Coronary optical coherence tomography: A practical overview of current clinical applications | Revista Portuguesa de Cardiologia (English edition)

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In addition to research purposes, we recognize the invaluable potential of OCT as a diagnostic technique and as an adjunctive tool for percutaneous coronary intervention (PCI).<a class="elsevierStyleCrossRefs" href="#bib0330">2,3</a>Data relevant to this topic have recently been published and we review the evidence on current clinical applications of OCT from a practical perspective. The potential use of OCT in the successive stages in coronary artery disease management is discussed, including morphologic lesion characterization and quantification of stenosis, guidance for the decision to perform percutaneous coronary intervention and subsequent planning, and evaluation of immediate and long-term results following PCI.Morphologic lesion characterizationAnimal and human post-mortem studies have shown the ability of OCT to accurately characterize coronary atherosclerotic plaques.<a class="elsevierStyleCrossRefs" href="#bib0330">2,5</a> Due to its high spatial resolution, OCT has proved superior to other imaging modalities, including IVUS, for detecting different plaque components.<a class="elsevierStyleCrossRefs" href="#bib0330">2,5,6</a> A landmark post-mortem study showed a high sensitivity and specificity for detecting fibrous, fibrocalcific and lipid-rich plaques in histological specimens.<a class="elsevierStyleCrossRef" href="#bib0345">5</a> OCT is currently the only method with sufficient resolution to accurately measure the fibrous cap.<a class="elsevierStyleCrossRef" href="#bib0355">7</a> Historically, thin-cap fibroatheromas (TCFAs) are the substrate of approximately two-thirds of acute myocardial infarctions as presented in pathology series.<a class="elsevierStyleCrossRef" href="#bib0360">8</a> Recently, this has been validated in vivo in the OCTAVIA study.<a class="elsevierStyleCrossRef" href="#bib0365">9</a>Furthermore, macrophage infiltration, which is a marker of plaque instability, may be identified using OCT.<a class="elsevierStyleCrossRef" href="#bib0370">10</a> In acute coronary syndrome (ACS) OCT is useful for identification of plaque dissection, ulceration, and erosion, calcified nodules and thrombus<a class="elsevierStyleCrossRef" href="#bib0355">7</a> (<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>). In addition, OCT can differentiate between red and white thrombi.<a class="elsevierStyleCrossRef" href="#bib0375">11</a> A complete description of the appearance of atherosclerotic and thrombotic components on OCT is beyond the scope of this review and is reported elsewhere.<a class="elsevierStyleCrossRef" href="#bib0380">12</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>OCT is particularly valuable in providing insights into the pathophysiological mechanisms of ACS and may help with the development of individualized therapeutic strategies.<a class="elsevierStyleCrossRef" href="#bib0385">13</a> TCFA, plaque rupture and red thrombus have been detected in most patients with ST-elevation myocardial infarction and are more frequent in comparison to non-ST elevation ACS.<a class="elsevierStyleCrossRefs" href="#bib0390">14,15</a> However, not all ACS lesions showed plaque rupture and the presence of intact fibrous cap was associated with better prognosis.<a class="elsevierStyleCrossRefs" href="#bib0400">16,17</a> Moreover, plaque rupture, intracoronary thrombi, lipid-rich plaques and TCFAs were more frequent in culprit compared to nonculprit lesions.<a class="elsevierStyleCrossRef" href="#bib0410">18</a>There are, however, some pitfalls in plaque characterization, mainly related to the low penetration depth. Penetration is lowest for thrombotic material, which may lead to signal-free shadowing, and non-protruding red thrombi may be misinterpreted as necrotic lipid pools due to a similar OCT signal pattern.<a class="elsevierStyleCrossRef" href="#bib0380">12</a> Furthermore, in the majority of lesions an accurate measurement of lipid pool thickness cannot be performed.<a class="elsevierStyleCrossRef" href="#bib0380">12</a>Stable coronary syndrome: predicting physiology and assessing stenosis severityOCT may be used to assess lesions of intermediate stenosis severity in vessels without a large size.<a class="elsevierStyleCrossRef" href="#bib0340">4</a> The proposed thresholds of minimal luminal area (MLA) and minimal luminal diameter (MLD) for detecting a hemodynamically significant lesion are based on recent validations against fractional flow reserve (FFR), which is considered the gold standard for assessing hemodynamic significance.<a class="elsevierStyleCrossRefs" href="#bib0415">19–22</a> In most studies, FFR ≤0.80 was taken as the threshold and the derived cut-offs of MLA and MLD ranged from 1.59 mm2 to 2.54 mm2 and from 1.23 mm to 1.77 mm, respectively.<a class="elsevierStyleCrossRefs" href="#bib0420">20–22</a> Taking FFR <0.75 as the threshold, an MLA <1.91 mm2 and an MLD <1.35 mm have been identified as the best cut-off values.<a class="elsevierStyleCrossRef" href="#bib0435">23</a> A recent consensus report suggests a MLA threshold of 1.95 mm2, which has moderate sensitivity and negative predictive value for hemodynamic significance.<a class="elsevierStyleCrossRefs" href="#bib0340">4,24</a> In small vessels lower thresholds should probably be used.<a class="elsevierStyleCrossRef" href="#bib0440">24</a> In most studies, however, the correlation between FFR- and OCT-derived measurements was only moderate.<a class="elsevierStyleCrossRefs" href="#bib0420">20,21,23</a> Despite potentially higher precision in determining MLA, this simple cross-section value cannot predict physiology accurately, as shown in a recent meta-analysis.<a class="elsevierStyleCrossRef" href="#bib0445">25</a> The ability of OCT to automatically segment the lumen through the entire pullback enables volumetric analysis of the vessel for the first time. Applying the physical principles of fluid dynamics, a better correlation with FFR was obtained by deriving virtual flow reserve.<a class="elsevierStyleCrossRef" href="#bib0450">26</a>Importantly, MLA values obtained with OCT are consistently lower than with IVUS. It has been speculated that the absence of non-uniform rotation distortion on OCT allows for a more precise contour of the lumen.<a class="elsevierStyleCrossRef" href="#bib0455">27</a>Percutaneous coronary intervention guided by optical coherence tomographyAdjunctive tool in decision-making for percutaneous coronary interventionFew data are available on the clinical impact of using OCT for guiding the decision to perform PCI, but the results are encouraging. In a single-center study, 90 patients with ambiguous or intermediate lesions underwent PCI if MLA was <3.5 mm2 or in the presence of thrombus.