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BOOM: A New Technique Guided by OCT

A novel approach could increase precision of stent placement at bifurcation points.

Issue: January/February 2019

ByEvan Shlofmitz, DO

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Bifurcation lesions continue to pose many challenges to successful PCI and optimal outcomes. Multiple strategies and techniques have been described. Now, there is a new OCT-guided technique that could improve how a stent is implanted during PCI for bifurcation lesions.

OCT allows comprehensive evaluation of the carina in a bifurcation and identification of coronary ostia. Using angiographic co-registration (ACR) with OCT, an operator can localize precisely where a stent can be implanted to ensure complete coverage of the ostium, avoiding geographic miss while minimizing stent protrusion into the proximal main branch.

The BOOM Technique

Working with Allen Jeremias, MD, director of interventional cardiology research and associate director of the cardiac catheterization laboratory at St. Francis Hospital-The Heart Center, Richard A. Shlofmitz, MD, chairman of the department of cardiology at St. Francis, and Cardiology Today’s Intervention Editorial Board Member Jeffrey Moses, MD, director of advanced cardiac interventions at St. Francis and director of interventional cardiovascular therapeutics at Columbia University Medical Center, our team developed a novel technique termed Bifurcation and Ostial OCT Mapping (BOOM). First described in a case report published in Cardiovascular Revascularization Medicine in May, we demonstrated that OCT-ACR permits clear-cut accuracy with stent placement at an ostial location. This can be easily confirmed with post-PCI OCT.

Angiography alone can be inaccurate in identifying the exact bifurcation or ostial origin and despite obtaining multiple angiographic views, angiographic guidance often results in stent placement either short of the target or overlapped with the parent vessel. Both of these situations are undesirable, with the potential for increased restenosis. Incorporating OCT-ACR allows dynamic, real-time feedback to ensure localization and stent implantation into the intended segment (Figure).

Source: Evan Shlofmitz, DO. Printed with permission.

Stent Implantation Improved

At the TCT 2018 conference in September, initial results from use of the BOOM strategy were presented from a prospective registry. Utilizing this strategy in 44 patients undergoing PCI at a bifurcation point with a single-stent strategy guided by OCT-ACR (Optis Integrated System, Abbott Vascular), stent implantation occurred within 3 mm of the intended location in all cases. The primary endpoint of precise stent placement within 1 mm of the ostial lesion occurred in more than 84% of cases. No patient had greater than 1 mm stent strut protrusion beyond the bifurcation, with minimal geographic miss. For the initial feasibility study, this technique was limited to cases with a single-stent strategy with disease extension up to but not beyond the ostium, but it can be incorporated with two-stent treatment of bifurcation lesions to minimize stent strut overlap in the main branch. In a two-stent bifurcation strategy, BOOM allows avoidance of a crush, preserving the intended stent architecture.

Whether there are long-term clinical benefits to the BOOM approach remains to be evaluated in future studies. Initial data, however, demonstrate this technique is both feasible and easily reproducible to predict and control where a stent is implanted.

• References:
• Sawaya FJ, et al. JACC Cardiovasc Interv. 2016;doi:10.1016/j.jcin.2016.06.056.
• Shlofmitz E, et al. Cardiovasc Revasc Med. 2018;doi:10.1016/j.carrev.2018.05.005.
• Shlofmitz E, et al. J Am Coll Cardiol. 2018;doi:10.1016/j.jacc.2018.08.1569.

• For more information:
• Evan Shlofmitz, DO, is an interventional cardiology fellow at Medstar Washington Hospital Center, Georgetown University School of Medicine, and was previously an intravascular imaging and physiology fellow at the Cardiovascular Research Foundation/Columbia University Medical Center. He can be reached at evan.shlofmitz@medstar.net.

Disclosure: Shlofmitz reports no relevant financial disclosures.