Percutaneous coronary intervention (PCI) of complex bifurcation lesions is challenging and associated with greater procedural risk and worse clinical outcomes compared with PCI of nonbifurcation lesions.¹ Angiographic visualization of bifurcation lesions is oftentimes inadequate, limiting precise stent implantation.

Optical coherence tomography (OCT) is an infrared light-based, high-resolution imaging modality that allows characterization of intravascular plaque morphology and precise vessel and stent measurements.² OCT provides higher-resolution imaging compared with intravascular ultrasound and can be valuable in complex bifurcation PCI.³ The OCT or Angiography Guidance for PCI in Complex Bifurcation Lesions (OCTOBER) trial studied the clinical outcomes of OCT guidance in complex bifurcation PCI compared with angiographic guidance alone.⁴

In this randomized trial, 600 patients were randomized to receive OCT-guided PCI and 601 patients received angiography-guided PCI. The primary outcome was composite of major adverse cardiac events (MACE) (cardiac death, target-lesion myocardial infarction, or ischemia-driven target-lesion revascularization) at a median follow-up of 2 years. MACE occurred in 59 patients (10.1%) in the OCT-guided PCI group and in 83 patients (14.1%) in the angiography-guided PCI group (hazard ratio, 0.70; 95% confidence interval, 0.50 to 0.98; P=0.035). Procedure-related complications were similar between the groups (6.8% vs. 5.7% of patients, respectively). Median contrast use and procedure time was 300 mL and 113 minutes in the OCT-guided PCI group and 200 mL and 80 minutes in the angiography-guided PCI group.

The OCTOBER Trial demonstrated that imaging-guided PCI using OCT was associated with lower MACE compared with angiography-guided PCI among patients undergoing complex bifurcation PCI. There was no difference in procedure-related complications between the two groups. The greater use of contrast and longer procedure time in the OCT-guided PCI group may be a consideration in certain patient populations such as those with chronic kidney disease.

References

1. Ninomiya K, Serruys PW, Garg S, et al. Predicted and observed mortality at 10 years in patients with bifurcation lesions in the SYNTAX trial. JACC Cardiovasc Interv 2022;15:1231-42.
2. Araki M, Park S-J, Dauerman HL, et al. Optical coherence tomography in coronary atherosclerosis assessment and intervention. Nat Rev Cardiol 2022;19:684-703.
3. Onuma Y, Katagiri Y, Burzotta F, et al. Joint consensus on the use of OCT in coronary bifurcation lesions by the European and Japanese bifurcation clubs. EuroIntervention 2019;14:e1568-e1577.
4. Holm NR, Andreasen LN, Neghabat O, et al; OCTOBER Trial Group. OCT or angiography guidance for PCI in complex bifurcation lesions. N Engl J Med 2023;389:1477-87.