Perwaiz Meraj

Optical coherence tomography compared with intravascular ultrasound and with angiography to guide coronary stent implantation (ILUMIEN III: OPTIMIZE PCI): a randomised controlled trial

BACKGROUND Percutaneous coronary intervention (PCI) is most commonly guided by angiography alone. Intravascular ultrasound (IVUS) guidance has been shown to reduce major adverse cardiovascular events (MACE) after PCI, principally by resulting in a larger postprocedure lumen than with angiographic guidance. Optical coherence tomography (OCT) provides higher resolution imaging than does IVUS, although findings from some studies suggest that it might lead to smaller luminal diameters after stent implantation. We sought to establish whether or not a novel OCT-based stent sizing strategy would result in a minimum stent area similar to or better than that achieved with IVUS guidance and better than that achieved with angiography guidance alone. METHODS In this randomised controlled trial, we recruited patients aged 18 years or older undergoing PCI from 29 hospitals in eight countries. Eligible patients had 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. We 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. Participants were randomly assigned (1:1:1; with use of an interactive web-based system in block sizes of three, stratified by site) to OCT guidance, IVUS guidance, or angiography-guided stent implantation. We did OCT-guided PCI using a specific protocol to establish stent length, diameter, and expansion according to reference segment external elastic lamina measurements. All patients underwent final OCT imaging (operators in the IVUS and angiography groups were masked to the OCT images). The primary efficacy endpoint was post-PCI minimum stent area, measured by OCT at a masked independent core laboratory at completion of enrolment, in all randomly allocated participants who had primary outcome data. The primary safety endpoint was procedural MACE. We tested non-inferiority of OCT guidance to IVUS guidance (with a non-inferiority margin of 1·0 mm2), superiority of OCT guidance to angiography guidance, and superiority of OCT guidance to IVUS guidance, in a hierarchical manner. This trial is registered with ClinicalTrials.gov, number NCT02471586. FINDINGS Between May 13, 2015, and April 5, 2016, we randomly allocated 450 patients (158 [35%] to OCT, 146 [32%] to IVUS, and 146 [32%] to angiography), with 415 final OCT acquisitions analysed for the primary endpoint (140 [34%] in the OCT group, 135 [33%] in the IVUS group, and 140 [34%] in the angiography group). The final median minimum stent area was 5·79 mm2 (IQR 4·54-7·34) with OCT guidance, 5·89 mm2 (4·67-7·80) with IVUS guidance, and 5·49 mm2 (4·39-6·59) with angiography guidance. OCT guidance was non-inferior to IVUS guidance (one-sided 97·5% lower CI -0·70 mm2; p=0·001), but not superior (p=0·42). OCT guidance was also not superior to angiography guidance (p=0·12). We noted procedural MACE in four (3%) of 158 patients in the OCT group, one (1%) of 146 in the IVUS group, and one (1%) of 146 in the angiography group (OCT vs IVUS p=0·37; OCT vs angiography p=0·37). INTERPRETATION OCT-guided PCI using a specific reference segment external elastic lamina-based stent optimisation strategy was safe and resulted in similar minimum stent area to that of IVUS-guided PCI. These data warrant a large-scale randomised trial to establish whether or not OCT guidance results in superior clinical outcomes to angiography guidance. FUNDING St Jude Medical.

The fluoro-less and contrast-less peripheral endovascular intervention: a concept for the future today

INTRODUCTION Percutaneous endovascular revascularization requires fluoroscopic guidance and radiopaque contrast use. This approach becomes problematic, especially in patients with advanced renal disease or allergies to iodinated contrast medium. The direct (exposure) and indirect (lead garment) burden of radiation affects patients and operators alike. PURPOSE We propose a completely contrast-free, fluoroscopy-free approach to endovascular diagnostic arterial imaging and percutaneous intervention using available technologies, and outline a timeframe for its implementation. PROJECT DESCRIPTION/METHODOLOGY Ultrasound imaging of the leg creates a roadmap of the vessel and identifies the lesion of interest. Device-based sensors using a low-powered electromagnetic field allow for wiring of the vessel. This is followed by the use of intravascular ultrasonography and near infrared spectroscopy to characterize the lesion dimensions and composition. After completion of the diagnostic phase of the process, the interventional portion with deployment of an angioplasty balloon and/or stent is performed using the electromagnetic field-guided sensors. FEASIBILITY The project uses already available technologies. BENEFITS/ANTICIPATED OUTCOMES This project demonstrates the real potential of performing endovascular peripheral intervention without fluoroscopy or contrast in a practical, user-friendly way with the currently available technology. The prospects in renal function preservation and radiation avoidance for both patients and operators are extremely attractive.

INCIDENCE OF TEMPORARY TRANSVENOUS PACEMAKER PLACEMENT WITH CORONARY ORBITAL ATHERECTOMY COMPARED TO ROTATIONAL ATHERECTOMY

Transvenous temporary pacing (TVP) is often used during percutaneous coronary intervention (PCI) in patients undergoing rotational atherectomy (RA) and is recommended for prophylactic use in all cases involving the RCA. The placement of transvenous pacing has cost implications, but more importantly

DECREASED FLUOROSCOPY TIME AND CONTRAST USE WHEN UTILIZING OPTICAL COHERENCE TOMOGRAPHY (OCT) GUIDED SUPERFICIAL FEMORAL ARTERY CHRONIC TOTAL OCCLUSION INTERVENTION

Superficial femoral artery (SFA) chronic total occlusion (CTO) peripheral vascular intervention (PVI) is a challenging procedure given the longer procedure times, larger amount of radiation dose and decreased procedural success. The aim is to determine the safety, efficacy and feasibility of the

BIVALIRUDIN VERSUS HEPARIN MONOTHERAPY IN PATIENTS WITH ST ELEVATION MYOCARDIAL INFARCTION UNDERGOING PERCUTANEOUS CORONARY INTERVENTION: AN ANALYSIS OF ACUTE ADVERSE OUTCOMES AND COST

Bivalirudin compared with heparin has been shown to reduce rates of bleeding and death in patients undergoing primary percutaneous coronary intervention (PCI). In light of recent evidence, this study compares the acute outcomes and cost in a contemporary population of patients with ST elevation

DRUG-ELUTING STENTS ARE ASSOCIATED WITH BETTER OUTCOMES COMPARED TO BARE-METAL STENTS IN UNSTABLE ANGINA OR NON ST-ELEVATION MYOCARDIAL INFARCTION PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION

The 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (PCI) considered drug-eluting stents (DES) as a useful alternative to bare-metal ones (BMS). The hypotheses of this study are that the use of DES is non-random in unstable angina (UA) or non ST-elevation myocardial infarction (