Randomized Clinical Trails regarding IVUS vs. OCT Guided PCI
CBSMD
May, 2018"Clinical
use of intracoronary imaging. Part 1: guidance and optimization of
coronary interventions. An expert consensus document of the European
Association of Percutaneous Cardiovascular Interventions: Endorsed by
the Chinese Society of Cardiology" summarized RCT evidence regarding IVUS vs. OCT guided PCI. The expert consensus described that the "current evidence suggest that OCT is non-inferior to IVUS for PCI guidance with respect to the acute procedural result, as well as mid-term clinical outcomes. Although the results of available studies should be interpreted in the context of best clinical practice standards. "
Technical advantages and disadvantages of both intravascular imaging are presented in the Table 1. "It is the consensus opinion of this expert group that IVUS and OCT are equivalent (and superior to angiography) in guiding and optimizing most PCI procedures. Both modalities can identify features of optimal stent implantation (expansion, apposition, and complications), as well as mechanisms of stent failure that cannot be captured using coronary angiography alone. However, the benefits and limitations of each modality require consideration."
Additional information regarding the strengths of IVUS and OCT in specific clinical scenarios derived from expert consensus, summized by CBSMD.
long lesions
ostial left main lesions
CTO-lesions
patients with renal insufficiency
larg amount of thrombus
OCT can visulized calcified plaque without artefacts 1 and penetrate calcium to certain degree, and thus evaluate its thickness more accurately than IVUS.2
non-ostial left main lesions
lumen or stent-related morphologies with instent-restenosis, thrombus and culprit plaque in ACS patients
residual edge dissection3, incorrect wire position and stent malapposition3
3D OCT imaging for stent fracture
tissue prolapse3
pullback acquisition faster
Intravascular Imaging
Plaque Composition
Lesion / Patientsgroup/ Complications better with IVUS or OCT
IVUS
lipid-rich tissue, use IVUS to determine stenting size in the presence of diffuse disease
OCT
Reference
3. ILLUMIEN III
RCT Trails comparing IVUS vs. OCT guided PCI & Clinical Benefit in MACE
Nov, 2016 - RCT in patients with one or more target lesions located in a native coronary artery with a visually estimated reference vessel diameter of 2.25-3.50 mm and a length of less than 40 mm - "Optical coherence tomography compared with intravascular ultrasound and with angiography to guide coronary stent implantation (ILUMIEN III: OPTIMIZE PCI): a randomised controlled trial" addressed the question whether OCT-guided PCI using a specific optimization protocol (mainly OCT imaging plus FFR) is comparable to IVUS-guided PCI.
Limitations - ILUMIEN III trail excluded patients
with left main or ostial right coronary artery stenoses, bypass graft
stenoses, chronic total occlusions, planned two-stent bifurcations, and
in-stent restenosis.
Nov,
2017 - RCT in patients with lesion length around 18mm and first formally powered for a significant difference in target vessel failure within 12 months - "Optical frequency domain imaging vs. intravascular
ultrasound in
percutaneous coronary intervention (OPINION trial): one-year
angiographic and clinical results" tested successfully for the first
time that OCT-guided PCI using a lumen-based approach was non-inferior
to IVUS-guided PCI with powered for the clinical endpoint Target Vessel Failure with 1-year. OPINION trail also reported significant difference in the average stent size (OCT 2.92 ±0.39 mm vs. IVUS 2.99±0.39 mm, p=.005) when applying a lumen-based stenting sizing approach. 8 months later, the differences in the average stent size did not translate into differences in angiographic in-stent MLD.
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