<a class="elsevierStyleCrossRef" href="#bib0460">28</a> Post-dilatation or additional stent implantation was performed in cases of stent underexpansion, incomplete stent apposition (ISA), significant intraluminal tissue prolapse, or edge dissection extending beyond 200 μm.<a class="elsevierStyleCrossRef" href="#bib0460">28</a> In addition to high procedural success, good clinical outcomes were reported at 4.6±3.2 months of follow-up, with 2.2% repeat revascularization and no stent thrombosis.<a class="elsevierStyleCrossRef" href="#bib0460">28</a> An ongoing randomized trial (FORZA) is evaluating the feasibility of PCI guided by OCT in angiographically intermediate lesions with stenosis area ≥75% assessed by OCT, or 50–75% with MLA <2.5 mm2, or if a major plaque ulceration is detected.<a class="elsevierStyleCrossRef" href="#bib0465">29</a>Recently, OCT has been used to guide treatment in ACS in a different way. The unique ability of the method to detect thrombus and plaque rupture adds an unprecedented level of confidence in determining the underlying mechanism of plaque instability.<a class="elsevierStyleCrossRef" href="#bib0355">7</a> In a small study of 100 patients treated with thrombus aspiration followed by OCT, no stent was implanted if the occlusion was mostly thrombotic and no significant coronary narrowing was detected by OCT, provided that the patient was symptom-free and TIMI flow was ≥2 (20 patients).<a class="elsevierStyleCrossRef" href="#bib0470">30</a> Follow-up OCT studies showed a “normal vessel” and there were no adverse events at 12-month follow-up. The safety and feasibility of medical management without stent placement in selected ACS patients with large thrombus burden detected by OCT has also been reported in other studies, in which OCT revealed lesion characteristics that were not disclosed by angiography and facilitated treatment decisions.<a class="elsevierStyleCrossRefs" href="#bib0475">31,32</a>Adjunctive tool for planning percutaneous coronary interventionSimilarly to IVUS, OCT may be used to help plan the intervention and, when used systematically, it has been reported to alter procedural strategy in over 80% of cases.<a class="elsevierStyleCrossRef" href="#bib0485">33</a> OCT can provide highly reproducible measurements of lesion length and reference vessel lumen diameter, which may guide stent selection.<a class="elsevierStyleCrossRef" href="#bib0340">4</a> Information on plaque components such as calcification may suggest the use of ancillary devices such as rotational atherectomy.<a class="elsevierStyleCrossRef" href="#bib0335">3</a> OCT is the only method that can accurately image calcium thickness, and a combination of high thickness and circumferential distribution may identify non-dilatable lesions.<a class="elsevierStyleCrossRef" href="#bib0335">3</a> Moreover, a lower calcium angle depicted by OCT correlates with asymmetric (eccentric) stent expansion and a higher calcium angle correlates with stent underexpansion.<a class="elsevierStyleCrossRef" href="#bib0490">34</a> OCT may also be useful during complex procedures such as PCI of chronic total occlusions, where it may identify subintimal wire entrapment or double channels.<a class="elsevierStyleCrossRef" href="#bib0340">4</a>Another potential use of OCT regarding PCI planning is risk stratification. Previous OCT studies have linked lesion morphology with periprocedural microvascular damage or myocardial infarction. In non-ST-elevation ACS, the presence of TCFA and the size of the lipid arc at the culprit plaque were predictors of no-reflow.<a class="elsevierStyleCrossRef" href="#bib0495">35</a> The presence of TCFA was also associated with elevation of post-PCI myocardial necrosis markers, particularly if colocalized with spotty calcification.<a class="elsevierStyleCrossRef" href="#bib0500">36</a> In addition, in-stent thrombus or dissection detected by OCT after PCI also predicted periprocedural myocardial infarction.<a class="elsevierStyleCrossRef" href="#bib0505">37</a> Although these OCT findings could aid risk stratification before or during PCI, larger studies are needed to confirm the role of this clinical application.Adjunctive tool for post-stenting assessmentOne of the main contributions of OCT is in assessing stent expansion, sizing and apposition (defined elsewhere<a class="elsevierStyleCrossRefs" href="#bib0335">3,38</a>) more accurately and with lower interobserver variability than angiography or IVUS. Stent underexpansion and undersizing have been linked to stent restenosis and stent thrombosis.<a class="elsevierStyleCrossRef" href="#bib0515">39</a> The minimum stent area and lumen area of the reference vessel can be measured using OCT, enabling accurate estimation of stent expansion.<a class="elsevierStyleCrossRef" href="#bib0335">3</a> ISA (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>) delays neointimal coverage of the struts and is associated with stent thrombosis, although neointimal hyperplasia usually tends to reduce ISA over time.<a class="elsevierStyleCrossRefs" href="#bib0335">3,40</a> OCT can measure the distance between the struts and the vessel wall and quantify the number of struts with incomplete apposition.<a class="elsevierStyleCrossRefs" href="#bib0525">41,42</a> Stent apposition is thus assessed at the strut level.<a class="elsevierStyleCrossRef" href="#bib0530">42</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>Regarding vascular injury after PCI, intimal dissection at the stent edges, small thrombi and tissue prolapse commonly occur following stent deployment (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>).<a class="elsevierStyleCrossRef" href="#bib0535">43</a> OCT is much more sensitive than IVUS for detecting these vascular responses.<a class="elsevierStyleCrossRef" href="#bib0535">43</a> Nevertheless, their prognostic impact is controversial, as discussed below.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>OCT may thus be useful after stent deployment, as it may prompt optimization with further stenting or high-pressure or larger-sized balloon inflation, with low procedural complication rates.<a class="elsevierStyleCrossRefs" href="#bib0540">44,45</a> Angiographic guidance for PCI in 335 patients was compared with angiographic plus OCT guidance in 335 patients in a propensity-score adjusted analysis (the CLI-OPCI study).<a class="elsevierStyleCrossRef" href="#bib0545">45</a> OCT disclosed adverse features, including stent malapposition, stent underexpansion, lumen narrowing, thrombus, or edge dissection, requiring further stenting or additional balloon dilatation in 34.7% of patients. The OCT-guided approach resulted in lower adjusted risk of cardiac death or nonfatal myocardial infarction at 12 months of follow-up (OR 0.49, 95% confidence interval 0.25–0.96).