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The introduction of multislice computed tomography angiography (MSCT) has provided new information for percutaneous coronary intervention (PCI), especially in complex lesions. It provides valuable adjustments about coronary lesions, which are predictors of procedural success, for example, in chronic total occlusions, in bifurcations and recently in aorto-ostial lesion PCI. In multiple fields, tomographic coronary analysis facilitates decision making by providing data that is unobtainable from conventional coronary angiography. The aim of this article is to assess the contribution of MSCT in PCI.

Aims: To assess whether a strategy of invasive management without stents in selected acute coronary syndrome (ACS) patients with a large thrombus burden (LTB) might be feasible and safe.\ud \ud Methods and results: We performed a prospective non-randomised observational cohort study of invasive treatment decisions guided by optical coherence tomography (OCT) in selected ACS patients with LTB. Among 852 ACS patients who had undergone invasive coronary angiography, 101 (11.8%) patients with large thrombus burden on initial angiography underwent thrombectomy to restore TIMI 3 flow without stenting. All of these patients then had repeat angiography with OCT (days 0-2 [Group 1], days 3-6 [Group 2] or days 7-30 [Group 3]). No adverse events occurred between the initial and second angiograms. Residual thrombus was detected in 68% of patients with OCT (respectively, 94%, 79% and 32% in Group 1, Group 2 and Group 3), and 20% of cases with angiography. Plaque rupture was detected by OCT in 65% of cases. Minimal lumen area was 2.81 mm2, 3.40 mm2 and 4.89 mm2 in Group 1, Group 2 and Group 3, respectively. Sixty-two percent of patients were stented (respectively, 76%, 61% and 50%). During a minimum follow-up period of 12 months in all patients, one non-fatal MI occurred and one PCI was performed for angina.\ud \ud Conclusions: Medical management without stents is safe and feasible in selected ACS patients with LTB. OCT revealed culprit lesion characteristics that were not disclosed by angiography and facilitated treatment decisions.

Background Time-domain optical coherence tomography (TD-OCT) allows assessment of the anatomy and features of unstable coronary artery lesions, including discrimination between the thrombotic and atherosclerotic plaque components. We sought to investigate the feasibility of thrombus quantification and its monitoring in patients with high thrombotic burden acute coronary syndromes. Methods Patients with successfully revascularized acute coronary syndromes and a large thrombus burden on initial coronary angiography who beneficiated from repeated TD-OCT examinations in our institution were suitable for inclusion. Coronary lesion stenosis degree was determined by quantitative coronary angiography (QCA) methods. Thrombus volume, maximal surface and minimal luminal area (MLA) were quantified by serial area measurement within the athero-thrombotic culprit lesion in 1 mm intervals before any stenting. Results Eleven patients underwent 2 consecutive TD-OCT examinations. The OCT image quality was suitable for thrombus quantification in n=9 subjects (89% men/ age=62.4±5.7y/ 89% STEMI). All patients were under anticoagulant and dual antiplatelet therapy between the two procedures (mean delay: 4.1±0.4 days). No adverse events were observed following OCT analysis. We measured a progressive reduction of thrombus burden between the two analysis, as assessed by the decrease of thrombus volume (5.3±1.7 vs.11.0±3.4 mm3, p=0.004), length (7.4±1.0 vs. 10.9±1.8 mm, p=0.02) and increase of MLA (2.5±0.6 mm2 vs. 1.8±0.3 mm2, p=0.02). However, the degree of stenosis analyzed by QCA didn’t significantly decrease over time (49.7±4.6% vs. 55.7±6.6%, p= 0.15). The thrombus volume reduction was time dependent, as witnessed by the high correlation between the percentage of thrombus volume decrease and the delay between analysis (R=0.87, p=0.002). The observed thrombus volume reduction rate was evaluated to 12% of the initial volume per day under medical therapy. Conclusion TD-OCT assessment of thrombus volume in patients with ACS is feasible, safe and could allow in vivo clot regression monitoring.