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ISR vs De Novo Lesion Treatment During OCT-Guided PCI: Insights From the LightLab Initiative
Brian A Bergmark1,2, Mordechai Golomb3, Julia F Kuder2
1CTO/Complex Coronary Intervention Program, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Insights
Percutaneous coronary intervention for in-stent restenosis (ISR) is challenging. Optical coherence tomography (OCT) use in ISR PCI procedures revealed longer procedure times and poorer stent expansion, highlighting OCT's role in optimizing treatment.
Area of Science:
- Cardiovascular Interventions
- Interventional Cardiology
- Medical Imaging
Background:
- Long-term outcomes following percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) remain suboptimal.
- Limited detailed procedural data exist for ISR PCI, hindering effective lesion assessment and treatment strategies.
- Understanding procedural nuances is crucial for improving outcomes in ISR patients.
Purpose of the Study:
- To evaluate procedural characteristics and outcomes of optical coherence tomography (OCT)-guided PCI for ISR compared to de novo lesions.
- To assess the impact of OCT on treatment decisions and stent optimization in ISR.
- To identify factors contributing to acute procedural success in ISR PCI.
Main Methods:
- The LightLab Initiative enrolled 2592 OCT-guided PCI procedures across 17 US hospitals (2019-2021).
- Procedural data, including lesion assessment and stent deployment, were collected contemporaneously.
- OCT imaging was utilized for pre-procedural lesion assessment and post-procedural stent evaluation, comparing ISR (n=458) with de novo lesions.
Main Results:
- ISR lesions were more complex (Type C: 64.8% vs 52.9%) and associated with higher rates of femoral access (46.4% vs 37.7%) compared to de novo lesions.
- OCT significantly influenced treatment decisions more frequently in ISR PCI (94.2% vs 85.2%).
- ISR PCI utilized more advanced lesion modification techniques (scoring balloons, cutting balloons, atherectomy) and resulted in longer procedure times (62 vs 51 min) with lower final minimum stent area and expansion.
Conclusions:
- OCT-guided PCI for ISR involves more complex lesions and requires greater use of advanced techniques.
- Despite increased intervention, ISR PCI procedures yielded suboptimal stent expansion.
- OCT plays a critical role in guiding treatment decisions for ISR, potentially improving outcomes in this high-risk group.
Background:
Long-term outcomes after percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) are poor, yet limited granular procedural data exist evaluating lesion assessment, vessel treatment, and acute procedural outcomes.
Methods:
The LightLab Initiative was a multicenter, prospective, observational study with contemporaneous procedural data collection during PCI procedures. Data were collected during PCIs performed by 48 interventional cardiologists at 17 US hospitals (2019-2021). Optical coherence tomography (OCT) was performed pre-PCI for lesion assessment and post-PCI for stent optimization, and results were compared between ISR and de novo lesion PCI.
Results:
In total, 2592 OCT-guided PCIs involving 2944 lesions were included, of which 458 procedures (17.7%) were ISR PCI. Compared with de novo lesion PCI, ISR lesions were more commonly type C (64.8% vs 52.9%) and performed via femoral artery access (46.4% vs 37.7%). Use of OCT changed operator assessment and treatment decisions more frequently in ISR PCI (94.2% vs 85.2%; P = .002). Scoring balloons (21.8% vs 2.5%), cutting balloons (16.4% vs 3.4%), and atherectomy (26.3% vs 9.9%) were used more commonly in ISR PCI (all P < .0001), and ISR PCI procedures were longer (62 vs 51 min). Moreover, the final achieved minimum stent area and percent expansion (4.4 vs 5.1 mm2 and 80% vs 83%, respectively; both P < .0001) were lower in ISR PCI.
Conclusions:
In this real-world cohort of patients who underwent OCT-guided PCI, ISR procedures were longer and final minimum stent area and percent expansion were lower despite greater use of advanced lesion modification. OCT frequently altered physician decision making, emphasizing its utility in potentially reducing recurrent stent failure in this high-risk population.
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