PRECI PRECISION PCI PCI TAK AKES ES TH THE E MYSTERY OUT UT - - PowerPoint PPT Presentation

PRECI PRECISION PCI PCI TAK AKES ES TH THE E MYSTERY OUT UT OF AN ANGIOPL PLASTY

RICHARD SHLOFMITZ, MD CHAIRMAN OF DEPT. OF CARDIOLOGY

• ST. FRANCIS HOSPITAL

ROSLYN, NEW YORK

SURPR URPRISES A S ARE O E OK W WITH TH CHO HOCOLATE TE

I THINK IT IS A CARAMEL? KNOW WHAT YOU ARE GETTING!

A FEW QUEST STIONS NS…

• 1. DO YOU IMAGE BEFORE &/OR AFTER?
• 2. SOMETIMES OR ALWAYS?
• 3. DO YOU DO FFR INDEPENDENT OF OCT?

BOTH ALWAYS NEVER

“I D DON’ N’T T USE O USE OCT” T”

TAKE KES TOO MUCH MUCH T TIME IME TOO M MUCH I CH INFORMA MATIO ION EXTRA RA C CONTRAS RAST EXPEN ENSIV SIVE EXTRA A FLOU OURO T RO TIME MY MY R RESULTS ARE G GREAT – “IVUS E US EYES” S”

P R E C I S I ON P N P C I

STEP 7 - LUMINAL GAIN STEP 6 - APPOSITION STEP 5 - EDGE DETECTION STEP 4 - COREGISTRATION STEP 3 - SIZE STEP 2 - LENGTH STEP 1 - MORPHOLOGY

STEP 1 – MORPHOLOGY

1) “KNOW WHAT YOU’RE DEALING WITH” 2) DEVELOP A STRATEGIC PRE TREATMENT APPROACH 3) DEVELOP A STRATEGIC STENTING APPROACH

• Low reflectivity
• Heterogeneous
• Sharp margins
• Isolated, strong reflections

Calcified

“KNOW WHAT YOU’RE DEALING WITH”

• High reflectivity
• Homogenous
• Finely textured

Fibrous Lipid-rich

• Low reflectivity
• Homogenous
• Diffuse margins

DIRECT STENTING COMPLIANT BALLOON NC AND/OR SCORING/CUTTING ATHERECTOMY NIH SUPERFICIAL

FIBROTIC

NODULAR

LIPIDIC MIXED PLAQUE (F,L,C)

DEEP

HIGH CALCIFIC BURDEN NO CALCIFIC BURDEN LOW CALCIFIC BURDEN

DEVELOP A STRATEGIC PRE TREATMENT APPROACH

DIAGNOSE LIPID RICH PLAQUE

LIPID -RICH THICK CAP THIN CAP

DIRECT STENTING APPROACH

THICK THIN

*THE CALCIUM PROBLEM*

UNDERESTIMATION OF CALCIUM STENT UNDEREXPANSION STENT MALAPPOSITION INCREASE RISK OF COMPLICATIONS INCREASED LIKELIHOOD OF IMPROPER VESSEL PREP LONGER PROCEDURES MORE STENTS

SUPERFICIAL NODULAR DEEP

CALCIUM DEEP

NODULAR TRADITIONAL TECHNIQUES (NC BALLOON/ SCORING/CUTTING)

SUPERFICIAL

ABLATIVE TECHNIQUES (ATHERECTOMY)

DIAGNOSE CALCIFIC PLAQUE

DESCRIPTION OF DEEP CALCIUM

PRESENCE OF THICK FIBROTIC CAP

• NON-LUMINAL

TRADITIONAL TECHNIQUES (NC BALLOON/ SCORING/CUTTING)

DESCRIPTION OF CALCIFIED NODULE

SUPERFICIAL CALCIUM

• LUMINALLY PROTRUSIVE
• ATTENNUATION PRESENT (PROB DUE

TO THROMBUS) FROM THROMBOGENIC SURFACE

ATHERECTOMY

DESCRIPTION OF SUPERFICIAL CALCIUM

MINIMAL TO NO FIBROTIC LAYER

• DEPTH OF CALCIUM LIKELY

MEASURABLE ATHERECTOMY

WH WHY OCT I T IS ESSEN SENTI TIAL F FOR DIAGNOSIS & TX OF CALCIFIED LESIONS

1 – MORPHOLOGY 2 - DEPTH 3 – ARC 4 - LENGTH

A SCORING ALGORITHM HELPS US RECOGNIZE WHEN WE NEED HELP

 GREATER .5mm DEPTH  GREATER 180∘ ARC  GREATER THAN 5mm in LENGTH

• 1. Fujino et. al. A New Optical Coherence Tomography-based calcium scoringsystem to predict stent under-expansion

EuroIntervention 2018 Feb 6. pii: EIJ-D-17-00962.

