SCAI KERN CHAP 10 OCT Flashcards
(22 cards)
Q1: Which imaging modality provides higher axial resolution, OCT or IVUS?
Q2: What is the axial resolution range for OCT?
Q3: What is the axial resolution range for IVUS?
Q4: Which modality has greater penetration depth, OCT or IVUS?
Q5: What is the penetration depth of OCT?
Q6: What is the penetration depth of IVUS?
Q7: What types of structures attenuate OCT imaging?
Q8: Why is flushing required during OCT imaging?
Q9: What fluids are used for flushing during OCT?
Q10: How does blood affect OCT signals?
Q11: What recent technology uses OCT-derived vessel geometries?
Q12: What computational method is applied to OCT vessel geometries?
Q13: What does virtual fractional flow reserve (vFFR) evaluate?
Q14: What two aspects can this developing OCT technology assess simultaneously?
Q15: Why is this combined functional and morphological assessment important?
A1: OCT
A2: 10-20 µm
A3: 50-150 µm
A4: IVUS
A5: 1-2 mm
A6: 5-6 mm
A7: Thrombus, lipid necrotic core, calcium ( structures that absorb infrared lights )
A8: To displace blood from the imaging field ( blood attenuates IR light by scattering )
A9: Radiocontrast or sometimes saline
A10: Blood attenuates OCT signal by scattering infrared light
A11: Virtual fractional flow reserve (vFFR)
A12: Computational fluid dynamics
A13: Functional significance of coronary lesions
A14: Functional significance and morphological plaque characteristics
A15: It improves diagnosis and treatment planning
Q1: What are the main components of an OCT imaging system?
Q2: With what should the imaging catheter be flushed during OCT acquisition?
Q3: Why is the same flushing material used in the catheter and coronary artery?
Q4: What is critical for optimal OCT image acquisition regarding the guide catheter?
Q5: What should be avoided during guide catheter engagement?
Q6: What medication is recommended before OCT image acquisition?
Q7: Why is intracoronary nitroglycerin given prior to OCT imaging?
Q8: What effect does nitroglycerin have on the vessel?
Q9: What complication does nitroglycerin help reduce during OCT?
Q10: Why is proper flushing important in OCT imaging?
A1: Imaging catheter, drive motor control, and software
A2: Radiocontrast or occasionally saline
A3: To ensure consistent flushing and image quality
A4: Appropriate guide catheter engagement
A5: Ejection of the guide catheter
A6: Intracoronary nitroglycerin
A7: To dilate the vessel
A8: Vasodilation
A9: Catheter-induced coronary spasm
A10: To displace blood and improve image clarity
Q1: Where is the OCT catheter positioned relative to the target lesion?
Q2: What is done to the OCT catheter before imaging after positioning?
Q3: What is the purpose of the small puff given through the guide catheter?
Q4: What should be done if blood clearance is suboptimal during OCT imaging?
Q5: What device may be required to prevent reflux of flush medium into the aorta?
Q6: What happens after optimal guide catheter engagement and blood clearance?
Q7: How can the flush be administered during OCT pullback?
Q8: What is the common flush rate for the left coronary artery?
Q9: What is the total flush volume for the left coronary artery?
Q10: What is the common flush rate for the right coronary artery?
Q11: What is the total flush volume for the right coronary artery?
Q12: What is the pressure limit for flushing during OCT?
Q13: Why might larger flush volumes be required?
Q14: What imaging is performed during OCT pullback to help with coregistration?
Q15: What is the sequence of OCT imaging steps?
A1: Approximately 10 mm distal to the target lesion
A2: Purged again
A3: To ensure optimal guide catheter engagement and blood clearance
A4: Adjust guide catheter position and engagement
A5: Guide catheter extension
A6: Automated pullback of the OCT catheter is activated
A7: Manually or by automated injector
A8: 4 mL/s
A9: 14 to 16 mL
A10: 3 mL/s
A11: 12 to 14 mL
A12: 300 psi
A13: For larger arteries
A14: Cine angiography
A15: Position, purge, puff, pullback
Q1: What does the bright-dark-bright trilaminar appearance in normal coronary artery OCT images represent?
Q2: Which three layers correspond to the trilaminar appearance?
Q3: What happens to the normal architecture in diseased vessels on OCT?
Q4: What type of plaques appear as low-attenuating signal-rich (bright) lesions?
Q5: How do lipid-rich plaques appear on OCT?
Q6: What covers the high-attenuating signal-poor regions in lipid-rich plaques?
Q7: How do calcific plaques appear on OCT?
Q8: What characterizes the appearance of calcific plaques on OCT?