<a class="elsevierStyleCrossRef" href="#bib0545">45</a> In another study, even after achieving an optimal angiographic result following stenting, removal of in-stent thrombus detected by OCT using balloon dilatation was shown to be a safe approach.<a class="elsevierStyleCrossRef" href="#bib0550">46</a> Of note, left main intervention can be performed with OCT guidance, and in a head-to-head comparison against IVUS, OCT identified more findings that prompted additional interventions.<a class="elsevierStyleCrossRef" href="#bib0555">47</a> The DOCTORS trial is currently evaluating the utility of OCT for optimizing the results of coronary angioplasty in non-ST-segment elevation ACS, beyond angiography alone.<a class="elsevierStyleCrossRef" href="#bib0560">48</a>Nevertheless, following stent deployment, minor stent malapposition with a short distance between the struts and the vessel wall, small thrombus, mild tissue prolapse, or minor stent edge dissection do not seem to be associated with worse prognosis.<a class="elsevierStyleCrossRef" href="#bib0565">49</a> Improvement is expected during follow-up when these small non-flow limiting abnormalities are left untreated, without adverse impact on clinical outcome.<a class="elsevierStyleCrossRef" href="#bib0565">49</a> Conversely, a dissection flap thickness >0.31 mm carries an adverse clinical impact in the long term.<a class="elsevierStyleCrossRef" href="#bib0570">50</a> Regarding malapposition, some operators recommend no additional post-dilatation unless there is >200 μm distance between the stent and wall vessel at multiple strut locations.<a class="elsevierStyleCrossRef" href="#bib0340">4</a>Follow-up evaluationStent coverageOCT has been used extensively to assess neointimal hyperplasia and strut coverage with different types of stents, placed using different stenting techniques, with or without adjunctive techniques. Different quantitative measurements may be obtained.<a class="elsevierStyleCrossRefs" href="#bib0335">3,51–55</a> Accuracy is greater than with IVUS; not only the completeness of individual strut coverage but also the thickness of coverage can be assessed.<a class="elsevierStyleCrossRefs" href="#bib0335">3,51</a> OCT studies have shown that a greater percentage of uncovered struts is associated with increased risk of major adverse events after drug-eluting stent (DES) implantation, a cut-off of ≥5.9% of uncovered struts on follow-up OCT having been reported.<a class="elsevierStyleCrossRef" href="#bib0600">56</a>Stent restenosisQuantitative measurements such as percentage lumen obstruction can be obtained by OCT.<a class="elsevierStyleCrossRef" href="#bib0335">3</a> In addition, different tissue patterns of in-stent restenosis (ISR) have been described, including layered, homogeneous and heterogeneous patterns.<a class="elsevierStyleCrossRef" href="#bib0605">57</a> A heterogeneous pattern is more frequent in focal than in diffuse ISR and has been associated with the presence of fibrinoid or proteoglycans.<a class="elsevierStyleCrossRef" href="#bib0605">57</a> In bare-metal stents, early ISR is usually homogeneous due to neointimal proliferation, which is rich in smooth muscle cells, while late ISR may have a heterogeneous appearance due to lipid pools, calcification and neovascularization, suggesting that neoatherosclerosis is the underlying mechanism.<a class="elsevierStyleCrossRef" href="#bib0610">58</a> ISR of DES is typically characterized by a layered or heterogeneous intrastent tissue band and may be part of the spectrum of in-stent neoatherosclerotic changes, such as TCFA-containing neointima, particularly if the stent had been placed for at least 20 months.<a class="elsevierStyleCrossRef" href="#bib0610">58</a>In a recent study on ISR, morphological assessment using OCT was useful for identifying lesions favorable for paclitaxel-coated balloon dilatation or DES placement.<a class="elsevierStyleCrossRef" href="#bib0615">59</a> Of the 428 treated ISR lesions, a homogenous structure was associated with higher rates of repeated ISR and target lesion revascularization using plain balloon angioplasty alone compared with paclitaxel-coated balloon dilatation or DES placement (target lesion revascularization rates of 38.7%, 10.6% and 10.7%, respectively, in a follow-up of 211±40 days); conversely, no differences were found between the three treatment approaches in ISR lesions of heterogeneous appearance.<a class="elsevierStyleCrossRef" href="#bib0615">59</a>Stent thrombosisThe mechanisms for stent thrombosis may be readily elucidated by OCT, as mentioned above. Strut malapposition or underexpansion, incomplete strut coverage, stent fracture, incomplete lesion coverage by the stent, edge dissection, in-stent neoatherosclerosis and ruptured neointima, particularly in areas of lipid-laden neointima, may be detected by OCT.<a class="elsevierStyleCrossRefs" href="#bib0340">4,60,61</a>Future directionsAs a clinical tool, OCT is currently potentially able to replace IVUS in every situation with the exception of diagnosis of lesions in the ostial left main or right coronary arteries, in which the flow in the aorta prevents adequate blood clearance.<a class="elsevierStyleCrossRefs" href="#bib0330">2–4</a> However, most of these patients should be assessed with FFR.<a class="elsevierStyleCrossRefs" href="#bib0330">2–4</a> Another exception is chronic total occlusions in which antegrade injections are of potential concern.<a class="elsevierStyleCrossRefs" href="#bib0330">2–4</a>The method continues to evolve, with pullback speeds now reaching 40 mm/s<a class="elsevierStyleCrossRef" href="#bib0630">62</a> and the potential for a paradigm shift, with opportunities to save contrast compared to conventional angiography. The introduction of angiographic frame co-registration enables precise spatial location for stent implantation.<a class="elsevierStyleCrossRef" href="#bib0635">63</a>OCT can replicate IVUS metrics that are essentially cross-sectionally derived, but most importantly allows for full volumetric analysis of the vessel.<a class="elsevierStyleCrossRef" href="#bib0455">27</a> Virtual fractional flow reserve derived from OCT is a potentially disruptive technology in predicting physiology and assessing results after stenting.<a class="elsevierStyleCrossRef" href="#bib0455">27</a>Finally, OCT is the most accurate method for follow-up assessment after placement of bioresorbable stents, considering their low opacity at fluoroscopy and the lower accuracy of IVUS.