Liệu cắt lớp quang học OCT có thể thay thế cho siêu âm trong lòng mạch IVUS? - Nguyễn Quốc Thái

Liệu cắt lớp quang học OCT có thể 
thay thế cho siêu âm trong lòng 
mạch IVUS? 
TS.BS. Nguyễn Quốc Thái 
Viện Tim Mạch Việt Nam 
Siêu âm trong lòng mạch (IVUS) 
• IVUS (Intravascular ultrasonography) là phương pháp chẩn 
đoán hình ảnh xâm nhập để cung cấp hình ảnh trong lòng 
mạch vành (cũng như các mạch máu khác). 
Ứng dụng của IVUS can thiệp ĐMV 
•Tính chất mảng xơ vữa 
•Kế hoạch trước PCI 
•Đánh giá kết quả sau PCI 
•Phát hiện các biến chứng trong PCI 
Tính chất mảng xơ vữa 
Phân loại mảng xơ vữa: 
• Mềm (Soft): giàu lipid 
• Xơ hoá (Fibrotic): phần lớn 
• Vôi hoá (Calcium) 
• Hỗn hợp (Mix plaque) 
Phân bố mảng xơ vữa: 
• Đồng tâm (concentric) 
• Lệch tâm (eccentric) 
Ứng dụng của IVUS 
Interventional Applications 
• Assessment of Target Lesion 
Lesion severity, size, length, atheroma burden, 
Plaque distribution and depth, presence of thrombi or dissection 
• Choosing balloon & stent 
 Balloon sizing 
 Stent sizing & length 
• Need for rotational atherectomy 
Proximal Reference 
Lesion Site (+ve 
remodelling) Distal Reference 
B1 B2 
Assessment for Intervention Sizing 
DES era – Stent most normal prox. to most normal distal 
• Use larger balloons at low pressures for unapposed stents 
Optimal Stent Deployment Criteria 
5 mm 
Balloon 
Needed 
Assess Complications - Dissection 
Stent edge dissection 
1.5 mm 0 7.5 mm 
Dissection 
2009 2011 2013 2014/2015 2016 
C7-XR™ System ILUMIEN™ System ILUMIEN™ OPTIS™ System OPTIS™ Integrated 
OPTIS™ Mobile 
• First Frequency 
Domain OCT System 
• 100 fps / 500 lines 
• Occlusion-free 
• Combined FFR and OCT 
• Wireless FFR 
• Advanced software tools 
• Real time 3D reconstruction 
• Tableside control from DOC 
• Fully Integrated into 
Cath Lab 
• Angio Co-registration 
• Tableside Controller 
• Angio Co-registration 
• Tableside Controller 
• Mobile cart connect into 
Cath Lab during procedure 
• For use in multiple 
Cath Labs 
Commitment to Innovation 
• Flexible fiberoptic catheter used for light 
delivery 
• Catheter rotates to create image frames 
• Catheter pulls back to map vessel 
segment 
How does it all work? 
Normal coronary artery 
 Uniform silhouette 
 3 layers visible in vessel wall 
Data on file at LLI 
Imaging 
catheter 
Guidewire 
shadow 
Adventitia 
Media 
Intima 
Healthy Artery – Normal Appearance 
The Role of OCT1 
OCT Imaging 
Pre-Intervention 
Assessment 
Stent Deployment 
Apposition, 
Expansion Final MSA, 
and Geographical Miss 
Complication 
and Post Procedural 
Assessments 
1. Assess plaque composition 
2. Identify reference segments 
3. Choose stent size 
4. Determine expansion/MSA 
5. Determine apposition 
6. Rule out geographical miss 
7. Identify edge dissections 
8. Identify tissue protrusion 
9. Confirm procedural success 
Ali, Ziad., When and How to Use OCT to Improve Procedural 
Outcomes. www.tctmd.com 
OPUSS Class: This 5 Centre Prospective study reported first large comparative data between the 
OCT versus matched IVUS images in human coronary arteries. 
Fig 1. Adapted from Kubo T, et. Al. 
High Resolution Leads to Measurement Accuracy 
7.45 
7.45±0.1
7 
7.45 
8.03±0.158 
Fig 2. Adapted from Kubo T, et. Al. 
Kubo T, et al. JACC Cardiovasc Imaging 2013;6:1095-1104 
Selecting Stent Diameter 
1 
2 
3.96 
3.90 
3.00 
2.87 
1 2 
1. Maximum diameter of the smaller reference. 
2. Average of the maximum diameters of the prox. and distal references. 
3. Maximum diameter of the largest reference. 
4. Mid-wall to mid-wall diameters (between lumen and media) 
5. Media-to-media diameter 
Increasingly 
Aggressive 
6. Abizaid, A. Use of Imaging to Optimize and Understand BRS. Presented at Coronary Intravascular Imaging and Physiology Symposium 2016. 
LCX 
Dx 
LM 
MLA 1.95 mm2 
Ø = 1.56 mm, AS = 76.5% 
From where to where? 
Lesion length 26 mm 
Area 8.29 mm2 
Ø = 3.12 mm 
Area 8.32 mm2 
Ø = 3.04 mm 
PRE-INTERVENTION ASSESSMENT WITH AUTOMATIC 
MEASUREMENTS1 
Ali, Ziad., When and How to Use OCT to Improve Procedural Outcomes. www.tctmd.com 
LCX 
Dx 
LM 
MLA 1.95 mm2 
Ø = 1.56 mm, AS = 76.5% 
From where to where? 
