Zero-Contrast Optical Coherence Tomography- and Physiology-Guided Percutaneous Coronary Intervention for Severely Calcified Lesion

An 80-year-old man with severe kidney dysfunction (estimated glomerular filtration rate, 26 mL/min/1.73 m²) not requiring hemodialysis presented with effort angina. Diagnostic angiography with minimum contrast showed a diffuse lesion in the proximal right coronary artery (RCA; Figure A). On a later day, optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) with dextran injection was performed. Because multiple cracks were seen in the severely calcified lesion after pre-dilation (Figure B,C; Supplementary Movie 1), an everolimus-eluting stent (3.25–33 mm) was implanted (Figure D). The final OCT showed sufficient luminal expansion (minimum stent area, 6.01 mm²; Figure E,F; Supplementary Movie 2), and the fractional flow-reserve (FFR) indicated no residual ischemia (Figure G–J). No contrast medium was injected during the procedure.

Figure.

(A) Angiogram showing a diffuse lesion in the proximal right coronary artery (RCA; arrowheads) and a moderate stenosis in the mid-RCA (arrow). (B) Dextran-based optical coherence tomography (OCT) showing thick calcification (asterisks) and crack formation (arrow) after balloon dilatation. (C) OCT showing cracks (arrowheads). (D) Implanted everolimus-eluting stent (EES). (E) OCT showing the well-dilated lesion with EES. (F) Absence of significant malapposition on OCT. (G) Fractional flow-reserve (FFR) wire positioned at the distal end of a moderate stenosis (arrowhead). (H) FFR at the arrowhead in G. (I) FFR wire positioned at the distal end of the EES (arrowhead). (J) FFR at the arrowhead in I.

The alternative dextran injection facilitated OCT of sufficient quality, and further FFR assessment confirmed that PCI was hemodynamically sufficient. Zero-contrast OCT-guided PCI in combination with FFR assessment is a promising option even for severe calcified lesion in patients with severe kidney dysfunction.¹

Disclosures

J.A. and Y.M. received lecture fees from Abbott Vascular. The other authors declare no conflicts of interest.

Supplementary Files

Supplementary Movie 1. Dextran-based OCT pullback showing a diffuse severely calcified lesion.

Supplementary Movie 2. Dextran-based final OCT pullback.

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-19-0302

Reference

• 1.   Ali ZA, Karimi Galougahi K, Nazif T, Maehara A, Hardy MA, Cohen DJ, et al. Imaging- and physiology-guided percutaneous coronary intervention without contrast administration in advanced renal failure: A feasibility, safety, and outcome study. Eur Heart J 2016; 37: 3090–3095.