<a class="elsevierStyleCrossRef" href="#bib0640">64</a>ConclusionThe current clinical applications of OCT encompass the successive stages in coronary artery disease management, from initial lesion evaluation to assessment of the final results of PCI, including accurate lesion characterization and quantification of stenosis, guidance for the decision to perform PCI and subsequent planning, and evaluation of immediate and long-term results following PCI.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres818313" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec815346" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres818314" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec815347" "titulo" => "Palavras-chave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Introduction" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Morphologic lesion characterization" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Stable coronary syndrome: predicting physiology and assessing stenosis severity" ] ] ] 5 => array:3 [ "identificador" => "sec0020" "titulo" => "Percutaneous coronary intervention guided by optical coherence tomography" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Adjunctive tool in decision-making for percutaneous coronary intervention" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Adjunctive tool for planning percutaneous coronary intervention" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Adjunctive tool for post-stenting assessment" ] ] ] 6 => array:3 [ "identificador" => "sec0040" "titulo" => "Follow-up evaluation" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Stent coverage" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Stent restenosis" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Stent thrombosis" ] ] ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Future directions" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-06-22" "fechaAceptado" => "2015-09-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec815346" "palabras" => array:4 [ 0 => "Clinical application" 1 => "Coronary artery disease" 2 => "Percutaneous coronary intervention" 3 => "Optical coherence tomography" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec815347" "palabras" => array:4 [ 0 => "Aplicação clínica" 1 => "Doença coronária" 2 => "Intervenção coronária percutânea" 3 => "Tomografia de coerência ótica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Coronary optical coherence tomography has emerged as the most powerful in-vivo imaging modality to evaluate vessel structure in detail. It is a useful research tool that provides insights into the pathogenesis of coronary artery disease. This technology has an important clinical role that is still being developed. We review the evidence on the wide spectrum of potential clinical applications for coronary optical coherence tomography, which encompass the successive stages in coronary artery disease management: accurate lesion characterization and quantification of stenosis, guidance for the decision to perform percutaneous coronary intervention and subsequent planning, and evaluation of immediate and long-term results following intervention." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "A tomografia de coerência ótica coronária surgiu como a modalidade de imagem in-vivo que permite a avaliação estrutural vascular mais detalhada. Trata-se de uma ferramenta valiosa em investigação, tendo contribuído para melhor entendimento da patogénese da doença coronária. Apresenta igualmente um papel importante na prática clínica, e o leque de sua aplicabilidade tem aumentado. Enquadrando na evidência disponível, discutimos neste artigo as principais aplicações da tomografia de coerência ótica coronária na prática clínica, que englobam as diferentes etapas na abordagem da doença coronária, incluindo a caracterização da lesão e quantificação da estenose, o papel na decisão de realizar angioplastia, o contributo na planificação da mesma e a avaliação dos resultados a curto e a longo prazo após a intervenção." ] ] "nomenclatura" => array:1 [ 0 => array:3 [ "identificador" => "nom0005" "titulo" => "List of abbreviations" "listaDefinicion" => array:1 [ 0 => array:1 [ "definicion" => array:11 [ 0 => array:2 [ "termino" => "ACS" "descripcion" => "acute coronary syndrome" ] 1 => array:2 [ "termino" => "DES" "descripcion" => "drug-eluting stent" ] 2 => array:2 [ "termino" => "FFR" "descripcion" => "fractional flow reserve" ] 3 => array:2 [ "termino" => "ISA" "descripcion" => "incomplete stent apposition" ] 4 => array:2 [ "termino" => "ISR" "descripcion" => "in-stent restenosis" ] 5 => array:2 [ "termino" => "IVUS" "descripcion" => "intravascular ultrasound" ] 6 => array:2 [ "termino" => "MLA" "descripcion" => "minimal luminal area" ] 7 => array:2 [ "termino" => "MLD" "descripcion" => "minimal luminal diameter" ] 8 => array:2 [ "termino" => "OCT" "descripcion" => "optical coherence tomography" ] 9 => array:2 [ "termino" => "PCI" "descripcion" => "percutaneous coronary intervention" ] 10 => array:2 [ "termino" => "TCFA" "descripcion" => "thin-cap fibroatheroma" ] ] ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1287 "Ancho" => 2834 "Tamanyo" => 426643 ] ] "descripcion" => array:1 [ "en" => "(A) Left main artery lesion: appearance on optical coherence tomography, with ulceration (arrow); (B) thrombus (triangles) and a thin-cap fibroatheroma (asterisk); (C) these findings were undetected by invasive coronary angiography." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1229 "Ancho" => 3169 "Tamanyo" => 571377 ] ] "descripcion" => array:1 [ "en" => "(A–C) Optical coherence tomography showing a large spontaneous ulceration in the circumflex artery." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1765 "Ancho" => 1625 "Tamanyo" => 338679 ] ] "descripcion" => array:1 [ "en" => "Optical coherence tomography revealing stent malapposition with a large distance between struts and vessel wall." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1537 "Ancho" => 2669 "Tamanyo" => 543252 ] ] "descripcion" => array:1 [ "en" => "(A) Edge dissection, and (B) small thrombus following stent placement, detected by optical coherence tomography." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:64 [ 0 => array:3 [ "identificador" => "bib0325" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Quantitative coronary angiography in the current era: principles and applications" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. 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Review article

Coronary optical coherence tomography: A practical overview of current clinical applications

Tomografia de coerência ótica coronária: uma revisão prática das aplicações clínicas atuais

Rui Cruz Ferreiraa, Tiago Pereira-da-Silvaa,

Corresponding author

tiagopsilva@sapo.pt

Corresponding author.

