Real time 3D-OCT predicts restenosis by identifying geographic miss between overlapping stents after complex multivessel percutaneous coronary intervention

A 78-year-old male patient with a history of cerebrovascular accident and left hemiparesis presented with evolved inferior wall myocardial infarction and preserved left ventricle (LV) function. Coronary angiogram revealed triple-vessel disease. After heart team discussion, he was advised multivessel percutaneous coronary intervention (PCI). He underwent PCI to right coronary artery (2× sirolimus-eluting stent) in the first stage with good result. After 4 weeks, he again presented to the emergency department with acute coronary syndrome (ACS). He underwent imaging-guided left main (LM) bifurcation PCI (mini-crush technique) with 2 ×× everolimus-eluting stent (EES) across LM to left anterior descending artery (LAD) and 2 ×× EES in left circumflex artery (LCX). Real-time three-dimensional optical coherence tomography (3D-OCT) identified 1 mm geographic miss between overlapping stents in heavily calcified LAD. Cine fluoroscopy and intravascular ultrasound (IVUS) did not identify the same. In view of elderly age, already high contrast load, mild renal impairment, and low-risk OCT features, he was managed conservatively. He was doing well until 10 months after PCI, when he presented again to the emergency department with ACS and LV dysfunction. CAG showed critical in-stent restenosis (ISR) at the LAD stent overlap area. Other stents were all patent with mild ISR in LCx. He underwent PCI to LAD with 1 ×× EES. He is in follow-up for the last 1 year without any complaints and improved LV function. The availability of real-time 3D-OCT machines allowed us to easily identify “geographic miss” which is sometimes difficult to detect with cine flouroscopy or IVUS, particularly in heavily calcified vessels. This newer technology adds another dimension to intravascular imaging-guided PCI and has shown great promise particularly in complex and bifurcation PCI.