Optical coherence tomography may be a good option for guiding PCI

medwireNews: Optical coherence tomography (OCT) appears to be superior to angiography and noninferior to intravascular ultrasound (IVUS) for guiding percutaneous coronary intervention (PCI), with potential for improved clinical outcomes, indicate findings from three trials presented at the ESC Congress 2023 in Amsterdam, the Netherlands. ILUMIEN IV: OPTIMAL PCI trial In the first trial – ILUMIEN IV: OPTIMAL PCI – use of OCT guidance was associated with a minimum stent area that was a significant 0.36 mm2 bigger, on average, than that achieved with angiography, at 5.72 mm2 and 5.36 mm2, respectively. “In previous trials in intravascular ultrasonography–guided PCI has resulted in longer event-free survival,” note Gregg Stone (Mount Sinai Hospital, New York, USA) and fellow investigators in a simultaneous publication in The New England Journal of Medicine. However, the proportion of patients with target-vessel failure at 2 years, defined as a composite of death from cardiac causes, target-vessel myocardial infarction, or ischemia-driven target-vessel revascularization, did not differ between the two groups. It occurred in 88 of 1233 patients in the OCT group and 99 of 1254 in the angiography group, at Kaplan–Meier estimates of 7.4% and 8.2% respectively. The trial was conducted in 18 countries and involved 2487 patients at high risk for coronary artery lesions, due to having medication-treated diabetes (40.1%) or complex coronary artery lesions (67.6%). The patients were aged a mean of 65 years and just over 75% were men. The researchers explain that, in the current trial, “OCT-guided PCI results in greater use of advanced lesion-preparation techniques and the use of larger and longer stents implanted at higher pressures than angiography-guided PCI.” It also results in “a lower frequency of severe dissection, major stent malapposition, major tissue protrusion, and untreated focal reference segment disease, findings that have also previously been associated with freedom from adverse events,” they add. In terms of safety, procedure-related stent thrombosis and thrombotic events within 2 years were less frequent with OCT than angiography guidance (0.0 vs 0.1% and 2.3 vs 4.1%, respectively). OCTOBER trial The second trial, also published in The New England Journal of Medicine, compared OCT- and angiography-guided PCI for complex bifurcation lesions and in this case OCT-guided PCI was associated with a significant 29% lower incidence of major adverse cardiac events (MACE) at a median of 2 years. MACE, defined as a composite of death from a cardiac cause, target-lesion myocardial infarction, or ischemia-driven target lesion revascularization, occurred in 10.1% of 600 patients randomly assigned to OCT-guided PCI and in 14.1% of 601 assigned to angiography-guided PCI. “Our findings confirm those of mechanistic studies that showed OCT could be of particular value in optimizing procedural results in PCI,” say Niels Holm (Aarhus University Hospital, Denmark) and fellow OCTOBER investigators. The participants were aged a mean of 66 years and around 79% were men. PCI was indicated for the patients because of non–ST-segment elevation acute myocardial infarction of secondary lesions needing revascularization after a recent acute myocardial infarction. The researchers note that a similar proportion of patients undergoing OCT- and angiography-guided PCI had bifurcation lesions involving the left main coronary artery, at a respective 18.5% and 19.3%. “The incidence of procedure-related complication was low,” the team reports, “and there was no notable difference between the two groups,” at 6.8% in the OCT group and 5.7% in the angiography group. OCTIVUS trial In the third open-label, pragmatic trial, published concurrently in Circulation, the focus turned from comparisons of OCT- with angiography-guided PCI to IVUS-guided PCI in 2008 patients with significant coronary artery lesions. Duk-Woo Park (University of Ulsan College of Medicine, Seoul, Korea) and the OCTIVUS investigators found that OCT-guided PCI performed in 1005 patients was noninferior to IVUS-guided PCI in 1003 individuals, regarding a composite primary endpoint of death from cardiac causes, target-vessel-related myocardial infarction, or ischemia-driven target-vessel revascularization at 1 year. Events occurred in a respective 25 and 31 patients, with Kaplan–Meier estimates of 2.5% and 3.1% and an absolute reduction with OCT guidance of 0.60 percentage points, which was within the upper confidence interval for noninferiority of 0.97 percentage points. The participants were a mean age of 64.7 years and 79% were men. In all, 33.4% had diabetes, 76.6% had stable ischemic heart disease, and 23.4% presented with acute coronary syndrome. The types of coronary artery lesions were diverse, with multivessel disease in 61.6%, left main disease in 13.1%, bifurcation disease in 52.6%, and diffuse long disease in 58.2%. There was a similar incidence of contrast-induced nephropathy in the OCT and IVUS groups (1.4 vs 1.5%), despite more contrast dye being used in the OCT group, the team reports. The incidence of major procedural complications was lower with OCT than IVUS (2.2 vs 3.7%), and there were no imaging procedure-related complications in either group. “Both OCT and IVUS can be utilized safely and effectively in the vast majority of procedures, demonstrating comparable acute and long-term outcomes,” say Park et al. They call for further research “to provide better identification of which patients or lesions can mostly merit imaging-guided PCI, given that the best strategy may be no imaging-guidance necessary in low-risk populations with low event rates.” medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2023 Springer Healthcare Ltd, part of the Springer Nature Group ESC Congress 2023; Amsterdam, the Netherlands: 25–28 August N Engl J Med 2023; doi:10.1056/NEJMoa2305861 N Engl J Med 2023; doi:10.1056/NEJMoa2307770 Circulation 2023; doi:10.1161/CIRCULATIONAHA.123.066429

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Optical coherence tomography may be a good option for guiding PCI

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