ROLE OF OCT IN CARDIOVASCULAR DISEASE.PRINCIPLES,TECHNIQUES,ADVANTAGES AND INDICATIONS.

2. • A new technology for performing high-resolution cross sectional imaging.
• Analogous to IVUS imaging, uses light instead of sound.
• Provides cross sectional images of tissue structure on the micron scale in situ and in real
time.
• A type of Optical biopsy and is a powerful imaging technology for medical diagnostics
because unlike conventional histopathology which requires removal of a tissue specimen
and processing for microscopic examination, OCT can provide images of tissue in situ and in
real time.
• OCT can be used where standard excisional biopsy is hazardous or impossible, to reduce
sampling errors associated with excisional biopsy, and to guide interventional procedures.
INTRODUCTION

3. • Huang et al. in 1991.
• The light source used for OCT imaging is in the Near-infrared range, around 1,300-nm
wavelength, selected to achieve both penetration and delineation of vascular structures[tissue
penetration is limited to 1 to 3 mm as compared with 4 to 8 mm achieved by intravascular
ultrasound].
• Cross-sectional images are generated by measuring the Echo time delay and Intensity of light
that is reflected or backscattered from internal structures in tissue .
• The Echo time delay cannot be measured directly [speed of light (3x108 m/s) is much faster
than that of sound (1,500 m/s)--- direct quantification cannot be achieved on such a time
scale.
• Correlation or Interferometry techniques.
Principles of operation

4. • Interferometry measures the echo time delay and intensity of backscattered light by
interfering it with light that has travelled a known reference path length and time
delay.
• Michelson-type interferometer.
• The interferometer splits the emitted light source into a Reference and Sample
beam; the reference beam is directed to a reference mirror at known distance, the
sample beam is directed to the structures of interest.
• The backscattered light from the sample is interfered with reflected light from the
reference arm and their interference fringes are detected by a photodetector.

5. • When the back-reflected optical intensity of the two arms (interference signal) is
measured and compared, the optical properties of the tissue can be deduced .
• The intensity of the back-reflected light can be measured and quantified digitally in
grey scale, enabling the creation of a digital image.
• The imaging depth of TD-OCT is approximately 1.5–2.0 mm with an axial and lateral
resolution of 15 mm and 25mm, respectively

8. • Blood strongly scatters light-- intravascular OCT requires a blood-free field lasting
several seconds to allow imaging.
OCT Image Acquisition
•Injecting continuous saline/ contrast flushes
through the guiding or delivery catheters.
•Proximal balloon occlusion of the vessel with
distal saline/contrast injection.
•Time-consuming
• Require a high degree of operator expertise
•FD OCT systems do not require proximal
occlusion
•Bolus injection of saline, contrast, or other
Solution, injected at rates of 2 to 4 ml/s, and
an automated 20 mm/s pullback within a
monorail rapid exchange catheter allows
imaging of a 6-cm-long coronary segment
during a 3-s injection
TD-OCT FD- OCT

9. • The OCT Image Wire-- guidewire-like profile.
• Inserted using an over-the-wire balloon catheter (Helios).
• The Helios balloon--- maximum external diameter of 1.5 mm---- compatible with large
6-F guiding catheters (0.071-inch inner diameter).
• Advanced distally to the segment of interest over a conventional angioplasty guidewire
(0.014-inch).
• The guidewire is exchanged with the OCT Image Wire---occlusion balloon is pulled
back ------ repositioned in a healthy proximal segment.
• The balloon is inflated at pressure that allows totally clean imaging from blood, usually
between 0.4 to 0.7 atm ----- dedicated inflator.

10. • A contrast injector pump with a warming cuff is set at 0.5 cc/s infusion ---- can
be increased to up to 1.0 cc/s until blood is completely cleared.
• The solution injected through the distal port of the occlusion balloon catheter--
--- start several seconds before balloon occlusion.
• The pullback speed adjusted from 0.5 to 3.0 mm/s, and the entire image wire is
pulled from distal to proximal along the coronary artery.

