expert review document on methodology, terminology, and clinical applications of optical coherence tomography: physical principles, methodology of image acquisition, and clinical application for assessment of coronary arteries and atherosclerosis". Eur Heart J. 31 (4): 401–15. doi:10.1093/eurheartj/ehp433. PMID 19892716.
  12. ↑ Yamamoto MH, Kondo S, Mizukami T, Yasuhara S, Wakabayashi K, Kobayashi N, Sambe T, Hibi K, Nanasato M, Sugiyama T, Kakuta T, Kondo T, Mitomo S, Nakamura S, Takano M, Yonetsu T, Ashikaga T, Dohi T, Yamamoto H, Kozuma K, Yamashita J, Yamaguchi J, Ohira H, Mitsumata K, Namiki A, Kimura S, Honye J, Kotoku N, Higuma T, Natsumeda M, Ikari Y, Sekimoto T, Mori H, Suzuki H, Otake H, Isomura N, Ochiai M, Suwa S, Shinke T (December 2022). "Rationale and design of the TACTICS registry: Optical coherence tomography guided primary percutaneous coronary intervention for patients with acute coronary syndrome". J Cardiol. 80 (6): 505–510. doi:10.1016/j.jjcc.2022.07.002. PMID 35907707 Check |pmid= value (help).
  13. ↑ Ali ZA, Karimi Galougahi K, Mintz GS, Maehara A, Shlofmitz RA, Mattesini A (June 2021). "Intracoronary optical coherence tomography: state of the art and future directions". EuroIntervention. 17 (2): e105–e123. doi:10.4244/EIJ-D-21-00089. PMC 9725016 Check |pmc= value (help). PMID 34110288 Check |pmid= value (help).
  14. ↑ Kubo T, Ino Y, Tanimoto T, Kitabata H, Tanaka A, Akasaka T (2011). "Optical coherence tomography imaging in acute coronary syndromes". Cardiol Res Pract. 2011: 312978. doi:10.4061/2011/312978. PMC 3177459. PMID 21941666.
  15. ↑ Ali ZA, Karimi Galougahi K, Mintz GS, Maehara A, Shlofmitz RA, Mattesini A (June 2021). "Intracoronary optical coherence tomography: state of the art and future directions". EuroIntervention. 17 (2): e105–e123. doi:10.4244/EIJ-D-21-00089. PMC 9725016 Check |pmc= value (help). PMID 34110288 Check |pmid= value (help).
  16. ↑ Fujino A, Mintz GS, Matsumura M, Lee T, Kim SY, Hoshino M, Usui E, Yonetsu T, Haag ES, Shlofmitz RA, Kakuta T, Maehara A (April 2018). "A new optical coherence tomography-based calcium scoring system to predict stent underexpansion". EuroIntervention. 13 (18): e2182–e2189. doi:10.4244/EIJ-D-17-00962. PMID 29400655.
  17. ↑ Ali ZA, Galougahi KK (April 2018). "Shining light on calcified lesions, plaque stabilisation and physiologic significance: new insights from intracoronary OCT". EuroIntervention. 13 (18): e2105–e2108. doi:10.4244/EIJV13I18A346. PMID 29624174.
  18. ↑ Ino Y, Kubo T, Matsuo Y, Yamaguchi T, Shiono Y, Shimamura K, Katayama Y, Nakamura T, Aoki H, Taruya A, Nishiguchi T, Satogami K, Yamano T, Kameyama T, Orii M, Ota S, Kuroi A, Kitabata H, Tanaka A, Hozumi T, Akasaka T (October 2016). "Optical Coherence Tomography Predictors for Edge Restenosis After Everolimus-Eluting Stent Implantation". Circ Cardiovasc Interv. 9 (10). doi:10.1161/CIRCINTERVENTIONS.116.004231. PMID 27688261.
  19. ↑ Prati F, Romagnoli E, Gatto L, La Manna A, Burzotta F, Limbruno U, Versaci F, Fabbiocchi F, Di Giorgio A, Marco V, Ramazzotti V, Di Vito L, Trani C, Porto I, Boi A, Tavazzi L, Mintz GS (December 2016). "Clinical Impact of Suboptimal Stenting and Residual Intrastent Plaque/Thrombus Protrusion in Patients With Acute Coronary Syndrome: The CLI-OPCI ACS Substudy (Centro per la Lotta Contro L'Infarto-Optimization of Percutaneous Coronary Intervention in Acute Coronary Syndrome)". Circ Cardiovasc Interv. 9 (12). doi:10.1161/CIRCINTERVENTIONS.115.003726. PMID 27965297.
