Multiple utilities of OCT im guidimg PCI of left main coronary artery

Multiple utilities of OCT in guiding PCI of left main coronary artery
-The complete imaging solution

Learning points: OCT helped in different ways in this case of PCI to LMCA

54 years old male was referred for CAG following an admission with ACS – few weeks prior. He had good LV function, was a hypertensive, diabetic and smoker. 

CAG showed tight lesion in LAD, Occluded Ramus and a non-flow limiting irregularity in LMCA. Ramus was opened up and stented from near ostium. Since LM lesion was not clear, OCT was done. Showed plaque ruptures in both LAD and LMCA.  

Learning point 1 – Multiple plaque ruptures can occur simultaneously  and can be picked up by OCT. In this case LMCA lesion would have been left alone if OCT was not done.

Figure 1 : LAD tight lesion and LMCA mild irregularity

Figure 2: Shows plaque rupture in both LAD and LMCA.

LAD was stented with 3.5 x 18 mm SE Co – Cr Stent and LM-LAD was stented with  4 x 20 mm Pt-Cr SES. Stent size was chosen based on OCT and post-dilation was done based on OCT derived measurements. 

Post stenting there was haziness in the LAD stent, OCT showed well expanded stent with intraluminal thrombus (Figure 3). Anticoagulation was optimized and stent was given a  prolonged inflation with 3.75 balloon at 18 atmospheres after which the angiographic haziness disappeared.  

Figure 3: Haziness in LAD stent. Zoomed-up view of the segment.

Figure 4: Thrombus inside LAD stent.

USEFULNESS OF OCT IN THIS CASE.

1. Identifying two “culprit” lesions  with plaque rupture, the LMCA lesion would have missed.
2. Sizing of stent and optimization.
3. Imaging identified thrombus in LAD stent, which was corrected by prolonged post-dilation and optimizing anticoagulation.