Stable Coronary Artery Disease: Assistance in Complex Percutaneous Coronary Intervention

, Jagat Narula2, Yuliya Vengrenyuk3 and Samin Sharma4



(1)
Director, Cardiac Catheterization Laboratory, Director, Structural Heart Intervention Program, Director, Interventional Cardiology Fellowship Program, Zena and Michael A. Wiener Professor of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York, USA

(2)
Director, Intravascular Imaging Core Laboratory, Instructor, Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York, USA

(3)
Philip J. and Harriet L. Goodhart Chair in Cardiology, Chief of Cardiology, Mount Sinai St. Luke’s Hospital, Professor of Medicine and Radiology, Associate Dean, Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York, USA

(4)
Director, Clinical and Interventional Cardiology, President, Mount Sinai Heart Network, Dean, International Clinical Affiliations, Anandi Lal Sharma Professor of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York, USA

 



Electronic Supplementary Material

The online version of this chapter (doi:10.​1007/​978-3-319-62666-6_​3) contains supplementary material, which is available to authorized users.


Keywords
Percutaneous coronary interventionCalcified lesionsBifurcation lesionsRotational and orbital atherectomyCutting balloon angioplastyProvisional stentingSide branchPeriprocedural myocardial infarctionUnprotected left mainKissing balloon inflationIn-stent restenosisStent apposition and expansionEdge dissection



3.1 Introduction


Optical coherence tomography (OCT) has been increasingly used in clinical practice as a guide during percutaneous coronary intervention (PCI) . Prior to stent implantation, OCT can provide accurate measurements of the minimal lumen area, the distal and proximal reference areas, and lesion length. The accuracy of the OCT measurements has been established by the ex vivo lumen diameter assessment of Plexiglas phantoms [1]. The minimal lumen area (MLA) measured by OCT in vivo was slightly smaller than intravascular ultrasound (IVUS)-MLA, but the correlation between the two measurements was highly significant (r = 0.82; p < 0.001) [2]. OCT showed excellent reproducibility for both the lumen area and the lesion length measurements with low intraobserver, interobserver, and interpullback variability [3, 4]. Fully automatic computer-assisted lumen contour detection in OCT images has been shown to represent a reliable tool for in vivo assessment of stented coronary vessels [5, 6]. These preprocedural measurements can help select stent and balloon sizes.

OCT is particularly useful during challenging procedures, such as calcified lesions, bifurcation, and unprotected left main (ULM) PCI . OCT imaging can help characterize lesion morphology and select treatment strategy based on plaque characteristics. It is being proposed that lipid-rich lesions may be amenable to medical therapy and resolution of luminal obstruction verified by improved fractional flow reserve (FFR) [7]. PCI of calcified lesions has been associated with lower rates of procedural success and higher rates of subsequent adverse cardiovascular events [8]. Because of reduction in vessel wall compliance, calcified lesions have higher risks of stent underexpansion and malapposition and acute postprocedural complications such as dissection and perforation. Development of atheroablation techniques, in particular rotational and orbital atherectomy, significantly improved the success rate of calcified lesion PCI. OCT allows measurements of calcification size and depth and their precise location within the lesion, which might help select the appropriate atheroablation technique.

Treatment of coronary artery bifurcation lesions remains a challenging area in interventional cardiology despite major advances in bifurcation stenting approach [9, 10]. Side branch (SB) occlusion can result in vessel closure and ischemia, leading to increased incidence of periprocedural myocardial infarction (MI) and even cardiac deaths after PCI [11]. Provisional stenting remains the main approach to treatment of bifurcation lesions; however, it may result in significant narrowing of the SB ostium after main vessel stenting. High-resolution OCT imaging can characterize SB stenosis before and after stenting, select appropriate treatment strategy, and evaluate the effects of SB treatment. Three-dimensional OCT reconstruction provides a unique opportunity to assess the true morphology of the main and side vessels [12]. Preprocedure assessment of bifurcation lesion morphology with OCT can help identify SBs with a high risk of occlusion. The presence of large lipid plaque in the proximal segment of the main vessel (MV) has been shown to be an independent OCT predictor of SB stenosis severity after MV stenting [13, 14].

Coronary artery bypass graft (CABG) surgery has historically been the treatment of choice for patients with unprotected left main coronary artery (LMCA) disease. However, with the introduction of drug-eluting stents (DESs), selected patients with unprotected LMCAs have been increasingly treated with PCI [15, 16]. A recent pilot trial demonstrated the safety and feasibility of frequency-domain OCT for unprotected left main PCI [17]. Compared to IVUS, OCT provided a similar assessment of lumen and stent dimensions but was more sensitive in detecting malapposition and edge dissections.

Finally, OCT imaging before stenting can provide patient risk stratification for periprocedural MI, since OCT-derived thin-cap fibroatheroma and evidence of plaque rupture have been associated with elevation of post-PCI myocardial necrosis markers [18, 19]. Compared to plaque burden by intravascular ultrasound (IVUS) and plaque lipid content by near infrared spectroscopy (NIRS), OCT fibrous cap thickness was the most important independent predictor of periprocedural MI in a recent multimodality imaging study [20].