11. • FD-OCT systems
 Imaging --- without balloon occlusion.
The pullback speed can reach up to 20 to 40 mm/s and is performed during
contrast injection (4 cc/s) to assure complete blood clearance.
Imaging of 4 to 6 cm of coronary artery segments can be achieved with <15 cc of
contrast per pullback.
 For non occlusion techniques, iodinated contrast media is preferred over
saline or ringer’s lactate because of the advantage of high viscosity solutions in
completely removing blood.

12. • The applied energies in OCT are low --- no functional or structural damage to the tissue.
• One study evaluated the safety and feasibility of OCT in 76 patients using the occlusive
technique.
• Vessel occlusion time was 48 . 3 Sec.
• The most frequent complication was the presence of transient events, such as chest
discomfort, brady - or tachycardia, and ST-T changes on ECG, all of which resolved
immediately after the procedure.
• No major complications, including myocardial infarction, emergency
revascularisation, death, acute vessel occlusion, dissection, thrombus
formation, embolism, or vasospasm along the procedure related artery were
observed.
Safety of OCT

13. • Introduction of the non-occlusive technique ----- reduction in the procedural
time ---- rate of chest pain and ECG changes during image acquisition.
• New systems with high speed pullbacks ----- Permit coronary imaging in a few
seconds.

14. Clinical Application

15. • ACS ------ Rupture of a coronary plaque .
• Detection of lesions at high risk of rupture (so called ‘‘vulnerable plaques’’) is
of major importance for the prevention of future ACS.
• OCT --- one of the most promising --- provides unique information about the
plaque composition, the presence of macrophages, and the thickness of the
fibrous cap
Plaque Characterization

16. • The propensity to destabilise and rupture is highly dependent on Plaque
composition.
• In comparison with histology, OCT has been shown to be highly sensitive and
specific for characterising different types of atherosclerotic plaques.
• Yabushita et al analysed 357 diseased carotid and coronary segments ex vivo
and classified them as fibrous, fibro- calcific, and lipid-rich plaques.
oFibrous plaques -- homogeneous, signal-rich regions
oFibro - calcific plaques --- signal-poor regions/ sharp borders
oLipid-rich plaques ---signal-poor regions with diffuse borders
Plaque composition

17. FIBROUS
PLAQUE
FIBROCALCIFIC
PLAQUE
LIPID RICH
PLAQUE
SENSITIVITY 71–79% 95–96% 90–94%
SPECIFICITY 97–98% 97% 90–92%
comparison with histology

20. • Ex vivo validations --- OCT superior to conventional and integrated backscatter
IVUS for the characterisation of coronary atherosclerotic plaque composition.
• In vivo, OCT is superior for the identification of lipid pools.
• OCT appearance of coronary plaques in different groups of patients:
lipid-rich plaque was identified in 90% of ST-segment elevation myocardial
infarction (STEMI) and 75% of non–ST-segment elevation myocardial infarction
(NSTEMI), as compared with < 60% of stable angina pectoris (SAP) lesions.

21. • Thin capped fibroatheromas (TCFA) - defined pathologically by the triad of:
 Lipid core.
 Fibrous cap with a thickness < 65 micron m.
 Cell infiltration of the fibrous cap.
• OCT for in vivo assessment of fibrous cap thickness ---- Unique ability to image
superficial detail.
Characterization of fibrous cap thickness

22. • In the ACS patients, TCFA was observed in 72 % STEMI and 50 % NSTEMI
culprit lesions as compared with 20 % SAP lesions (p =0.01) [Jang I-K, Tearney
GJ, MacNeill BD, et al. In vivo characterization of coronary atherosclerotic plaque by
use of optical coherence tomography. Circulation 2005;111:1551–5]
• The same groups exhibited mean fibrous cap thicknesses of 47, 54, and 103
micron m , respectively.
• Similar findings have been reported by subsequent studies (77% to 83%
STEMI, 46% NSTEMI, and 3% to 25% SAP; p=0.001)[Kubo T et al. Assessment of
culprit lesion morphology in acute myocardial infarction: ability of optical coherence
tomography compared with intravascular ultrasound and coronary angioscopy. J Am Coll
Cardiol 2007;50:933–9].