Q9: What type of thrombus is high-attenuating and casts a shadow on the vessel wall?
Q10: How does white thrombus appear on OCT?
Q11: What is the attenuation characteristic of fibrous plaques?
Q12: What is the attenuation characteristic of lipid-rich plaques?
Q13: Are calcific plaques sharply or poorly demarcated on OCT?
Q14: What is the most common pathology observed in the lumen on OCT?
Q15: What is the significance of shadows cast by thrombus on OCT images?
A1: Light reflected from the three vessel layers
A2: Intima, media, and adventitia
A3: Loss of normal trilaminar architecture
A4: Fibrous plaques
A5: High-attenuating, signal-poor (dark) regions
A6: Fibrous cap
A7: Low-attenuating, sharply demarcated signal-poor regions
A8: Low attenuation and sharp borders
A9: Red thrombus is black ( high absorbing or high attenuating )
A10: Low-attenuating (light) white thrombus is white
A11: Low attenuation, signal-rich (bright)
A12: High attenuation, signal-poor (dark)
A13: Sharply demarcated
A14: Thrombus (red or white)
A15: Indicates presence of dense material blocking the OCT signal
** white or bright = reflects the light that is why it is bright = does not absorb the light = low absorption means low attenuation.
*** dark = does not reflect the light = absorbs the light = attenuates ( high attenuation) the light.
** when the structure absorbs the light ( attenuates the light ) like lipid, everything beyond is shadowed because of the absorption. So you do not see structures beyond the lipid rich plaque.
***** calcium is an excpetion, it looks like sharply demarcated dark ellipses ( does not reflect light i.e. low signal and does not absorb light either i.e. black )
Q1: What high-resolution imaging modality enables identification of culprit lesions in ACS?
Q2: Name three types of culprit lesions identifiable by OCT in ACS.
Q3: How can identifying different causes of ACS be clinically useful?
Q4: How can OCT help in patients with spontaneous coronary artery dissections?
Q5: What type of MI can OCT help clarify regarding culprit lesions?
Q6: What does MI with nonobstructive coronary arteries refer to?
Q7: What is a high-risk vulnerable plaque identifiable by OCT?
Q8: What does TCFA stand for?
Q9: Why are thin-cap fibroatheromas clinically significant?
Q10: How does OCT contribute to the management of non-ST segment elevation MI?
Q11: What is an eruptive calcified nodule?
Q12: What is plaque rupture?
Q13: What is plaque erosion?
Q14: Can OCT distinguish between different pathological causes of ACS?
Q15: Is there further discussion about TCFA in other chapters?
A1: Optical Coherence Tomography (OCT)
A2: Plaque rupture, erosion, eruptive calcified nodule
A3: It allows tailored management of ACS
A4: By evaluating vessel wall and lesions
A5: Non-ST segment elevation MI
A6: MI without significant coronary artery obstruction
A7: Thin-cap fibroatheroma (TCFA)
A8: Thin-cap fibroatheroma
A9: They are prone to rupture and cause ACS
A10: By resolving ambiguity of culprit lesions
A11: A type of calcified lesion causing ACS
A12: A break in the fibrous cap exposing the necrotic core
A13: Damage to the endothelial layer without rupture
A14: Yes
A15: Yes
Q1: What imaging modality can guide PCI using a standardized approach?
Q2: What does pre-PCI OCT imaging assess to strategize the procedure?
Q3: How does lesion morphology assessment help in PCI planning?
Q4: What are proximal and distal stent landing zones identified by OCT?
Q5: Why is measuring vessel diameter important pre-PCI?
Q6: What is assessed post-PCI using OCT to optimize stent placement?
Q7: What does medial edge dissection detected by OCT indicate?
Q8: What is malapposition in the context of stenting?
Q9: What does underexpansion of stents require?
Q10: What does the mnemonic MLD stand for in pre-PCI OCT assessment?
Q11: What does the mnemonic MAX stand for in post-PCI OCT assessment?
Q12: How does OCT help in selecting balloon and stent sizes?
Q13: Why is it important to identify landing zones with minimal disease?
Q14: What is the clinical significance of detecting medial dissection post-PCI?
Q15: How does the MLD-MAX approach benefit PCI outcomes?