• 1. Maximum Calcium Angle (°)

1 point 2 points

• 2. Maximum Calcium Thickness

(mm)

• 3. Calcium Length (mm)

Total score

0 point 1 point 0 point 1 point 90°< Angle ≤180° > 180 ° ≤ 0.5 mm > 0.5 mm > 5.0 mm ≤ 5.0 mm 0 point ≤ 90 °

0 to 4 points OCT-based Calcium Volume Index (CVI) Score

A step-wise decrease in stent expansion according to the CVI score

RISK STRATIFICATION FOR UNDEREXPANSION

• 1. Fujino et. al. A New Optical Coherence Tomography-based calcium scoringsystem to predict stent under-expansion

EuroIntervention 2018 Feb 6. pii: EIJ-D-17-00962.

FIBROTIC ISR LIPIDIC ISR CALCIFIC ISR UNDEREXPANSION

ISR NIH UNDER EXPANSION

HIGH PRESSURE BALLOONING/ LASER ATHERECTOMY CALCIFIC FIBROTIC LIPIDIC SCORING/ CUTTING/NC ABLATIVE THERAPIES

DIAGNOSE MECHANISM OF ISR

STEP 2 – LESION LENGTH ANALYSIS

1) FIND GOOD LANDING SITES FOR STENT EDGE 2) AVOID DISSECTIONS (NORMAL VESSEL/ FIBROTIC IF DIFFUSE)

LESION LENGTH ANALYSIS

DISTAL REFERENCE

STRATEGIC TREATMENT ASSESSMENT

• Vessel Size and Lesion Length Assessment

PROXIMAL REFERENCE

STEP P 3 – STENT DIAMETER SIZING

1) SIZE TO VESSEL IF NORMAL 2) SIZE TO BEST AVAILABLE LUMEN IF DIFFUSE

STENT SIZING: LUMEN TO LAMINA

LUMINAL MEASUREMENTS MEDIAL MEASUREMENTS

MEAN DIAMETER 2.07mm MEAN DIAMETER 2.67mm

STEP P 4 – CO CO-REGISTRATION

1) PRECISION PLACEMENT 2) ANGIOGRAPHIC AMBIGUITY

COREGISTRATION W/ STENT ROADMAP

Eliminates angiographic ambiguity Minimizes geographic miss during stent placement

PRECISION PCI: OSTIAL LESIONS

KNOW WHERE YOUR STENT BEGINS

STEP 5 – EXPANSION STEP 6 – MALAPPOSITION STEP 7 – COMPLICATION ASSESSMENT

STENT POST DEPLOYMENT ANALYSIS

DISTAL EDGE REFERENCE 1) Documentation of Apposition 2) Documentation of Luminal Gain and Stent Expansion 3) Complication Assessment PROXIMAL EDGE REFERENCE EXCELLENT LUMINAL GAIN!

STENT POST DEPLOYMENT ANALYSIS

DIAGNOSE EDGE DISSECTION

LOW ARC DEGREE INTIMAL TEAR HIGH ARC DEGREE INTIMAL TEAR MEDIAL TEAR INTRAMURAL HEMATOMA

HOW LONG DOES IMAGING REALLY TAKE? E?

OCT GUIDED PCI – IMAGE ADQUISITION TOTAL – 15 secs

OCT GUIDED PCI - PRE ASSESSMENT

STEP 3 - SIZE STEP 2 - LENGTH STEP 1 - MORPHOLOGY

TOTAL - 1.29 mins

STEP 4 – COREGISTRATION

STEP 7 - LUMINAL GAIN STEP 6 - APPOSITION STEP 5 - EDGE DETECTION

OCT GUIDED PCI – POST ASSESSMENT TOTAL - 58 secs

ACQUISITION + PRE ASSESSMENT + ACQUISITION + POST ASSESSMENT 0.15 mins + 1.29 mins + 0.15 mins + 0.58mins = 2.57 mins

OCT GUIDED PCI : TOTAL TIME

WHAT DOES A 3min OCT STUDY GIVE A BUSY PRACTICIONER?

• PRECISION PCI
• PCI PLANNING STRATEGY
• LESION MODIFICATION
• STENT SIZING
• CONFIRMATION OF RESULT
• EDGE DISSECTION
• NO SIGNIFICANT PLAQUE AT

EDGES

• OPTIMAL EXPANSION AND

APPOSITION

WHO WOULD YOU RATHER BE?

ANGIOGRAPHY IMAGING

“I DO DON’ N’T USE O USE OCT CT”

TAKE KES TOO MUCH MUCH T TIME IME TOO M MUCH I CH INFORMA MATIO ION EXTRA RA C CONTRAS RAST EXPEN ENSIV SIVE EXTRA A FLOU OURO T RO TIME I I THI HINK MY K MY RESULTS A ARE GREAT

“I “I ALWA WAYS U USE O OCT” T”

TAKES ES ~3 MINS MINS ACCURATELY A ASSES SSESS R RESU ESULTS LESS ESS CONT NTRAST ST ( (50% 50% les ess ci cine r e runs) FEWER ER S STENT ENTS S  LESS E S EXPEN ENSIV SIVE LESS ESS CINES ES, L , LESS F SS FLOUR URO I I KNOW MY MY RESULTS A ARE GREAT

PRECISION PCI