Illusion or reality? How 3-dimensional optical coherence tomography overcomes the limitations of angiography: OCT-guided percutaneous coronary intervention of left main stem disease involving LAD/LCx bifurcation

Angiography is still the workhorse imaging approach for the vast majority of percutaneous coronary revascularization (PCR) cases. However, the limitations of angiographic guidance for coronary procedures have been well established. This case report demonstrates how 3-dimensional optical coherence tomography (3D OCT) can change the treatment strategy, which, had only the angiography results been considered, seemed to be straightforward. A 67-year-old male patient presented with non-ST-elevation myocardial infarction. A coronary angiogram revealed a tight lesion of the proximal left anterior descending artery (LAD). Angiographically, the vessel ostium appeared not to be involved. To clarify the disease border and determine the right stenting strategy, 3D OCT was performed. Measurements revealed heavy disease of the LAD, ranging from the ostium to the left main coronary artery (LMCA). It was decided to proceed with a provisional stenting strategy of the LMCA and the LAD. After postdilatation, the angiography revealed a good result for the LAD, but significant pinching of the ostium of the LCx. The kissing balloon technique was then applied at the LAD/LCx bifurcation. The final OCT examination documented a well-expanded stent without areas of malapposition and an open LCx ostium without significant narrowing. Intracoronary images obtained using OCT add significant information to what is provided by angiography alone, thereby improving the interpretation of angiographic images and the planning of the PCR procedure.