  20. ↑ Prati F, Romagnoli E, La Manna A, Burzotta F, Gatto L, Marco V, Fineschi M, Fabbiocchi F, Versaci F, Trani C, Tamburino C, Alfonso F, Mintz GS (July 2018). "Long-term consequences of optical coherence tomography findings during percutaneous coronary intervention: the Centro Per La Lotta Contro L'infarto - Optimization Of Percutaneous Coronary Intervention (CLI-OPCI) LATE study". EuroIntervention. 14 (4): e443–e451. doi:10.4244/EIJ-D-17-01111. PMID 29633940.
  21. ↑ Prati F, Romagnoli E, Burzotta F, Limbruno U, Gatto L, La Manna A, Versaci F, Marco V, Di Vito L, Imola F, Paoletti G, Trani C, Tamburino C, Tavazzi L, Mintz GS (November 2015). "Clinical Impact of OCT Findings During PCI: The CLI-OPCI II Study". JACC Cardiovasc Imaging. 8 (11): 1297–305. doi:10.1016/j.jcmg.2015.08.013. PMID 26563859.
  22. ↑ van Zandvoort LJ, Tomaniak M, Tovar Forero MN, Masdjedi K, Visseren L, Witberg K, Ligthart J, Kardys I, Lemmert ME, Diletti R, Wilschut J, de Jaegere P, Zijlstra F, Van Mieghem NM, Daemen J (March 2020). "Predictors for Clinical Outcome of Untreated Stent Edge Dissections as Detected by Optical Coherence Tomography". Circ Cardiovasc Interv. 13 (3): e008685. doi:10.1161/CIRCINTERVENTIONS.119.008685. PMID 32089001 Check |pmid= value (help).
  23. ↑ Shlofmitz E, Jeremias A, Parviz Y, Karimi Galougahi K, Redfors B, Petrossian G, Edens M, Matsumura M, Maehara A, Mintz GS, Stone GW, Shlofmitz RA, Ali ZA (June 2021). "External elastic lamina vs. luminal diameter measurement for determining stent diameter by optical coherence tomography: an ILUMIEN III substudy". Eur Heart J Cardiovasc Imaging. 22 (7): 753–759. doi:10.1093/ehjci/jeaa276. PMID 33167000 Check |pmid= value (help).
  24. ↑ Ali ZA, Maehara A, Généreux P, Shlofmitz RA, Fabbiocchi F, Nazif TM, Guagliumi G, Meraj PM, Alfonso F, Samady H, Akasaka T, Carlson EB, Leesar MA, Matsumura M, Ozan MO, Mintz GS, Ben-Yehuda O, Stone GW (November 2016). "Optical coherence tomography compared with intravascular ultrasound and with angiography to guide coronary stent implantation (ILUMIEN III: OPTIMIZE PCI): a randomised controlled trial". Lancet. 388 (10060): 2618–2628. doi:10.1016/S0140-6736(16)31922-5. PMID 27806900.
  25. ↑ Kubo T, Shinke T, Okamura T, Hibi K, Nakazawa G, Morino Y, Shite J, Fusazaki T, Otake H, Kozuma K, Ioji T, Kaneda H, Serikawa T, Kataoka T, Okada H, Akasaka T (November 2017). "Optical frequency domain imaging vs. intravascular ultrasound in percutaneous coronary intervention (OPINION trial): one-year angiographic and clinical results". Eur Heart J. 38 (42): 3139–3147. doi:10.1093/eurheartj/ehx351. PMC 5837511. PMID 29121226.
  26. ↑ Ali Z, Landmesser U, Karimi Galougahi K, Maehara A, Matsumura M, Shlofmitz RA, Guagliumi G, Price MJ, Hill JM, Akasaka T, Prati F, Bezerra HG, Wijns W, Mintz GS, Ben-Yehuda O, McGreevy RJ, Zhang Z, Rapoza RR, West NE, Stone GW (January 2021). "Optical coherence tomography-guided coronary stent implantation compared to angiography: a multicentre randomised trial in PCI - design and rationale of ILUMIEN IV: OPTIMAL PCI". EuroIntervention. 16 (13): 1092–1099. doi:10.4244/EIJ-D-20-00501. PMC 9725042 Check |pmc= value (help). PMID 32863246 Check |pmid= value (help).