, Lino Patrícioa, Hiram Bezerrab, Marco Costab

a Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisbon, Portugal

b University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA

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the wavelength used in OCT is shorter&#44; enabling higher spatial resolution &#40;10&#8211;20 &#956;m axial resolution and 20&#8211;30 &#956;m lateral resolution&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">2&#44;5&#44;6</span></a> However&#44; except for calcium&#44; penetration depth of OCT is lower than with IVUS&#44; particularly for thrombotic and lipid components&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">2</span></a> Coronary OCT systems have evolved from first-generation time-domain systems to second-generation frequency-domain OCT&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">4</span></a> The latter produces images at higher frame rates with slightly deeper penetration&#44; using a short&#44; non-occlusive flush and rapid spiral pullback&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">2&#44;4</span></a> We had the opportunity to perform the first OCT studies in Portugal&#46; In addition to research purposes&#44; we recognize the invaluable potential of OCT as a diagnostic technique and as an adjunctive tool for percutaneous coronary intervention &#40;PCI&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Data relevant to this topic have recently been published and we review the evidence on current clinical applications of OCT from a practical perspective&#46; The potential use of OCT in the successive stages in coronary artery disease management is discussed&#44; including morphologic lesion characterization and quantification of stenosis&#44; guidance for the decision to perform percutaneous coronary intervention and subsequent planning&#44; and evaluation of immediate and long-term results following PCI&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Morphologic lesion characterization</span><p id="par0070" class="elsevierStylePara elsevierViewall">Animal and human post-mortem studies have shown the ability of OCT to accurately characterize coronary atherosclerotic plaques&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">2&#44;5</span></a> Due to its high spatial resolution&#44; OCT has proved superior to other imaging modalities&#44; including IVUS&#44; for detecting different plaque components&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">2&#44;5&#44;6</span></a> A landmark post-mortem study showed a high sensitivity and specificity for detecting fibrous&#44; fibrocalcific and lipid-rich plaques in histological specimens&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">5</span></a> OCT is currently the only method with sufficient resolution to accurately measure the fibrous cap&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">7</span></a> Historically&#44; thin-cap fibroatheromas &#40;TCFAs&#41; are the substrate of approximately two-thirds of acute myocardial infarctions as presented in pathology series&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">8</span></a> Recently&#44; this has been validated in vivo in the OCTAVIA study&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Furthermore&#44; macrophage infiltration&#44; which is a marker of plaque instability&#44; may be identified using OCT&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">10</span></a> In acute coronary syndrome &#40;ACS&#41; OCT is useful for identification of plaque dissection&#44; ulceration&#44; and erosion&#44; calcified nodules and thrombus<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">7</span></a> &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>&#41;&#46; In addition&#44; OCT can differentiate between red and white thrombi&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">11</span></a> A complete description of the appearance of atherosclerotic and thrombotic components on OCT is beyond the scope of this review and is reported elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">12</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">OCT is particularly valuable in providing insights into the pathophysiological mechanisms of ACS and may help with the development of individualized therapeutic strategies&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">13</span></a> TCFA&#44; plaque rupture and red thrombus have been detected in most patients with ST-elevation myocardial infarction and are more frequent in comparison to non-ST elevation ACS&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">14&#44;15</span></a> However&#44; not all ACS lesions showed plaque rupture and the presence of intact fibrous cap was associated with better prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">16&#44;17</span></a> Moreover&#44; plaque rupture&#44; intracoronary thrombi&#44; lipid-rich plaques and TCFAs were more frequent in culprit compared to nonculprit lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">18</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">There are&#44; however&#44; some pitfalls in plaque characterization&#44; mainly related to the low penetration depth&#46; Penetration is lowest for thrombotic material&#44; which may lead to signal-free shadowing&#44; and non-protruding red thrombi may be misinterpreted as necrotic lipid pools due to a similar OCT signal pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">12</span></a> Furthermore&#44; in the majority of lesions an accurate measurement of lipid pool thickness cannot be performed&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Stable coronary syndrome&#58; predicting physiology and assessing stenosis severity</span><p id="par0090" class="elsevierStylePara elsevierViewall">OCT may be used to assess lesions of intermediate stenosis severity in vessels without a large size&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">4</span></a> The proposed thresholds of minimal luminal area &#40;MLA&#41; and minimal luminal diameter &#40;MLD&#41; for detecting a hemodynamically significant lesion are based on recent validations against fractional flow reserve &#40;FFR&#41;&#44; which is considered the gold standard for assessing hemodynamic significance&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">19&#8211;22</span></a> In most studies&#44; FFR &#8804;0&#46;80 was taken as the threshold and the derived cut-offs of MLA and MLD ranged from 1&#46;59 mm<span class="elsevierStyleSup">2</span> to 2&#46;54 mm<span class="elsevierStyleSup">2</span> and from 1&#46;23 mm to 1&#46;77 mm&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">20&#8211;22</span></a> Taking FFR &#60;0&#46;75 as the threshold&#44; an MLA &#60;1&#46;91 mm<span class="elsevierStyleSup">2</span> and an MLD &#60;1&#46;35 mm have been identified as the best cut-off values&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">23</span></a> A recent consensus report suggests a MLA threshold of 1&#46;95 mm<span class="elsevierStyleSup">2</span>&#44; which has moderate sensitivity and negative predictive value for hemodynamic significance&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">4&#44;24</span></a> In small vessels lower thresholds should probably be used&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">24</span></a> In most studies&#44; however&#44; the correlation between FFR- and OCT-derived measurements was only moderate&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">20&#44;21&#44;23</span></a> Despite potentially higher precision in determining MLA&#44; this simple cross-section value cannot predict physiology accurately&#44; as shown in a recent meta-analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">25</span></a> The ability of OCT to automatically segment the lumen through the entire pullback enables volumetric analysis of the vessel for the first time&#46; Applying the physical principles of fluid dynamics&#44; a better correlation with FFR was obtained by deriving virtual flow reserve&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">26</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Importantly&#44; MLA values obtained with OCT are consistently lower than with IVUS&#46; It has been speculated that the absence of non-uniform rotation distortion on OCT allows for a more precise contour of the lumen&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">27</span></a></p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Percutaneous coronary intervention guided by optical coherence tomography</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Adjunctive tool in decision-making for percutaneous