Innovative invasive management without stent implantation guided by optical coherence tomography in acute coronary syndrome

Abstract

Background: A two-step strategy of invasive management without stenting, guided by optical coherence tomography (OCT), in selected patients with acute coronary syndrome (ACS), might avoid systematic stent implantation and allow medical therapy alone.

Aims: To assess the feasibility and safety of such a procedure, and to define coronary imaging characteristics in a specific population.

Methods: This single-centre proof-of-concept study included all patients with ACS who benefited from a two-step revascularization procedure with optimal reperfusion during primary percutaneous coronary intervention followed by delayed angiography and OCT. OCT imaging determined medical therapy treatment alone without stenting in case of absence of vulnerable plaque rupture and <70% stenosis. Follow-up consisted of screening for major adverse cardiac events (MACE) at 12months.

Results: Forty-six patients were included, mainly men (86.9%) and smokers (65.2%), with a mean age of 47.1years. Most cases (80.4%) were large thrombus burden lesions. Delayed angiography and OCT were performed in a median period of 6 [3-10] days. No adverse events occurred between the initial and second angiograms. Plaque rupture was detected in 39.1% of patients, plaque erosion in 54.3% and calcified nodule in 6.5%. Twenty-three patients benefited from systematic delayed OCT over a median period of 171days, showing an increase in minimal lumen area. At 12months, two patients (4.3%) presented MACE and were stented. No sudden death or myocardial infarction recurrence occurred.

Conclusions: Analysing ACS mechanisms by OCT might facilitate treatment decisions in patients with ST-segment elevation myocardial infarction managed by a two-step procedure. Conservative treatment with antithrombotic therapy without stenting seems to be a reliable option in a selected population.

Keywords: Acute coronary syndrome; Antithrombotic therapy; Imagerie par cohérence optique; Optical coherence tomography; Percutaneous coronary intervention; Plaque erosion; Plaque rupture; Rupture de plaque; Syndrome coronarien aigu; Traitement anti-thrombotique; Érosion de plaque.