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… BOTH 1. DO YOU IMAGE BEFORE &/OR AFTER? 2. SOMETIMES OR ALWAYS? ALWAYS 3. DO YOU DO FFR INDEPENDENT OF OCT? 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 1 - MORPHOLOGY STEP 2 - LENGTH STEP 3 - SIZE STEP 4 - COREGISTRATION STEP 5 - EDGE DETECTION STEP 6 - APPOSITION STEP 7 - LUMINAL GAIN

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

“KNOW WHAT YOU’RE DEALING WITH” Fibrous Lipid-rich Calcified • Low reflectivity • High reflectivity • Low reflectivity • Heterogeneous • Homogenous • Homogenous • Sharp margins • Finely textured • Diffuse margins • Isolated, strong reflections

DEVELOP A STRATEGIC PRE TREATMENT APPROACH DIRECT STENTING COMPLIANT BALLOON NC AND/OR SCORING/CUTTING ATHERECTOMY LOW CALCIFIC BURDEN HIGH CALCIFIC BURDEN NO CALCIFIC BURDEN LIPIDIC FIBROTIC MIXED PLAQUE (F,L,C) DEEP NIH NODULAR SUPERFICIAL

DIAGNOSE LIPID RICH PLAQUE LIPID -RICH THICK THIN THIN CAP CAP DIRECT STENTING APPROACH THICK

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

DIAGNOSE CALCIFIC PLAQUE CALCIUM DEEP SUPERFICIAL DEEP NODULAR NODULAR ABLATIVE TECHNIQUES TRADITIONAL (ATHERECTOMY) TECHNIQUES (NC BALLOON/ SUPERFICIAL SCORING/CUTTING)

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.

RISK STRATIFICATION FOR UNDEREXPANSION OCT-based Calcium Volume Index (CVI) Score 0 point ≤ 90 ° 1. Maximum Calcium Angle (°) 90° < Angle ≤180 ° 1 point > 180 ° 2 points ≤ 0.5 mm 0 point 2. Maximum Calcium Thickness (mm) 1 point > 0.5 mm ≤ 5.0 mm 0 point 3. Calcium Length (mm) > 5.0 mm 1 point 0 to 4 points Total score A step-wise decrease in stent expansion according to the CVI score 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.

DIAGNOSE MECHANISM OF ISR ISR UNDEREXPANSION FIBROTIC ISR UNDER NIH EXPANSION CALCIFIC LIPIDIC LIPIDIC ISR HIGH PRESSURE FIBROTIC BALLOONING/ LASER ABLATIVE SCORING/ ATHERECTOMY THERAPIES CUTTING/NC CALCIFIC 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 STRATEGIC TREATMENT ASSESSMENT • Vessel Size and Lesion Length Assessment DISTAL REFERENCE 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 2.07 mm 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

STENT POST DEPLOYMENT ANALYSIS STEP 5 – EXPANSION STEP 6 – MALAPPOSITION STEP 7 – COMPLICATION ASSESSMENT

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

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 1 - MORPHOLOGY STEP 2 - LENGTH STEP 3 - SIZE TOTAL - 1.29 mins

STEP 4 – COREGISTRATION

OCT GUIDED PCI – POST ASSESSMENT STEP 5 - EDGE DETECTION STEP 6 - APPOSITION STEP 7 - LUMINAL GAIN TOTAL - 58 secs

OCT GUIDED PCI : TOTAL TIME ACQUISITION + PRE ASSESSMENT + ACQUISITION + POST ASSESSMENT 0.15 mins + 1.29 mins + 0.15 mins + 0.58mins = 2.57 mins

WHAT DOES A 3min OCT STUDY GIVE A BUSY PRACTICIONER?  PRECISION PCI  CONFIRMATION OF RESULT • PCI PLANNING STRATEGY • EDGE DISSECTION • LESION MODIFICATION • NO SIGNIFICANT PLAQUE AT • STENT SIZING EDGES • OPTIMAL EXPANSION AND APPOSITION

WHO WOULD YOU RATHER BE? ANGIOGRAPHY IMAGING

PRECISION PCI “I DO DON’ N’T USE O USE OCT CT” “I “I ALWA WAYS U USE O OCT” T” TAKE KES TOO MUCH MUCH T TIME IME TAKES ES ~3 MINS MINS TOO M MUCH I CH INFORMA MATIO ION ACCURATELY A ASSES SSESS R RESU ESULTS EXTRA RA C CONTRAS RAST LESS ESS CONT NTRAST ST ( (50% 50% les ess ci cine r e runs) EXPEN ENSIV SIVE FEWER ER S STENT ENTS S  LESS E S EXPEN ENSIV SIVE EXTRA A FLOU OURO T RO TIME LESS ESS CINES ES, L , LESS F SS FLOUR URO I I THI HINK MY K MY RESULTS A ARE GREAT I I KNOW MY MY RESULTS A ARE GREAT