23. • Potential for using OCT measurements of fibrous cap thickness as a possible
marker of plaque vulnerability.
• In a single-center prospective study, cap thickness has been shown to increase
in a statin-treated group [Takarada S,, Kubo T, et al. Effect of statin therapy on
coronary fibrous-cap thickness in patients with acute coronary syndrome: assessment by
optical coherence tomography study. Atherosclerosis 2009;202:491–7].
• In a smaller observational study, patients on statins had fewer plaque ruptures
(8% vs. 36%) and had a trend toward increased fibrous cap thickness (78
micron m vs. 49 micron m) compared with those not taking statin. [Chia S,et al.
Association of statin therapy with reduced coronary plaque rupture: an optical coherence
tomography study. Coron Artery Dis 2008;19:237– 42]

26. • Plaque rupture/ Subsequent thrombosis ----- ACS.
• OCT can identify intracoronary thrombus and plaque rupture with high accuracy.
• Kubo et al evaluated the ability of OCT to assess the culprit lesion morphology in acute
myocardial infarction in comparison with IVUS and angioscopy.
• Incidence of plaque rupture by OCT of 73%, significantly higher than that detected by
both angioscopy (47%, p = 0.035) and IVUS (40%, p = 0.009).
• Intracoronary thrombus was observed in all cases by OCT and angioscopy, but was
identified in only 33% of patients by IVUS.
Plaque rupture and intracoronary thrombus
identification

27. • Kume et al --- OCT distinguish between white and red thrombus. Red thrombus
appears as a high backscattering structure with signal-free shadowing while
white thrombus appears as a low backscattering structure.

28. • Intense infiltration of the fibrous cap is another of the features of vulnerable
plaques.
• Study by Tearney et al ---- OCT was able to quantify macrophages within the
fibrous cap.
• In vivo---- unstable patients present a significantly higher macrophage density
detected by OCT in the culprit lesion than stable patients.
• The sites of plaque rupture demonstrated a greater macrophage density than
non-ruptured sites.
Identification of intralesional macrophages

29. • Fine resolution at a superficial depth, OCT allows a uniquely detailed image of
the effects of stent implantation on the vessel wall.
• OCT allows:
Examination of the target vessel both pre- and post-intervention
 Defining stent struts readily
 Tissue prolapse between stent struts immediately
Tissue characterization of plaque before and after stent placement
OCT and Percutaneous Coronary Intervention

30. • Tissue prolapse, or protrusion of tissue between stent struts without apparent
surface disruption ----- depth of protrusion is >50micron m.
• Observed universally (97.5%) at some point along the stented segment
• IVUS-verified prolapse of 18% to 35%, suggesting OCT is both sensitive and specific.
• clinical significance ---- unclear, given that it occurs so frequently, and has not been
associated with early clinical events.
Tissue prolapse

31. • Disruption of the vessel surface with dissection flap, or association with an underlying
cavity
• 86.3% of stented vessels show a dissection flap and 68.8% show an underlying cavity
at some point along their length.
• Significance—if any—remains to be established.
• Edge dissections were present less commonly (26.3%), with no associated clinical
events.
Intrastent dissection

32. • The degree of stent strut apposition
extensively evaluated using OCT by a
number of investigators
[Raffel OC, Akasaka T, Jang IK. Cardiac
optical coherence tomography. Heart
2008;94:1200 –10]
• Leading edge of stent struts.
• Lumen–vessel wall interface.
Stent strut apposition/coverage

33. • 3-point classification defines stent strut apposition.
Embedded ----- the leading edge is buried within the intima by more than one-half its
thickness
Protrusion --- stent strut is apposed but not embedded
Malapposed ---- there is no intimal contact

34. • Another classification, describes whether or not the stent strut appears covered
with tissue, and whether struts are well apposed or Malapposed . Stent struts are,
therefore, classified as:
Well apposed and covered
well apposed and not covered
Malapposed and not covered
Malapposed but covered

35. • In a small series of OCT examinations after drug-eluting stent (DES) implantation
6,000 stent struts were examined : [Tanigawa J, Di Mario et al. The influence of strut
thickness and cell design on immediate apposition of drug-eluting stents assessed by optical
coherence tomography. Int J Cardiol 2009;134:180 – 8]
57.1% ---- Embedded
33.8%------Protruding
9.1% ------ Malapposed
The clinical relevance of these findings remains unclear.