  27. ↑ Nafee T, Shah A, Forsberg M, Zheng J, Ou J (2023). "State-of-art review: intravascular imaging in percutaneous coronary interventions". Cardiol Plus. 8 (4): 227–246. doi:10.1097/CP9.0000000000000069. PMC 10829907 Check |pmc= value (help). PMID 38304487 Check |pmid= value (help).
  28. ↑ Ali ZA, Maehara A, Généreux P, Shlofmitz RA, Fabbiocchi F, Nazif TM, Guagliumi G, Meraj PM, Alfonso F, Samady H, Akasaka T, Carlson EB, Leesar MA, Matsumura M, Ozan MO, Mintz GS, Ben-Yehuda O, Stone GW (November 2016). "Optical coherence tomography compared with intravascular ultrasound and with angiography to guide coronary stent implantation (ILUMIEN III: OPTIMIZE PCI): a randomised controlled trial". Lancet. 388 (10060): 2618–2628. doi:10.1016/S0140-6736(16)31922-5. PMID 27806900.
  29. ↑ van Zandvoort LJ, Tomaniak M, Tovar Forero MN, Masdjedi K, Visseren L, Witberg K, Ligthart J, Kardys I, Lemmert ME, Diletti R, Wilschut J, de Jaegere P, Zijlstra F, Van Mieghem NM, Daemen J (March 2020). "Predictors for Clinical Outcome of Untreated Stent Edge Dissections as Detected by Optical Coherence Tomography". Circ Cardiovasc Interv. 13 (3): e008685. doi:10.1161/CIRCINTERVENTIONS.119.008685. PMID 32089001 Check |pmid= value (help).
  30. ↑ Radu MD, Räber L, Heo J, Gogas BD, Jørgensen E, Kelbæk H, Muramatsu T, Farooq V, Helqvist S, Garcia-Garcia HM, Windecker S, Saunamäki K, Serruys PW (January 2014). "Natural history of optical coherence tomography-detected non-flow-limiting edge dissections following drug-eluting stent implantation". EuroIntervention. 9 (9): 1085–94. doi:10.4244/EIJV9I9A183. PMID 24064426.
  31. ↑ Prati F, Romagnoli E, Gatto L, La Manna A, Burzotta F, Limbruno U, Versaci F, Fabbiocchi F, Di Giorgio A, Marco V, Ramazzotti V, Di Vito L, Trani C, Porto I, Boi A, Tavazzi L, Mintz GS (December 2016). "Clinical Impact of Suboptimal Stenting and Residual Intrastent Plaque/Thrombus Protrusion in Patients With Acute Coronary Syndrome: The CLI-OPCI ACS Substudy (Centro per la Lotta Contro L'Infarto-Optimization of Percutaneous Coronary Intervention in Acute Coronary Syndrome)". Circ Cardiovasc Interv. 9 (12). doi:10.1161/CIRCINTERVENTIONS.115.003726. PMID 27965297.
  32. ↑ Prati F, Romagnoli E, La Manna A, Burzotta F, Gatto L, Marco V, Fineschi M, Fabbiocchi F, Versaci F, Trani C, Tamburino C, Alfonso F, Mintz GS (July 2018). "Long-term consequences of optical coherence tomography findings during percutaneous coronary intervention: the Centro Per La Lotta Contro L'infarto - Optimization Of Percutaneous Coronary Intervention (CLI-OPCI) LATE study". EuroIntervention. 14 (4): e443–e451. doi:10.4244/EIJ-D-17-01111. PMID 29633940.
  33. ↑ Prati F, Romagnoli E, Burzotta F, Limbruno U, Gatto L, La Manna A, Versaci F, Marco V, Di Vito L, Imola F, Paoletti G, Trani C, Tamburino C, Tavazzi L, Mintz GS (November 2015). "Clinical Impact of OCT Findings During PCI: The CLI-OPCI II Study". JACC Cardiovasc Imaging. 8 (11): 1297–305. doi:10.1016/j.jcmg.2015.08.013. PMID 26563859.