A1: Optical Coherence Tomography (OCT)
A2: Lesion morphology, stent landing zones, vessel diameter
A3: Determines appropriate lesion preparation strategies
A4: Zones with minimal or no disease for stent placement
A5: To select appropriate balloon and stent sizes
A6: Medial edge dissection, malapposition, underexpansion
A7: It may require additional stent implantation
A8: When the stent does not fully appose to the vessel wall
A9: Further postdilation
A10: Morphology, Length, Diameter
A11: Medial dissection, Apposition, eXpansion
A12: By providing accurate vessel measurements
A13: To reduce risk of edge complications
A14: It may cause adverse events if untreated
A15: Provides a systematic framework for PCI optimization
A1: Predominantly fibrous or lipid-rich plaques
A2: Noncompliant balloon, cutting/scoring balloon, atherectomy, intravascular lithotripsy (IVL)
A3: OCT
A4: The need for advanced calcium modification
A5: >50% of the circumference
A6: >0.5 mm
A7: >5 mm
A8: The “rule of 5”
A9: Atherectomy or intravascular lithotripsy (IVL)
A10: Because it provides detailed calcium assessment
A11: Stent expansion is lowest
A12: Intravascular lithotripsy
A13: To modify or remove calcified plaque
A14: Noncompliant cutting or scoring balloon
A15: To minimize vessel injury and optimize stent deployment
Q1: What lesion types may be prepared with an undersized balloon or direct stenting?
Q2: What types of balloons or devices are recommended for moderate-severe or severely calcified plaques?
Q3: Which imaging modality allows more detailed assessment of calcium, OCT or IVUS?
Q4: What can an OCT-based scoring system determine?
Q5: What is the maximum arc of calcium circumference associated with lowest stent expansion?
Q6: What is the maximum calcium thickness associated with lowest stent expansion?
Q7: What is the minimum calcium length associated with lowest stent expansion?
Q8: What is the name of the rule related to calcium characteristics in plaques?
Q9: What advanced calcium modification techniques may be needed for plaques meeting the “rule of 5”?
Q10: Why is OCT particularly helpful in assessing calcified plaques?
Q11: What happens to stent expansion in the presence of severe calcification?
Q12: What does IVL stand for?
Q13: What is atherectomy used for in plaque preparation?
Q14: What type of balloon is used for calcified plaques?
Q15: Why might undersized balloons be used in fibrous or lipid-rich plaques?
A1: Predominantly fibrous or lipid-rich plaques
A2: Noncompliant balloon, cutting/scoring balloon, atherectomy, intravascular lithotripsy (IVL)
A3: OCT
A4: The need for advanced calcium modification
A5: >50% ( 180 degree ) of the circumference is associated with the lowest stent expansion ( rule of 5 )
A6: >0.5 mm thickness is associated with the lowest stent expansion ( rule of 5 )
A7: >5 mm length is associated with the lowest stent expansion ( rule of 5 )
A8: The “rule of 5”
A9: Atherectomy or intravascular lithotripsy (IVL)
A10: Because it provides detailed calcium assessment
A11: Stent expansion is lowest
A12: Intravascular lithotripsy
A13: To modify or remove calcified plaque
A14: Noncompliant cutting or scoring balloon
A15: To minimize vessel injury and optimize stent deployment
Q1: What needs to be selected to determine lesion length?
Q2: What characteristics should proximal and distal reference segments have?
Q3: How is lesion length calculated?
Q4: Can reference segments be adjusted during lesion length measurement?
Q5: Why should lesion length correspond to the length of a drug-eluting stent?
Q6: What does this strategy help minimize?
Q7: What are stent edge problems?
Q8: What types of disease at reference segments can worsen clinical outcomes?
Q9: What does TCFA stand for?
Q10: Why is visibility of the vessel wall important in selecting reference segments?
A1: Proximal and distal reference segments
A2: Minimal atherosclerotic disease and greatest vessel wall visibility
A3: Automatically by imaging software
A4: Yes
A5: To match commercially available stent sizes
A6: Stent edge problems
A7: Problems at the edges of the stent such as restenosis or dissection
A8: Inflow and outflow disease, or TCFA
A9: Thin-cap fibroatheroma
A10: To ensure accurate measurement of lesion length
Q1: What are the two methods to determine appropriate device sizes?
Q2: Which strategy is preferred, EEL-guided or lumen-guided?
Q3: Why is the EEL-guided strategy preferred?
Q4: How much larger is the balloon or stent size typically with the EEL-guided strategy?
Q5: How is the stent size determined using the EEL-based strategy?
Q6: How is the stent size rounded in the EEL-based strategy?
Q7: What happens if the EEL is not well visualized?
Q8: What causes poor visualization of the EEL?
Q9: How is stent size determined when EEL is not well visualized?
Q10: How is postdilation balloon size determined?
Q11: Should the postdilation balloon size follow the same sizing strategy as stent size?
Q12: What does EEL stand for?
Q13: What is the significance of measuring at least one quadrant apart in EEL-guided strategy?