3.2 Case 1. Rotational Atherectomy of a Proximal LAD Lesion: Grinding the Lesion (Figs. 3.1 and 3.2, Videos 3.1 (Part I), 3.1 (Part II), 3.2, and 3.3)




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Fig. 3.1
A 47-year-old male, a smoker with hyperlipidemia and hypertension with a positive single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) and LAD stenosis on coronary computed tomography angiography (CTA) and was found to have stable angina. The coronary angiogram showed a 70–80% stenosis of the proximal LAD with calcification (a1 , arrow). OCT imaging confirmed the presence of severe calcification at the site of stenosis with a minimal lumen area of 1.9 mm2 (b1 , asterisk) and proximal to the MLA with a total length of 14 mm (c1 , dotted line). Calcified plaque was ablated by rotational atherectomy (RA) using a 1.75-mm burr for 60 s. OCT pullback performed after RA demonstrated a 32% increase in the minimal lumen area (b1 vs. b2), uniform plaque modification with a smooth cylindrical shape of the lumen (c2), and small intimal cuts (b2)


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Fig. 3.2
Coronary angiogram and OCT after stenting. An everolimus-eluting stent (3.5/24 mm) was implanted with a successful result on angiography (a). Postintervention OCT imaging confirmed good stent apposition and expansion with minimal stent area (MSA) of 7.3 mm2 (b, c)


3.3 Case 2. Orbital Atherectomy of a Heavily Calcified RCA Lesion: Shaving the Lesion (Figs. 3.3 and 3.4, Videos 3.4, 3.5, and 3.6)




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Fig. 3.3
A 64-year-old male who was a smoker with hyperlipidemia and hypertension and recent NSTEMI PCI to the proximal LAD presented with persistent chest pain. Abnormal stress MPI showed mild to moderate inferior ischemia. A coronary angiogram demonstrated a 70–80% occlusion of the proximal RCA with severe calcification (a1, arrow). Pre-PCI OCT imaging revealed circumferential calcification at the site of minimal lumen area (b1, asterisks) and moderate calcification proximal to the MLA (b2, b3, asterisks). Orbital atherectomy (OA) was performed with a 1.25-mm classic crown at 80,000 rpm for 40 s followed by 120,000 rpm for 40 s, resulting in acute lumen gain by angiography (a2 , arrow). OCT imaging after atherectomy confirmed effective calcium debulking with a 64% increase in minimal lumen area (b1 vs. b4) and significant modifications of fibrocalcific plaques (b5, b6, arrow)


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Fig. 3.4
Final post-PCI angiogram and OCT pullback were performed after a 4/23 mm everolimus eluting stent was implanted in the proximal RCA with a successful result by angiography (a) and OCT imaging (b, c)


3.4 Case 3. Orbital Atherectomy for Proximal LAD In-Stent Restenosis : Debulking an Iatrogenic Complication (Figs. 3.5 and 3.6, Videos 3.7 and 3.8)




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Fig. 3.5
A 67-year-old female with hyperlipidemia, controlled hypertension, and insulin-dependent diabetes mellitus (IDDM) was admitted with crescendo angina on maximal medical therapy and abnormal SPECT MPI demonstrating ischemia involving the anterior wall. The patient had a prior history of MI, CABG, and multiple PCIs. The last PCI of the mid LAD with a 3/38 mm DES was performed 6 months prior to the procedure. Coronary angiography revealed a significant in-stent restenosis lesion in the proximal LAD (a, arrow). An in-stent restenosis lesion with mostly homogeneous neointima was revealed by OCT; the minimal lumen area of the lesion was 1.96 mm2 (b2, c). A smaller amount of neointima and two stent layers were visualized by OCT in the segment distal to the MLA site (b1 , inset)


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Fig. 3.6
Postatherectomy OCT images and final poststenting angiogram. The lesion was treated with orbital atherectomy (OA) using a 1.25-mm classic crown at 80,000 rpm for 105 s followed by a cutting balloon (CB). Post-treatment OCT images demonstrated effective plaque removal (b1, b2, c, arrow) leading to acute lumen gain characterized by a 43% increase in the minimal lumen area (b2). A 3.5/18 mm everolimus eluting stent was deployed in the proximal LAD with a satisfactory angiographic result (a)


3.5 Case 4. Single Stenting of LAD-D1 Bifurcation Followed by Simultaneous Two-Balloon Inflation: About Kissing to Perfection (Figs. 3.7 and 3.8, Videos 3.9 and 3.10)




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Fig. 3.7
Coronary angiography, two- and three-dimensional OCT images before stenting. An 83-year-old male presented with exercise-induced chest discomfort. The patient’s medical history included controlled hypertension. Computed tomography angiography (CTA) showed severe LAD stenosis and SPECT MPI detected inducible myocardial ischemia. Coronary angiography demonstrated a mid LAD bifurcation lesion, Medina classification (1.1.1) (a, arrow). A large lipid-rich plaque proximal to the bifurcation area was detected by OCT (b2, asterisks). Mostly fibrotic plaque was visualized at the site of the MLA = 0.96 mm2 (b1). Since only mild calcification was detected by OCT, no atherectomy was performed. The side branch ostium area (SBOA) was 2.85 mm2 before PCI by three-dimensional OCT cut plane analysis (c2, c3, circled)


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Fig. 3.8
Coronary angiogram, two-dimensional and three-dimensional OCT images after stenting. This bifurcation region was treated by single stenting with kissing balloon inflation (a1). The postprocedural coronary angiogram showed no dissection in the side branch (a2). OCT pullback of the main vessel showed good stent apposition and expansion with a minimal stent area of 6.4 mm2 (b, arrow). There was no change in the side branch ostium area after PCI as assessed by three-dimensional OCT (c2, c3 circled)

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Dec 30, 2017 | Posted by in CARDIOLOGY | Comments Off on Stable Coronary Artery Disease: Assistance in Complex Percutaneous Coronary Intervention

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