39. • IVUS studies in late stent thrombosis after DES implantation ---- high prevalence of
incomplete stent apposition.
• persistent or acquired (not present after stent implantation)
• (1) expansive vessel remodelling
• (2) chronic stent recoil
• (3) dissolution of thrombus trapped between the stent and the vessel wall in
patients undergoing primary PCI for acute myocardial infarction
• (4) the resolution of an intramural haematoma created by vessel dissection during
PCI
Stent apposition at follow-up

40. • Prevalence of Malapposed struts by OCT is higher in sirolimus eluting stents (SES)
than in BMS.
• In another study that evaluated 57 SES at 6 months follow-up, 79 out of the 6840
struts visualised by OCT showed malapposition and were more often located in
areas of SES overlap

41. • Xie et al compared the neointimal coverage at 3 months follow-up in 16 patients
treated with BMS and 24 patients who underwent SES implantation.
• The neointimal thickness per strut[ 248 mm Vs 39 mm] and the percentage of
neointimal thickness area per cross section[ 45.0 % vs. 10.0 %] were higher in the
BMS group than in the SES group.
• The frequency of uncovered struts and Malapposed struts was higher in the SES
group than in the BMS group (15% vs. 0.1%, p<0.0001, and 15% vs. 1.1%, p<0.0001,
respectively).
• Matsumoto et al studied 34 patients (57 SES) with IVUS and OCT at 6 months follow-
up. The authors reported that 64% of the struts were covered by thin neointima
undetectable by IVUS .

42. • The most powerful histological predictor of stent thrombosis.
• DES inhibits neointimal proliferation to such an extent that it may not be detectable
by IVUS. The higher resolution of OCT allows the visualisation and measurement of
tiny layers of tissue covering the stent struts.
• A study in a carotid rabbit model evaluated the usefulness of OCT for identifying
strut coverage after stenting. No differences in the mean neointimal thickness
measured by histology and OCT. (The intra-and inter-observer reproducibility of
neointimal thickness measurements by OCT was excellent.)
Strut coverage following DES implantation

43. • DES type may also influence stent coverage.
• Paclitaxel - and Zotarolimus -eluting stents exhibit fewer exposed stent struts compared
with sirolimus.
• 1 study has demonstrated a stent strut exposure rate of 0.3% at 9 months with zotarolimus
compared with 12% for sirolimus . [Kim J-S et al. Comparison of neointimal coverage of
sirolimus-eluting stents and paclitaxel-eluting stents using optical coherence tomography at 9
months after implantation. Circ J 2010; 74:320 – 6.]
• Zotarolimus - eluting stents may also have low rates of uncovered stent struts comparable
to BMS in the setting of STEMI [Guagliumi G et al. Optical coherence tomography assessment
of in vivo vascular response after implantation of overlapping bare-metal and drug-eluting stents.
J Am Coll Cardiol Intv 2010;3:531–9]

44. • Another study evaluated the strut coverage in SES at 6 and 12 months follow-up.
• Forty-six SES (6561 struts) were studied in 36 patients.
• The authors reported that only four SES at 6 months (18.2%) and 10 SES at 12 months
(41.7%) were fully covered by tissue.
• Yamamoto et al evaluated the long term follow up of SES in 21 patients. Overall the
frequency of uncovered struts was 5%, and 81% of the patients presented uncovered struts
at 2 years follow-up.
• The presence of uncovered struts was more frequent at side branches and at overlapping
segments.

45. • Useful in the evaluation of the causes that contribute to restenosis after DES
implantation, such as incomplete coverage of lesion or gaps between stents.
• Stent fracture (defect of local drug delivery) has been related to restenosis in DES
and could be visualised with OCT.
• Non-uniform distribution of stent struts could affect the drug delivery and therefore
have an influence on restenosis in DES.
Assessment of restenosis

46. • OCT has not been able to distinguish if the tissue covering the struts is neointimal
tissue or fibrin.
• the presence of tissue covering the strut does not prove that normal endothelial
function in the area has been restored.
• Pathological and functional studies are needed to understand the real meaning of
the OCT findings in strut coverage

