Optical coherence tomography aids stent placement in complex coronary artery lesions

medwireNews: Optical coherence tomography (OCT) is an effective way to guide the placement of drug-eluting stents (DES) during percutaneous coronary intervention (PCI) when there are anatomically complex coronary artery lesions, according to data presented at the ESC Congress 2024 in London, UK. In the OCCUPI study, the primary endpoint of a major adverse cardiovascular event (MACE) – a composite of cardiac death, myocardial infarction (MI), stent thrombosis, or ischemia-driven target vessel revascularization (TVR) – at 1 year occurred significantly less frequently in patients who underwent OCT- rather than angiography-guided PCI, at 4.6% versus 7.6%. The study findings, which were simultaneously published in The Lancet, “support the therapeutic benefit of OCT as an effective intravascular imaging modality in treating complex lesions,” said principal investigator Byeong-Keuk Kim (Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea). Kim explained that complex coronary lesions were defined as those where there was chronic total occlusion, a long section of artery involved meaning that the expected stent length would need to be at least 28 mm, calcification, bifurcation, unprotected left main artery disease, small vessel disease (diameter <2.5 mm), restenosis of an existing stent, a lesion in a bypass graft, acute MI, intracoronary thrombus, or definite stent thrombosis. OCCUPI was conducted in 20 centers in South Korea. Just over 1600 patients aged between 19 and 85 years were recruited and 803 were randomly allocated to undergo OCT-guided DES placement and 801 to angiography-guided DES placement. The mean age of the included patients was 64 years, most (80.4%) were men, and around half (49.0%) had presented with an acute coronary syndrome. “The main reduction [in MACE] in the OCT-guided group was driven by lowering the occurrences of spontaneous MI and TVR, without raising concerns related to contrast-induced nephropathy,” reported Kim. Specifically, the rate of spontaneous MI was 0.9% with OCT-guided PCI versus 2.4% with angiography-guided PCI and the rate of TVR was 1.5% versus 4.1%, both significant differences. By contrast, there was no significant difference between the two techniques in the rate of contrast-induced nephropathy, at 1.3% versus 0.9%. Looking more closely at the group of patients who underwent OCT-guided PCI, the OCCUPI investigators assessed whether the DES had been placed optimally, and what effect this might have had on patient outcomes. They defined stent optimization as meeting three criteria: acceptable stent expansion, defined as a minimal stent area at least 80% of the mean reference lumen, at least 100% of the distal reference lumen, or more than 4.5 mm2 in a non-left main coronary lesion; acceptable edge dissection, defined as a circumference dissection of less than 60˚, a length dissected less than 3 mm, and no deep vessel injury; and acceptable stent apposition, defined as a maximal distance of up to 400 µm between the strut and the vessel wall. The results showed that patients in the OCI-guided PCI group who met the prespecified criteria for stent optimization had a significantly lower rate of MACE than those who had suboptimal stent placement, at 2.9% versus 8.6%. The study is not without limitations, Kim acknowledged. There was a relatively short follow-up period, total blinding of patients’ information was not feasible, and blinded OCT assessments were not performed in the angiography group. “Due to operators’ familiarity or ability to interpret the OCT images, the benefit of OCT-guidance may be affected,” Kim said. He added: “The lower than anticipated event rate of the primary endpoint led to a lower-than-expected power,” and the “comparisons of the occurrence of each component of the primary endpoint or hard endpoint such as death or MI could be underpowered.” Ulf Landmesser (Deutsches Herzzentrum Charité, Berlin, Germany) who was the invited discussant for the trial said that the results of OCCUPI were “very important.” Previously, the available evidence for image-guided PCI for DES in patients with complex coronary lesions was from trials that had mainly used intravascular ultrasound (IVUS), Landmesser observed. OCCUPI now shows that there is also evidence for using OCT. “The new [2024] ESC guidelines [for the management of chronic coronary syndromes] give a class I-A recommendation for using either IVUS or OCT for imaging guidance in patients with complex lesions,” Landmesser said. “I'm very happy that the OCCUPI trial strongly supports this conclusion.” medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2024 Springer Healthcare Ltd, part of the Springer Nature Group ESC Congress 2024; London, UK: 30 August–2 September Lancet 2004; doi:10.1016/S0140-6736(24)01454-5

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Optical coherence tomography aids stent placement in complex coronary artery lesions

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