  34. ↑ van Zandvoort LJ, Tomaniak M, Tovar Forero MN, Masdjedi K, Visseren L, Witberg K, Ligthart J, Kardys I, Lemmert ME, Diletti R, Wilschut J, de Jaegere P, Zijlstra F, Van Mieghem NM, Daemen J (March 2020). "Predictors for Clinical Outcome of Untreated Stent Edge Dissections as Detected by Optical Coherence Tomography". Circ Cardiovasc Interv. 13 (3): e008685. doi:10.1161/CIRCINTERVENTIONS.119.008685. PMID 32089001 Check |pmid= value (help).
  35. ↑ Ali Z, Landmesser U, Karimi Galougahi K, Maehara A, Matsumura M, Shlofmitz RA, Guagliumi G, Price MJ, Hill JM, Akasaka T, Prati F, Bezerra HG, Wijns W, Mintz GS, Ben-Yehuda O, McGreevy RJ, Zhang Z, Rapoza RR, West NE, Stone GW (January 2021). "Optical coherence tomography-guided coronary stent implantation compared to angiography: a multicentre randomised trial in PCI - design and rationale of ILUMIEN IV: OPTIMAL PCI". EuroIntervention. 16 (13): 1092–1099. doi:10.4244/EIJ-D-20-00501. PMC 9725042 Check |pmc= value (help). PMID 32863246 Check |pmid= value (help).
  36. ↑ Räber L, Mintz GS, Koskinas KC, Johnson TW, Holm NR, Onuma Y, Radu MD, Joner M, Yu B, Jia H, Meneveau N, de la Torre Hernandez JM, Escaned J, Hill J, Prati F, Colombo A, di Mario C, Regar E, Capodanno D, Wijns W, Byrne RA, Guagliumi G (September 2018). "Clinical use of intracoronary imaging. Part 1: guidance and optimization of coronary interventions. An expert consensus document of the European Association of Percutaneous Cardiovascular Interventions". Eur Heart J. 39 (35): 3281–3300. doi:10.1093/eurheartj/ehy285. PMID 29790954.
  37. ↑ Ali ZA, Karimi Galougahi K, Mintz GS, Maehara A, Shlofmitz RA, Mattesini A (June 2021). "Intracoronary optical coherence tomography: state of the art and future directions". EuroIntervention. 17 (2): e105–e123. doi:10.4244/EIJ-D-21-00089. PMC 9725016 Check |pmc= value (help). PMID 34110288 Check |pmid= value (help).
  38. ↑ Prati F, Romagnoli E, Burzotta F, Limbruno U, Gatto L, La Manna A, Versaci F, Marco V, Di Vito L, Imola F, Paoletti G, Trani C, Tamburino C, Tavazzi L, Mintz GS (November 2015). "Clinical Impact of OCT Findings During PCI: The CLI-OPCI II Study". JACC Cardiovasc Imaging. 8 (11): 1297–305. doi:10.1016/j.jcmg.2015.08.013. PMID 26563859.
  39. ↑ Prati F, Romagnoli E, La Manna A, Burzotta F, Gatto L, Marco V, Fineschi M, Fabbiocchi F, Versaci F, Trani C, Tamburino C, Alfonso F, Mintz GS (July 2018). "Long-term consequences of optical coherence tomography findings during percutaneous coronary intervention: the Centro Per La Lotta Contro L'infarto - Optimization Of Percutaneous Coronary Intervention (CLI-OPCI) LATE study". EuroIntervention. 14 (4): e443–e451. doi:10.4244/EIJ-D-17-01111. PMID 29633940.
  40. ↑ Wang B, Mintz GS, Witzenbichler B, Souza CF, Metzger DC, Rinaldi MJ, Duffy PL, Weisz G, Stuckey TD, Brodie BR, Matsumura M, Yamamoto MH, Parvataneni R, Kirtane AJ, Stone GW, Maehara A (December 2016). "Predictors and Long-Term Clinical Impact of Acute Stent Malapposition: An Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents (ADAPT-DES) Intravascular Ultrasound Substudy". J Am Heart Assoc. 5 (12). doi:10.1161/JAHA.116.004438. PMC 5210413. PMID 28007741.
