Optical Coherence Tomography to Better Assess Chronic Total Occlusion Percutaneous Intervention Results: The PERFECTO Study

Abstract

Background: Angioplasty of coronary chronic total occlusions (CTOs) was a breakthrough, but there is a lack of data concerning stent healing after these complex procedures.

Objectives: The main aim of the PERFECTO (Post-stEnting assessment of Reendothelialization with optical Frequency domain imaging aftEr CTO procedure) study is to assess, for the first time, stent strut apposition at the index CTO procedure and at 3-month follow-up using frequency-domain optical coherence tomography (FD-OCT).

Methods: From March 2018 to January 2020, 114 consecutive patients who underwent successful CTO recanalization >20 mm in length were prospectively included in 7 centers. FD-OCT was performed for ad hoc guidance during the index procedure and at 3-month follow-up. All patients received the same last-generation drug-eluting stent.

Results: Mean age was 63.2 years, and 87% were male. The rate of malapposed struts per patient was 7.84% at the end of the index procedure and 15.03% at 3-month follow-up (P < 0.0001), highlighting the phenomenon of acquired malapposition. Malapposed struts occurred more often with dissection and re-entry techniques and subintimal stenting compared to intimal techniques (12.8% vs 5.3%, P = 0.02). At 3-month follow-up, distal vessel minimal lumen area increased from 69% (index 2.19 mm² vs 3.71 mm² at 3 months, P < 0.0001). No complication occurred with FD-OCT.

Conclusions: CTO-percutaneous coronary intervention could affect stent healing with a high incidence of immediate and late-acquired malapposition. These results support the interest of using FD-OCT during follow-up to better assess CTO recanalization results. (Post-stenting Assessment of Reendothelialization With OFDI After CTO Procedure [PERFECTO]; NCT03209843).

Keywords: chronic total occlusion; late-acquired malapposition; optical coherence tomography.

Graphical abstract

Central Illustration

Proposition: Accuracy and Safety of FD-OCT to Assess Post CTO Results (A) Example of axial FD-OCT immediately after CTO-PCI “index procedure.” Deeply behind the struts, the media looks asymmetric: thinner on the top right quadrant than on the bottom left quadrant. Despite FD-OCT optimization, 2 struts remain malapposed. (B) Same-level axial FD-OCT at 3-month follow-up showing a late-acquired malapposition on the top right quadrant where the media looks the thinnest. Abbreviations as in Figures 1 and 2.

Figure 1

Flow Chart of the PERFECTO Study CTO = chronic total occlusion; FD-OCT = frequency-domain optical coherence tomography; OCT = optical coherence tomography; PCI = percutaneous coronary intervention; PERFECTO = Post-stEnting assessment of Reendothelialization with optical Frequency domain imaging aftEr CTO procedure.

Figure 2

Example of Late-Acquired Malapposition (A) Angiogram of the right coronary artery immediately after recanalization at the index procedure. (A') FD-OCT axial view of the same right coronary artery immediately after recanalization at the index procedure (green arrow). Struts are all well apposed with a good stent deployment. MSA = 8.3 mm² and MLA = 8.5 mm². (B) Angiogram of the same right coronary artery at 3 months without obvious angiographic malapposition. (B') Same-level FD-OCT axial view as A' (red arrow; the level of axial view is identified with the collateral branch) at 3 months. While the MSA is quite the same, there are now 5 malapposed struts and an increased MLA of 9.5 mm². FD-OCT = frequency-domain optical coherence tomography; MLA = minimal lumen area; MSA = minimal stent area.