coronary intervention</span><p id="par0100" class="elsevierStylePara elsevierViewall">Few data are available on the clinical impact of using OCT for guiding the decision to perform PCI&#44; but the results are encouraging&#46; In a single-center study&#44; 90 patients with ambiguous or intermediate lesions underwent PCI if MLA was &#60;3&#46;5 mm<span class="elsevierStyleSup">2</span> or in the presence of thrombus&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">28</span></a> Post-dilatation or additional stent implantation was performed in cases of stent underexpansion&#44; incomplete stent apposition &#40;ISA&#41;&#44; significant intraluminal tissue prolapse&#44; or edge dissection extending beyond 200 &#956;m&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">28</span></a> In addition to high procedural success&#44; good clinical outcomes were reported at 4&#46;6&#177;3&#46;2 months of follow-up&#44; with 2&#46;2&#37; repeat revascularization and no stent thrombosis&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">28</span></a> An ongoing randomized trial &#40;FORZA&#41; is evaluating the feasibility of PCI guided by OCT in angiographically intermediate lesions with stenosis area &#8805;75&#37; assessed by OCT&#44; or 50&#8211;75&#37; with MLA &#60;2&#46;5 mm<span class="elsevierStyleSup">2</span>&#44; or if a major plaque ulceration is detected&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">29</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Recently&#44; OCT has been used to guide treatment in ACS in a different way&#46; The unique ability of the method to detect thrombus and plaque rupture adds an unprecedented level of confidence in determining the underlying mechanism of plaque instability&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">7</span></a> In a small study of 100 patients treated with thrombus aspiration followed by OCT&#44; no stent was implanted if the occlusion was mostly thrombotic and no significant coronary narrowing was detected by OCT&#44; provided that the patient was symptom-free and TIMI flow was &#8805;2 &#40;20 patients&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">30</span></a> Follow-up OCT studies showed a &#8220;normal vessel&#8221; and there were no adverse events at 12-month follow-up&#46; The safety and feasibility of medical management without stent placement in selected ACS patients with large thrombus burden detected by OCT has also been reported in other studies&#44; in which OCT revealed lesion characteristics that were not disclosed by angiography and facilitated treatment decisions&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">31&#44;32</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Adjunctive tool for planning percutaneous coronary intervention</span><p id="par0110" class="elsevierStylePara elsevierViewall">Similarly to IVUS&#44; OCT may be used to help plan the intervention and&#44; when used systematically&#44; it has been reported to alter procedural strategy in over 80&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">33</span></a> OCT can provide highly reproducible measurements of lesion length and reference vessel lumen diameter&#44; which may guide stent selection&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">4</span></a> Information on plaque components such as calcification may suggest the use of ancillary devices such as rotational atherectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">3</span></a> OCT is the only method that can accurately image calcium thickness&#44; and a combination of high thickness and circumferential distribution may identify non-dilatable lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">3</span></a> Moreover&#44; a lower calcium angle depicted by OCT correlates with asymmetric &#40;eccentric&#41; stent expansion and a higher calcium angle correlates with stent underexpansion&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">34</span></a> OCT may also be useful during complex procedures such as PCI of chronic total occlusions&#44; where it may identify subintimal wire entrapment or double channels&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">4</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Another potential use of OCT regarding PCI planning is risk stratification&#46; Previous OCT studies have linked lesion morphology with periprocedural microvascular damage or myocardial infarction&#46; In non-ST-elevation ACS&#44; the presence of TCFA and the size of the lipid arc at the culprit plaque were predictors of no-reflow&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">35</span></a> The presence of TCFA was also associated with elevation of post-PCI myocardial necrosis markers&#44; particularly if colocalized with spotty calcification&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">36</span></a> In addition&#44; in-stent thrombus or dissection detected by OCT after PCI also predicted periprocedural myocardial infarction&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">37</span></a> Although these OCT findings could aid risk stratification before or during PCI&#44; larger studies are needed to confirm the role of this clinical application&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Adjunctive tool for post-stenting assessment</span><p id="par0120" class="elsevierStylePara elsevierViewall">One of the main contributions of OCT is in assessing stent expansion&#44; sizing and apposition &#40;defined elsewhere<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">3&#44;38</span></a>&#41; more accurately and with lower interobserver variability than angiography or IVUS&#46; Stent underexpansion and undersizing have been linked to stent restenosis and stent thrombosis&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">39</span></a> The minimum stent area and lumen area of the reference vessel can be measured using OCT&#44; enabling accurate estimation of stent expansion&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">3</span></a> ISA &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41; delays neointimal coverage of the struts and is associated with stent thrombosis&#44; although neointimal hyperplasia usually tends to reduce ISA over time&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">3&#44;40</span></a> OCT can measure the distance between the struts and the vessel wall and quantify the number of struts with incomplete apposition&#46;<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">41&#44;42</span></a> Stent apposition is thus assessed at the strut level&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">42</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Regarding vascular injury after PCI&#44; intimal dissection at the stent edges&#44; small thrombi and tissue prolapse commonly occur following stent deployment &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">43</span></a> OCT is much more sensitive than IVUS for detecting these vascular responses&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">43</span></a> Nevertheless&#44; their prognostic impact is controversial&#44; as discussed below&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">OCT may thus be useful after stent deployment&#44; as it may prompt optimization with further stenting or high-pressure or larger-sized balloon inflation&#44; with low procedural complication rates&#46;<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">44&#44;45</span></a> Angiographic guidance for PCI in 335 patients was compared with angiographic plus OCT guidance in 335 patients in a propensity-score adjusted analysis &#40;the CLI-OPCI study&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">45</span></a> OCT disclosed adverse features&#44; including stent malapposition&#44; stent underexpansion&#44; lumen narrowing&#44; thrombus&#44; or edge dissection&#44; requiring further stenting or additional balloon dilatation in 34&#46;7&#37; of patients&#46; The OCT-guided approach resulted in lower adjusted risk of cardiac death or nonfatal myocardial infarction at 12 months of follow-up &#40;OR 0&#46;49&#44; 95&#37; confidence interval 0&#46;25&#8211;0&#46;96&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">45</span></a> In another study&#44; even after achieving an optimal angiographic result following stenting&#44; removal of in-stent thrombus detected by OCT using balloon dilatation was shown to be a safe approach&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">46</span></a> Of note&#44; left main intervention can be performed with OCT guidance&#44; and in a head-to-head comparison against IVUS&#44; OCT identified more