  41. ↑ Steinberg DH, Mintz GS, Mandinov L, Yu A, Ellis SG, Grube E, Dawkins KD, Ormiston J, Turco MA, Stone GW, Weissman NJ (May 2010). "Long-term impact of routinely detected early and late incomplete stent apposition: an integrated intravascular ultrasound analysis of the TAXUS IV, V, and VI and TAXUS ATLAS workhorse, long lesion, and direct stent studies". JACC Cardiovasc Interv. 3 (5): 486–94. doi:10.1016/j.jcin.2010.03.007. PMID 20488404.
  42. ↑ Im E, Kim BK, Ko YG, Shin DH, Kim JS, Choi D, Jang Y, Hong MK (February 2014). "Incidences, predictors, and clinical outcomes of acute and late stent malapposition detected by optical coherence tomography after drug-eluting stent implantation". Circ Cardiovasc Interv. 7 (1): 88–96. doi:10.1161/CIRCINTERVENTIONS.113.000797. PMID 24425586.
  43. ↑ Räber L, Mintz GS, Koskinas KC, Johnson TW, Holm NR, Onuma Y, Radu MD, Joner M, Yu B, Jia H, Meneveau N, de la Torre Hernandez JM, Escaned J, Hill J, Prati F, Colombo A, di Mario C, Regar E, Capodanno D, Wijns W, Byrne RA, Guagliumi G (September 2018). "Clinical use of intracoronary imaging. Part 1: guidance and optimization of coronary interventions. An expert consensus document of the European Association of Percutaneous Cardiovascular Interventions". Eur Heart J. 39 (35): 3281–3300. doi:10.1093/eurheartj/ehy285. PMID 29790954.
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  46. ↑ Räber L, Mintz GS, Koskinas KC, Johnson TW, Holm NR, Onuma Y, Radu MD, Joner M, Yu B, Jia H, Meneveau N, de la Torre Hernandez JM, Escaned J, Hill J, Prati F, Colombo A, di Mario C, Regar E, Capodanno D, Wijns W, Byrne RA, Guagliumi G (September 2018). "Clinical use of intracoronary imaging. Part 1: guidance and optimization of coronary interventions. An expert consensus document of the European Association of Percutaneous Cardiovascular Interventions". Eur Heart J. 39 (35): 3281–3300. doi:10.1093/eurheartj/ehy285. PMID 29790954.
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  52. ↑ Min HS, Yoo JH, Kang SJ, Lee JG, Cho H, Lee PH, Ahn JM, Park DW, Lee SW, Kim YH, Lee CW, Park SW, Park SJ (August 2020). "Detection of optical coherence tomography-defined thin-cap fibroatheroma in the coronary artery using deep learning". EuroIntervention. 16 (5): 404–412. doi:10.4244/EIJ-D-19-00487. PMID 31718998.
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  54. ↑ Koskinas KC, Nakamura M, Räber L, Colleran R, Kadota K, Capodanno D, Wijns W, Akasaka T, Valgimigli M, Guagliumi G, Windecker S, Byrne RA (April 2018). "Current Use of Intracoronary Imaging in Interventional Practice　- Results of a European Association of Percutaneous Cardiovascular Interventions (EAPCI) and Japanese Association of Cardiovascular Interventions and Therapeutics (CVIT) Clinical Practice Survey". Circ J. 82 (5): 1360–1368. doi:10.1253/circj.CJ-17-1144. PMID 29540631.
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  57. ↑ Prati F, Di Vito L, Biondi-Zoccai G, Occhipinti M, La Manna A, Tamburino C, Burzotta F, Trani C, Porto I, Ramazzotti V, Imola F, Manzoli A, Materia L, Cremonesi A, Albertucci M (November 2012). "Angiography alone versus angiography plus optical coherence tomography to guide decision-making during percutaneous coronary intervention: the Centro per la Lotta contro l'Infarto-Optimisation of Percutaneous Coronary Intervention (CLI-OPCI) study". EuroIntervention. 8 (7): 823–9. doi:10.4244/EIJV8I7A125. PMID 23034247.
  58. ↑ Kubo T, Shinke T, Okamura T, Hibi K, Nakazawa G, Morino Y, Shite J, Fusazaki T, Otake H, Kozuma K, Ioji T, Kaneda H, Serikawa T, Kataoka T, Okada H, Akasaka T (November 2017). "Optical frequency domain imaging vs. intravascular ultrasound in percutaneous coronary intervention (OPINION trial): one-year angiographic and clinical results". Eur Heart J. 38 (42): 3139–3147. doi:10.1093/eurheartj/ehx351. PMC 5837511. PMID 29121226.
