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OCT Guided Left Main PCI

Operator: Pedro Moreno, MD
Fellow: Amit Hooda, MD

A 68-year-old man with a history of hypertension, diabetes mellitus, hyperlipidemia, and prior myocardial infarction two month prior presented with worsening angina and shortness of breath. Coronary angiography demonstrated a 70-80% lesion in the mid LM (Figure 1A) and 50-60% lesion in the proximal LAD with a patent DES in the mid LAD (Figure 1B).

Pre-intervention OCT revealed fibrocalcific plaque in the proximal LAD with MLA 2.2 mm2 (Figure 2A), fibrous plaque in the ostial LAD (Figure 2B), and eccentric fibrous plaque in the proximal LM with MLA 4.0 mm2 (Figure 2C).
Based on the OCT findings, proximal LAD lesion was intervened by performing pre-dilation with NC EmergeTM Balloon (3.25×20 mm) followed by deployment of a 3.5×23 mm DES (Figure 3A). Proximal LM lesion was pre-dilated using NC Emerge 3.25x20mm and stented using a 4.0×33 mm DES extending from the LM ostium to the proximal LAD (Figure 3B). Coronary angiography demonstrated satisfactory results after stent implantation (Figure 3C).

Post-stent OCT was performed without complete cannulation of the catheter in intention to assess the apposition of the stent deployed over the LM ostium. OCT confirmed optimal stent expansion and apposition in the proximal LAD with MSA 5.5mm2 (Figure 4A, there is residual blood in the vessel, however, stent struts can be clearly visualized) and LAD ostium (Figure 4B, small amount of residual blood is present in the cross section). Stent strut malapposition was detected by OCT in the proximal stent edge of the LM stent (Figure 4C) leading to a decision to perform post-dilatation with 4.5×15 mm NC EmergeTM Balloon (Figure 5A). Final angiography is shown in Figure 5B.

Displacement of arterial blood from the vessel lumen is required for OCT imaging, since the wavelength of OCT is shorter than red blood cell diameter. Blood clearance can be challenging in large vessels, such as the left main coronary artery, and in aorto-ostial lesions.1 In this case, we were able to successfully visualize aorto-ostial junction using OCT.

  1. IVUS-Guided Versus OCT-Guided Coronary Stent Implantation: A Critical Appraisal. JACC Cardiovasc Imaging. 2017;10:1487-1503

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