findings that prompted additional interventions&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">47</span></a> The DOCTORS trial is currently evaluating the utility of OCT for optimizing the results of coronary angioplasty in non-ST-segment elevation ACS&#44; beyond angiography alone&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">48</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Nevertheless&#44; following stent deployment&#44; minor stent malapposition with a short distance between the struts and the vessel wall&#44; small thrombus&#44; mild tissue prolapse&#44; or minor stent edge dissection do not seem to be associated with worse prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">49</span></a> Improvement is expected during follow-up when these small non-flow limiting abnormalities are left untreated&#44; without adverse impact on clinical outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">49</span></a> Conversely&#44; a dissection flap thickness &#62;0&#46;31 mm carries an adverse clinical impact in the long term&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">50</span></a> Regarding malapposition&#44; some operators recommend no additional post-dilatation unless there is &#62;200 &#956;m distance between the stent and wall vessel at multiple strut locations&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">4</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Follow-up evaluation</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Stent coverage</span><p id="par0140" class="elsevierStylePara elsevierViewall">OCT has been used extensively to assess neointimal hyperplasia and strut coverage with different types of stents&#44; placed using different stenting techniques&#44; with or without adjunctive techniques&#46; Different quantitative measurements may be obtained&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">3&#44;51&#8211;55</span></a> Accuracy is greater than with IVUS&#59; not only the completeness of individual strut coverage but also the thickness of coverage can be assessed&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">3&#44;51</span></a> OCT studies have shown that a greater percentage of uncovered struts is associated with increased risk of major adverse events after drug-eluting stent &#40;DES&#41; implantation&#44; a cut-off of &#8805;5&#46;9&#37; of uncovered struts on follow-up OCT having been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">56</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Stent restenosis</span><p id="par0145" class="elsevierStylePara elsevierViewall">Quantitative measurements such as percentage lumen obstruction can be obtained by OCT&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">3</span></a> In addition&#44; different tissue patterns of in-stent restenosis &#40;ISR&#41; have been described&#44; including layered&#44; homogeneous and heterogeneous patterns&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">57</span></a> A heterogeneous pattern is more frequent in focal than in diffuse ISR and has been associated with the presence of fibrinoid or proteoglycans&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">57</span></a> In bare-metal stents&#44; early ISR is usually homogeneous due to neointimal proliferation&#44; which is rich in smooth muscle cells&#44; while late ISR may have a heterogeneous appearance due to lipid pools&#44; calcification and neovascularization&#44; suggesting that neoatherosclerosis is the underlying mechanism&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">58</span></a> ISR of DES is typically characterized by a layered or heterogeneous intrastent tissue band and may be part of the spectrum of in-stent neoatherosclerotic changes&#44; such as TCFA-containing neointima&#44; particularly if the stent had been placed for at least 20 months&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">58</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In a recent study on ISR&#44; morphological assessment using OCT was useful for identifying lesions favorable for paclitaxel-coated balloon dilatation or DES placement&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">59</span></a> Of the 428 treated ISR lesions&#44; a homogenous structure was associated with higher rates of repeated ISR and target lesion revascularization using plain balloon angioplasty alone compared with paclitaxel-coated balloon dilatation or DES placement &#40;target lesion revascularization rates of 38&#46;7&#37;&#44; 10&#46;6&#37; and 10&#46;7&#37;&#44; respectively&#44; in a follow-up of 211&#177;40 days&#41;&#59; conversely&#44; no differences were found between the three treatment approaches in ISR lesions of heterogeneous appearance&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">59</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Stent thrombosis</span><p id="par0155" class="elsevierStylePara elsevierViewall">The mechanisms for stent thrombosis may be readily elucidated by OCT&#44; as mentioned above&#46; Strut malapposition or underexpansion&#44; incomplete strut coverage&#44; stent fracture&#44; incomplete lesion coverage by the stent&#44; edge dissection&#44; in-stent neoatherosclerosis and ruptured neointima&#44; particularly in areas of lipid-laden neointima&#44; may be detected by OCT&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">4&#44;60&#44;61</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Future directions</span><p id="par0160" class="elsevierStylePara elsevierViewall">As a clinical tool&#44; OCT is currently potentially able to replace IVUS in every situation with the exception of diagnosis of lesions in the ostial left main or right coronary arteries&#44; in which the flow in the aorta prevents adequate blood clearance&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">2&#8211;4</span></a> However&#44; most of these patients should be assessed with FFR&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">2&#8211;4</span></a> Another exception is chronic total occlusions in which antegrade injections are of potential concern&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The method continues to evolve&#44; with pullback speeds now reaching 40 mm&#47;s<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">62</span></a> and the potential for a paradigm shift&#44; with opportunities to save contrast compared to conventional angiography&#46; The introduction of angiographic frame co-registration enables precise spatial location for stent implantation&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">63</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">OCT can replicate IVUS metrics that are essentially cross-sectionally derived&#44; but most importantly allows for full volumetric analysis of the vessel&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">27</span></a> Virtual fractional flow reserve derived from OCT is a potentially disruptive technology in predicting physiology and assessing results after stenting&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">27</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Finally&#44; OCT is the most accurate method for follow-up assessment after placement of bioresorbable stents&#44; considering their low opacity at fluoroscopy and the lower accuracy of IVUS&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">64</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusion</span><p id="par0180" class="elsevierStylePara elsevierViewall">The current clinical applications of OCT encompass the successive stages in coronary artery disease management&#44; from initial lesion evaluation to assessment of the final results of PCI&#44; including accurate lesion characterization and quantification of stenosis&#44; guidance for the decision to perform PCI and subsequent planning&#44; and evaluation of immediate and long-term results following PCI&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Morphologic lesion characterization"
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          "titulo" => "Percutaneous coronary intervention guided by optical coherence tomography"
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              "titulo" => "Adjunctive tool for planning percutaneous coronary intervention"
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              "titulo" => "Adjunctive tool for post-stenting assessment"
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            1 => "Coronary artery disease"
            2 => "Percutaneous coronary intervention"
            3 => "Optical coherence tomography"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec815347"