A1: External elastic lamina (EEL)-guided and lumen-guided strategies
A2: EEL-guided strategy
A3: It leads to larger balloon or stent size and larger lumen area
A4: Approximately 0.5 mm larger
A5: Based on EEL-based mean diameter of distal reference
A6: Rounded ** down to nearest available stent size
A7: Use mean lumen diameter of distal reference instead
A8: Attenuation from plaque at reference segments
A9: Rounded ** up to next available stent size
A10: Based on respective reference diameter measurements
A11: Yes
A12: External elastic lamina
A13 : To ensure accurate and representative measurement
Q1: What segments are assessed after PCI for medial dissection?
Q2: What imaging modality is used to identify post-PCI edge dissections?
Q3: What percentage of cases show post-PCI edge dissections on OCT?
Q4: Do most dissections detected by OCT have significant clinical impact?
Q5: What is the clinical significance of major edge dissections on OCT?
Q6: When is additional stent placement recommended for edge dissections?
Q7: What degree of circumference involvement defines a major dissection?
Q8: What minimum length of dissection extending into the media warrants additional stenting?
Q9: Are there exceptions to placing additional stents for major dissections?
Q10: Why is detecting medial dissection post-PCI important?
A1: Proximal and distal reference segments
A2: Optical Coherence Tomography (OCT)
A3: Up to 40%
A4: No, most heal without significant impact
A5: Predictor of adverse clinical outcomes
A6: If dissection involves ≥60° circumference and ≥3 mm length into media
A7: ≥60° of circumference
A8: ≥3 mm in length dissection lenght that extends into the media
A9: Yes, if anatomically prohibitive
A10: To prevent adverse outcomes by optimizing treatment
Q1: What does stent malapposition refer to?
Q2: How common is acute stent malapposition on OCT after implantation?
Q3: Does acute stent malapposition increase the risk of stent failure or thrombosis?
Q4: When should further optimization be considered for stent malapposition?
Q5: What length of malapposition is considered large enough to require optimization?
Q6: What additional factor associated with malapposition warrants further optimization?
Q7: What type of balloon inflation is usually sufficient to correct malapposition?
Q8: At what pressure is the semicompliant balloon inflated for optimization?
Q9: Why is proximal malapposition concerning?
Q10: What imaging modality detects stent malapposition?
A1: Lack of contact between stent struts and vessel wall
A2: Approximately 50% of cases
A3: *** No, it does not appear to increase risk
A4: Proximal malapposition interfering with rewiring, large malapposition >3 mm, or associated with underexpansion
A5: Greater than 3 mm in length
A6: Stent underexpansion
A7: Semicompliant balloon inflation
A8: Nominal pressure
A9: It can interfere with rewiring during future procedures
A10: Optical Coherence Tomography (OCT)
Q1: What is a major predictor of stent failure?
Q2: How can stent expansion be assessed?
Q3: What does MSA stand for?
Q4: What is the recommended absolute MSA for non-left main lesions?
Q5: What is the recommended relative stent expansion percentage?
Q6: How is relative stent expansion calculated?
Q7: Which is more important for predicting adverse outcomes: absolute or relative stent expansion?
Q8: Is achieving the absolute MSA value always possible in small vessels?
Q9: What percentage of cases achieve expansion goals based on relative stent expansion criteria?
Q10: What should be done if stent underexpansion is identified?
Q11: What pressure is recommended for balloon inflation to correct underexpansion?
Q12: What type of balloon is used for high-pressure inflation in underexpanded stents?
Q13: What risks should be considered when attempting further optimization for underexpanded stents?
Q14: Why is relative stent expansion important in clinical practice?
Q15: What is the clinical significance of achieving adequate stent expansion?
A1: Stent expansion
A2: By absolute MSA or relative expansion measures
A3: Minimal stent area
A4: Greater than 4.5 mm²
A5: Greater than 80% of mean proximal and distal reference lumen area
A6: MSA divided by mean reference lumen area
A7: Absolute stent expansion (MSA)
A8: No
A9: Approximately 50%
A10: High-pressure balloon inflation
A11: ≥18 atm
A12: Noncompliant balloon
A13: Risk of complications such as perforation
A14: Because absolute MSA may not be achievable in small vessels
A15: It predicts better clinical outcomes and reduces stent failure
Q1: What is one anatomical area where OCT has limited role?
Q2: Why is OCT limited in assessing aorto-ostial coronary segments?
Q3: Why is contrast use during OCT image acquisition prohibited in some patients?
Q4: Which patient group is affected by the prohibition of contrast use in OCT?
Q5: What anatomical feature of the left main coronary artery affects OCT imaging?
Q6: Why might the left main coronary artery caliber prohibit adequate flush clearance?