Area 8.32 mm2 
Ø = 3.04 mm 
Area 8.79 mm2 
Ø = 3.25 mm 
Lesion length 28 mm 
PRE-INTERVENTION ASSESSMENT WITH AUTOMATIC 
MEASUREMENTS1 
Area 8.29 mm2 
Ø = 3.12 mm 
Ali, Ziad., When and How to Use OCT to Improve Procedural Outcomes. www.tctmd.com 
OCT vs. IVUS 
SO SÁNH GIỮA IVUS VÀ OCT 
Vessel Sizing & BVS Choice: 
Adapted from Orimiston et. al 
Figure 1. 
A,Stenosis in the obtuse marginal 
branch of the left circumflex 
coronary artery before ABSORB 
bioresorbable vascular scaffold 
(BVS) implantation; 
B, artery after deployment of a 
3.0X18 mm ABSORB BVS 
scaffold and after dilatation with a 
3.25-mm noncompliant 
balloon at 24 atm. 
“Strut discontinuity and malapposition are not evident angiographically.the problem is best detected by OCT”3 
Fig. 1 mages Adapted 
Ormiston et. al. 
2.Ormiston et. al. Bioresorbable Polymeric Vascular Scaffolds: A Cautionary Tale. Circ Cardiovasc Interv. 2011;4:535-538 
3.Gomez-Lara et. al. Agreement and Reproducibility of Gray-Scale Intravascular Ultrasound and Optical Coherence Tomography for 
 the Analysis of he Bioresorbable Vascular Scaffold Catheterization and Cardiovascular Interventions 79:890–902 (2012) 
OCT has limitations where IVUS can still offer superior imaging 
OCT offers better image quality, but IVUS still has niche applications 
“Gót chân Achilles” của OCT 
Nhược điểm của OCT so với IVUS 
1. Hạn chế dùng OCT cho BN có suy thận: do sử dụng can 
quang làm sạch máu trong quá trình thủ thuật 
2. Không thu được hình ảnh tốt ở các tổn thương lỗ ĐM 
chủ (do không thể làm sạch máu từ ĐMC đến lỗ ĐM vành 
phải hoặc lỗ LMT). 
3. Do khả năng đâm xuyên nông nên không đánh giá được 
gánh nặng mảng xơ vữa (plaque burden) ở những tổn 
thương tái cấu trúc (remodeling). 
4. IVUS guide trong can thiệp tổn thương tắc mạn tính 
IVUS in CTO PCI 
IVUS guide 
Các bằng chứng lâm sàng OCT vs. IVUS? 
BULLET GUIDE BULLET GUIDE 
HEADER GUIDE HEADER GUIDE 
CLI-OPCI 
OCT improves outcomes 
vs. angiography 
OPUS-Class Study 
Reliability of OCT 
measurement vs. IVUS 
and angiography 
OCT Safety and Efficacy 
Non-occlusive OCT study 
SJM Commitment to Clinical Evidence 
ILUMIEN IV 
Randomized Controlled Outcomes 
Under Development 
Others areas under 
consideration: 
 Bifurcation 
 BVS 
 ACS 
ILUMIEN I 
Define and evaluate OCT 
stent guidance parameters 
and determine impact on 
physician decision-making. 
ILUMIEN II 
OCT vs IVUS comparison of 
stent expansion 
ILUMIEN III 
OCT/IVUS/Angio prospective 
randomized trial 
Past 
Present–2015 
Future 
 A total of 1,002 lesions (832 patients) were assessed retrospectively at 5 High Volume 
OCT Centres 
 Patients had a complex lesion profile (Ellis Class B2/C) 
 LM (4.8%), LAD (50.7%), LCx. (21.4%) RCA (22.7%) & Grafts (0.4%) 
 Primary objective: 
 The impact of the presence of an OCT-based suboptimal stent deployment on clinical 
outcome (MACE). 
OCT-guided strategy during PCI8
OCT plus angio can improve clinical 
outcomes 8 
Patients With 
Suboptimal OCT 
Deployment (n=254) 
Patients With Optimal OCT 
Deployment (n = 578) 
P value 
Events at 1-year follow-up 
MACE 64 (25.2%) 41 (7.1%) 0.001 
Death 11 (4.3%) 13 (2.2%) 0.104 
Myocardial infarction 42 (16.5%) 22 (3.8%) 0.001 
Periprocedural MI 11 (4.3%) 11 (3.31.9%) 0.050 
During follow-up 31 (12.2%) 11 (1.9%) 0.001 
Target lesion repeat 
revascularization 
42 (16.5%) 14 (2.4%) 0.001 
Stent Thrombosis 26 (10.1%) 4 (0.7%) 0.001 
Days of follow-up 312 (118-584) 324 (129-575) 0.536 
Prati, F, Romagnoli, E, Burzotta, F., Limbruno, U.Clinical Impact of OCT Findings During 
PCI The CLI-OPCI II Study JACC: Cardiovasc. Imaging Vol. 8 , No. 11, 2015 
CLINICAL HIGHLIGHTS FROM ILUMIEN II6 
KẾT LUẬN 
1. Siêu âm trong lòng mạch (IVUS) và chụp cắt lớp quang 
học nội mạch (OCT) đều có vai trò trong hướng dẫn can 
thiệp ĐMV làm giảm các biến cố cũng như cải thiện kết 
cục sau can thiêp. 
2. Sự lựa chọn kỹ thuật chẩn đoán hình ảnh phụ thuộc 
vào vị trí cũng như tính chất tổn thương ĐMV.