  59. ↑ Ali ZA, Maehara A, Généreux P, Shlofmitz RA, Fabbiocchi F, Nazif TM, Guagliumi G, Meraj PM, Alfonso F, Samady H, Akasaka T, Carlson EB, Leesar MA, Matsumura M, Ozan MO, Mintz GS, Ben-Yehuda O, Stone GW (November 2016). "Optical coherence tomography compared with intravascular ultrasound and with angiography to guide coronary stent implantation (ILUMIEN III: OPTIMIZE PCI): a randomised controlled trial". Lancet. 388 (10060): 2618–2628. doi:10.1016/S0140-6736(16)31922-5. PMID 27806900.
  60. ↑ Kang DY, Ahn JM, Yun SC, Hur SH, Cho YK, Lee CH, Hong SJ, Lim S, Kim SW, Won H, Oh JH, Choe JC, Hong YJ, Yoon YH, Kim H, Choi Y, Lee J, Yoon YW, Kim SJ, Bae JH, Park DW, Park SJ (October 2023). "Optical Coherence Tomography-Guided or Intravascular Ultrasound-Guided Percutaneous Coronary Intervention: The OCTIVUS Randomized Clinical Trial". Circulation. 148 (16): 1195–1206. doi:10.1161/CIRCULATIONAHA.123.066429. PMID 37634092 Check |pmid= value (help).
  61. ↑ Ali ZA, Landmesser U, Maehara A, Matsumura M, Shlofmitz RA, Guagliumi G, Price MJ, Hill JM, Akasaka T, Prati F, Bezerra HG, Wijns W, Leistner D, Canova P, Alfonso F, Fabbiocchi F, Dogan O, McGreevy RJ, McNutt RW, Nie H, Buccola J, West NE, Stone GW (October 2023). "Optical Coherence Tomography-Guided versus Angiography-Guided PCI". N Engl J Med. 389 (16): 1466–1476. doi:10.1056/NEJMoa2305861. PMID 37634188 Check |pmid= value (help).
  62. ↑ Holm NR, Andreasen LN, Neghabat O, Laanmets P, Kumsars I, Bennett J, Olsen NT, Odenstedt J, Hoffmann P, Dens J, Chowdhary S, O'Kane P, Bülow Rasmussen SH, Heigert M, Havndrup O, Van Kuijk JP, Biscaglia S, Mogensen LJ, Henareh L, Burzotta F, H Eek C, Mylotte D, Llinas MS, Koltowski L, Knaapen P, Calic S, Witt N, Santos-Pardo I, Watkins S, Lønborg J, Kristensen AT, Jensen LO, Calais F, Cockburn J, McNeice A, Kajander OA, Heestermans T, Kische S, Eftekhari A, Spratt JC, Christiansen EH (October 2023). "OCT or Angiography Guidance for PCI in Complex Bifurcation Lesions". N Engl J Med. 389 (16): 1477–1487. doi:10.1056/NEJMoa2307770. PMID 37634149 Check |pmid= value (help).
  63. ↑ Lee JM, Choi KH, Song YB, Lee JY, Lee SJ, Lee SY, Kim SM, Yun KH, Cho JY, Kim CJ, Ahn HS, Nam CW, Yoon HJ, Park YH, Lee WS, Jeong JO, Song PS, Doh JH, Jo SH, Yoon CH, Kang MG, Koh JS, Lee KY, Lim YH, Cho YH, Cho JM, Jang WJ, Chun KJ, Hong D, Park TK, Yang JH, Choi SH, Gwon HC, Hahn JY (May 2023). "Intravascular Imaging-Guided or Angiography-Guided Complex PCI". N Engl J Med. 388 (18): 1668–1679. doi:10.1056/NEJMoa2216607. PMID 36876735 Check |pmid= value (help).
  64. ↑ Batty JA, Subba S, Luke P, Gigi LW, Sinclair H, Kunadian V (March 2016). "Intracoronary Imaging in the Detection of Vulnerable Plaques". Curr Cardiol Rep. 18 (3): 28. doi:10.1007/s11886-016-0705-1. PMC 4754333. PMID 26879196.
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