Q7: What alternative flushing agents have been investigated for OCT?
Q8: What issues remain with alternative flushing agents like normal saline?
Q9: What potential risk is associated with alternative flushing agents like normal saline ?
Q10: What is a general limitation of OCT related to blood clearance?
A1: Aorto-ostial coronary segments
A2: Difficulty clearing blood from coronary ostia
A3: Contrast use is prohibited in advanced chronic kidney disease
A4: Patients with advanced chronic kidney disease
A5: Large caliber
A6: It may prevent adequate flushing and blood clearance
A7: Normal saline and others
A8: Blood mixing and incomplete clearance
A9: Potential risk of arrhythmia
A10: Need for blood clearance for optimal imaging
Q1: What imaging technique identified adverse features warranting additional intervention in 35% of cases in the CLI-OPCI study?
Q2: What risk was reduced at 1 year with OCT-guided PCI after adjusting for confounders?
Q3: Which two imaging guidance methods were compared in the OPINION trial?
Q4: What was demonstrated about OCT guidance compared to IVUS guidance in the OPINION trial?
Q5: In the ILUMIEN III trial, OCT-guided PCI was noninferior to IVUS-guided PCI in terms of what measurement?
Q6: What type of trial was the OCTIVUS study (randomized or observational)?
Q7: How many patients were in the OCT-guided PCI group in the OCTIVUS trial?
Q8: How many patients were in the IVUS-guided PCI group in the OCTIVUS trial?
Q9: What composite endpoint was used in the OCTIVUS trial?
Q10: At what time point were outcomes measured in the OPINION and OCTIVUS trials?
Q11: What does PCI stand for?
Q12: What does IVUS stand for?
Q13: What does OCT stand for?
Q14: What does MSA stand for in the ILUMIEN III trial context?
Q15: What was the primary endpoint in the OPINION trial?
A1: OCT (Optical Coherence Tomography)
A2: Risk of myocardial infarction (MI) or cardiac death
A3: OCT-guided PCI and IVUS-guided PCI
A4: Noninferiority of OCT guidance compared to IVUS guidance ( TVF or target vessel failure at 1 year )
A5: Final Minimal Stent Area (MSA)
A6: Large-scale randomized controlled trial
A7: 1005 patients
A8: 1003 patients
A9: Cardiac death, target-vessel myocardial infarction (MI), or ischemia-driven target-vessel revascularization
A10: 1 year
A11: Percutaneous Coronary Intervention
A12: Intravascular Ultrasound
A13: Optical Coherence Tomography
A14: Minimal Stent Area
A15: Target vessel failure at 1 year
Q1: What trial compared OCT- and angiography-guided PCI in high-risk patients?
Q2: How many patients were in the OCT-guided group in the ILUMIEN IV trial?
Q3: How many patients were in the angiography-guided group in the ILUMIEN IV trial?
Q4: What measurement was larger in the OCT-guided PCI group compared to angiography-guided PCI in ILUMIEN IV?
Q5: What two factors contributed to larger stent expansion in OCT-guided PCI in ILUMIEN IV?
Q6: Was there a difference in the primary clinical endpoint between OCT and angiography guidance in ILUMIEN IV?
Q7: What clinical event was significantly reduced by OCT-guided PCI compared to angiography-guided PCI in ILUMIEN IV?
Q8: What trial compared OCT- and angiography-guided PCI in complex bifurcation lesions?
Q9: How many patients were in the OCT-guided group in the OCTOBER trial?
Q10: How many patients were in the angiography-guided group in the OCTOBER trial?
Q11: What was the composite endpoint reduced by OCT-guided PCI in the OCTOBER trial?
Q12: What trial studied intravascular imaging-guided PCI versus angiography-guided PCI in complex coronary lesions?
Q13: Which two imaging modalities were used in the RENOVATE-COMPLEX PCI trial?
Q14: Did the RENOVATE-COMPLEX PCI trial find consistent results between IVUS and OCT?
Q15: Are there differences in clinical outcomes between OCT- and IVUS-guided PCI according to the summary?
A1: ILUMIEN IV trial
A2: 1233 patients
A3: 1254 patients
A4: Final Minimal Stent Area (MSA)
A5: Selection of larger stents and more frequent postdilation at higher pressures
A6: No apparent difference
A7: Stent thrombosis
A8: OCTOBER trial
A9: 600 patients
A10: 601 patients
A11: Cardiac death, target-lesion MI, or ischemia-driven target-vessel revascularization
A12: RENOVATE-COMPLEX PCI trial
A13: IVUS and OCT
A14: Yes, consistent results in subgroup analysis
A15: No apparent difference