          "palabras" => array:4 [
            0 => "Aplica&#231;&#227;o cl&#237;nica"
            1 => "Doen&#231;a coron&#225;ria"
            2 => "Interven&#231;&#227;o coron&#225;ria percut&#226;nea"
            3 => "Tomografia de coer&#234;ncia &#243;tica"
          ]
        ]
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Coronary optical coherence tomography has emerged as the most powerful in-vivo imaging modality to evaluate vessel structure in detail&#46; It is a useful research tool that provides insights into the pathogenesis of coronary artery disease&#46; This technology has an important clinical role that is still being developed&#46; We review the evidence on the wide spectrum of potential clinical applications for coronary optical coherence tomography&#44; which encompass the successive stages in coronary artery disease management&#58; accurate lesion characterization and quantification of stenosis&#44; guidance for the decision to perform percutaneous coronary intervention and subsequent planning&#44; and evaluation of immediate and long-term results following intervention&#46;</p></span>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A tomografia de coer&#234;ncia &#243;tica coron&#225;ria surgiu como a modalidade de imagem <span class="elsevierStyleItalic">in-vivo</span> que permite a avalia&#231;&#227;o estrutural vascular mais detalhada&#46; Trata-se de uma ferramenta valiosa em investiga&#231;&#227;o&#44; tendo contribu&#237;do para melhor entendimento da patog&#233;nese da doen&#231;a coron&#225;ria&#46; Apresenta igualmente um papel importante na pr&#225;tica cl&#237;nica&#44; e o leque de sua aplicabilidade tem aumentado&#46; Enquadrando na evid&#234;ncia dispon&#237;vel&#44; discutimos neste artigo as principais aplica&#231;&#245;es da tomografia de coer&#234;ncia &#243;tica coron&#225;ria na pr&#225;tica cl&#237;nica&#44; que englobam as diferentes etapas na abordagem da doen&#231;a coron&#225;ria&#44; incluindo a caracteriza&#231;&#227;o da les&#227;o e quantifica&#231;&#227;o da estenose&#44; o papel na decis&#227;o de realizar angioplastia&#44; o contributo na planifica&#231;&#227;o da mesma e a avalia&#231;&#227;o dos resultados a curto e a longo prazo ap&#243;s a interven&#231;&#227;o&#46;</p></span>"
      ]
    ]
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      0 => array:3 [
        "identificador" => "nom0005"
        "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0025">List of abbreviations</span>"
        "listaDefinicion" => array:1 [
          0 => array:1 [
            "definicion" => array:11 [
              0 => array:2 [
                "termino" => "ACS"
                "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">acute coronary syndrome</p>"
              ]
              1 => array:2 [
                "termino" => "DES"
                "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">drug-eluting stent</p>"
              ]
              2 => array:2 [
                "termino" => "FFR"
                "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">fractional flow reserve</p>"
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              3 => array:2 [
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                "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">incomplete stent apposition</p>"
              ]
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                "termino" => "ISR"
                "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">in-stent restenosis</p>"
              ]
              5 => array:2 [
                "termino" => "IVUS"
                "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">intravascular ultrasound</p>"
              ]
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                "termino" => "MLA"
                "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">minimal luminal area</p>"
              ]
              7 => array:2 [
                "termino" => "MLD"
                "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">minimal luminal diameter</p>"
              ]
              8 => array:2 [
                "termino" => "OCT"
                "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">optical coherence tomography</p>"
              ]
              9 => array:2 [
                "termino" => "PCI"
                "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">percutaneous coronary intervention</p>"
              ]
              10 => array:2 [
                "termino" => "TCFA"
                "descripcion" => "<p id="par0055" class="elsevierStylePara elsevierViewall">thin-cap fibroatheroma</p>"
              ]
            ]
          ]
        ]
      ]
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        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Left main artery lesion&#58; appearance on optical coherence tomography&#44; with ulceration &#40;arrow&#41;&#59; &#40;B&#41; thrombus &#40;triangles&#41; and a thin-cap fibroatheroma &#40;asterisk&#41;&#59; &#40;C&#41; these findings were undetected by invasive coronary angiography&#46;</p>"
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        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
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          0 => array:4 [
            "imagen" => "gr2.jpeg"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#8211;C&#41; Optical coherence tomography showing a large spontaneous ulceration in the circumflex artery&#46;</p>"
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      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Optical coherence tomography revealing stent malapposition with a large distance between struts and vessel wall&#46;</p>"
        ]
      ]
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        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Edge dissection&#44; and &#40;B&#41; small thrombus following stent placement&#44; detected by optical coherence tomography&#46;</p>"
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    ]
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      "titulo" => "References"
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2015.09.010

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Year/Month	Html	Pdf	Total

2024 November	7	3	10
2024 October	63	28	91
2024 September	75	24	99
2024 August	62	26	88
2024 July	52	36	88
2024 June	45	19	64
2024 May	66	24	90
2024 April	57	26	83
2024 March	93	21	114
2024 February	74	21	95
2024 January	71	27	98
2023 December	55	28	83
2023 November	117	34	151
2023 October	60	19	79
2023 September	78	51	129
2023 August	61	14	75
2023 July	103	7	110
2023 June	74	27	101
2023 May	86	28	114
2023 April	71	6	77
2023 March	92	26	118
2023 February	68	26	94
2023 January	73	17	90
2022 December	114	31	145
2022 November	120	41	161
2022 October	130	32	162
2022 September	100	52	152
2022 August	120	42	162
2022 July	126	42	168
2022 June	114	36	150
2022 May	107	39	146
2022 April	146	58	204
2022 March	96	41	137
2022 February	105	27	132
2022 January	148	40	188
2021 December	63	35	98
2021 November	94	52	146
2021 October	105	54	159
2021 September	100	51	151
2021 August	119	53	172
2021 July	85	36	121
2021 June	82	31	113
2021 May	104	47	151
2021 April	248	104	352
2021 March	252	58	310
2021 February	184	42	226
2021 January	127	48	175
2020 December	158	39	197
2020 November	98	39	137
2020 October	108	30	138
2020 September	127	31	158
2020 August	102	34	136
2020 July	136	28	164
2020 June	122	40	162
2020 May	98	18	116
2020 April	108	28	136
2020 March	120	41	161
2020 February	252	36	288
2020 January	72	18	90
2019 December	76	32	108
2019 November	75	14	89
2019 October	60	14	74
2019 September	134	18	152
2019 August	71	13	84
2019 July	63	8	71
2019 June	51	12	63
2019 May	78	21	99
2019 April	39	20	59
2019 March	140	10	150
2019 February	124	9	133
2019 January	57	9	66
2018 December	57	14	71
2018 November	331	8	339
2018 October	932	21	953
2018 September	222	12	234
2018 August	127	8	135
2018 July	23	4	27
2018 June	44	10	54
2018 May	27	8	35
2018 April	57	8	65
2018 March	43	6	49
2018 February	26	7	33
2018 January	31	4	35
2017 December	46	9	55
2017 November	35	10	45
2017 October	38	14	52
2017 September	32	14	46
2017 August	37	12	49
2017 July	18	10	28
2017 June	33	10	43
2017 May	40	5	45
2017 April	34	1	35
2017 March	43	44	87
2017 February	67	4	71
2017 January	46	2	48
2016 December	52	8	60
2016 November	41	6	47
2016 October	52	2	54
2016 September	64	5	69
2016 August	22	4	26
2016 July	22	2	24
2016 June	17	1	18
2016 May	15	3	18
2016 April	17	2	19
2016 March	50	27	77

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