47. • Fully biodegradable stents---- promising future stents--- they may avoid the potential
complications of metallic DES----- late and very late stent thrombosis and the need for
prolonged dual antiplatelet treatment.
• ABSORB TRIAL ---- feasibility of implantation of the Bioabsorbable Everolimus eluting
coronary stent composed of a poly-L-lactic acid backbone coated with a degradable
polymer/Everolimus matrix.
• In 13 patients, OCT was performed after stent implantation and at 6 months follow-up.
• OCT allowed a very precise characterisation of the stent apposition ,coverage, and also
demonstrated structural changes in the Bioabsorbable DES over time.
• At baseline, 738 struts were visualised ----follow-up only 671 could be identified.
• optical properties of the remaining struts changed from baseline to follow-up ----- probably
related to the partial absorption process.
• OCT appears to be the best available tool for the assessment of absorption of stent struts.
Evaluation of future DES

49. • Residual blood --- Attenuates the OCT light
beam ---- defocus the beam if red cell
density is high.
• This reduces brightness of the vessel wall,
especially at large radial distances from
the Image Wire.
• Mistakenly labelling residual blood artifact
as thrombus or some other specific intra-
vascular finding.
Artifacts

50. • Artifacts related to eccentric wire position
Eccentricity of the image wire in the vessel
lumen image influence interpretation.
The reflection from metallic stent struts align
toward the imaging wire, akin to sunflowers
aligning to the sun or a “sunflower” effect or
“merry-go-round” effect .

51. • Saturation Artifact
Occurs when light reflected from a highly
specular surface (usually stent struts)
produces signals with amplitudes that exceed
the dynamic range of the data acquisition
system

52. • Sew-up Artifactis
Result of rapid artery or imaging wire
movement leading to misalignment of the
lumen border

53. • Bubble Artifact
Result of air bubbles in the Image Wire
sheath.
It attenuates the signal along a region of the
vessel wall, and images with this artifact are
not suitable for tissue characterization.

54. • Fold-over Artifactis
specific to the new generation of FD-OCT.
The longitudinal view demonstrates that the
cross section is located at the level of a side
branch.
when structure signals are reflected from
outside the system’s field of view. Typical
examples are side branch and large vessels.

55. • Need to displace blood or dilute the hematocrit, either with saline or contrast flush
injection, or a combination of the two.
• Shallow image penetration of 1 to 2.5 mm. This prevents assessments of cross-
sectional plaque area ---- OCT has only a limited role in the assessment of left main
stem and Saphenous vein graft atherosclerosis severity.
• The differentiation of calcific areas from lipid pools can be problematic . both result
in a low attenuation signal.
• Image artifacts
Limitations

56. Future Trends

57. • Fusion of IVUS and OCT would provide ideal imaging of luminal and vessel wall pathology.
• IVUS ---Increased penetration allow assessment of plaque burden and identification of
positive or negative remodeling.
• High-resolution OCT ---- Permits assessment of luminal morphology, accurate estimation of
fibrous cap thickness, identification of thrombus, and detection of plaque erosion and
rupture.
• The combined information provided by both modalities would permit a more precise
characterization of the type of plaque.
Combination of IVUS and OCT

58. • Sawada et al reported how the combined use of IVUS-VH analysis and OCT improved the
accuracy for TCFA detection.
• 56 patients with angina (126 plaques) were included in the study.
• Of the 61 plaques diagnosed initially as TCFA by IVUS-VH analysis criteria, only 28 had a thin
fibrous cap as measured by OCT, so they were considered as definite TCFAs.
• 8 OCT derived TCFAs did not have necrotic core in the IVUS-VH analysis, mainly due to the
misreading in OCT caused by dense calcium.
• combination of the information provided by different methods could be essential for better
identification of high risk coronary lesions

59. • A catheter combining an IVUS with an OCT probe would also be useful in planning
and assessing the outcome of percutaneous coronary intervention.
• IVUS would provide information about the correct stent diameter (on the basis of the
media-adventitia dimensions) ----- OCT would permit a detailed evaluation of the
final result and detection of dissections, stent malapposition, or the presence of
thrombus.
• There is currently no such catheter for clinical applications.

61. • 3D reconstruction of OCT images---- Automatically detect and quantify features of
interest as
Shape of lumen
MLA
Stent strut malapposition and Thrombus volume.
• Combination of FD-OCT and Spectroscopic technique—allow for detailed analysis
of the cellular and biochemical composition of Vulnerable plaque.

62. THANK YOU