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Endoscopic optical coherence tomography imaging

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Intravascular optical coherence tomography
Example of intracoronary optical coherence tomography (OCT) image of atherosclerosis. Between 6 and 8 o'clock it is possible to observe a fibrocalcific atherosclerotic plaque.

Intravascular optical coherence tomography (OCT) is a catheter-based imaging application of optical coherence tomography. It is an endoscopic imaging technology capable of acquiring high-resolution images from inside a blood vessel using optical fibers and laser technology.

One of its main applications is for coronary arteries, which are often treated by endoscopic, minimally-invasive surgical procedures. More recently, applications for peripheral arteries and for neurovascular procedures have been proposed and are being investigated. Neurovascular applications required significant technological developments, due to the highly tortuous anatomy of human cerebrovasculature.

Intravascular OCT rapidly creates three-dimensional images at a resolution of approximately 15 micrometers, an order of magnitude improved resolution with respect to intravascular ultrasound and X-ray coronary angiogram, the other imaging techniques adopted in clinical practice.[1] This offers additional information that can be used to optimize treatment and management of patients suffering from vascular disease.

Theory

OCT is analogous to medical ultrasound, measuring the backreflection of infrared light rather than sound. The time for light to be reflected back from the tissue under inspection is used to measure distances. However, due to the high speed of light, the backreflection time cannot be measured directly, but is instead measured using interferometry.[2]

OCT is measured using either time domain (TD-OCT) or frequency domain techniques (FD-OCT). Commercially available coronary OCT technology is based on Frequency domain techniques, resulting in a rapid acquisition procedures (1 to 2 seconds). Intracoronary OCT uses near-infrared light at 1300 nm and can visualize the microstructure of the arterial wall, its size, and therapeutic devices with high accuracy.

History

Initial goals of intravascular OCT were the imaging of atherosclerotic plaques characteristics in high resolution at 20 μm or better (to ascertain characteristics otherwise only available with histological techniques) and procedural guidance for catheter-bases coronary interventions.[2] The first report of endoscopic OCT was published in 1997, by researchers at the Massachusetts Institute of Technology and Massachusetts General Hospital. Team members included prof. James Fujimoto, Mark Brezinski, James Southern MD, PhD, Guillermo James Tearney, Micheal Hee, Joe Izatt, and Brett Bouma.

OCT achieves a superior resolution to intravascular ultrasound, the only intravascular imaging technology available at the time.[3] The first TD-OCT imaging catheter and system was commercialized by LightLab Imaging, Inc., a company based in Massachusetts formed following a technology transfer in 1997 from Fujimoto's lab (MIT). The most important technical advance for cardiology was the need for a reliable catheter/endoscope. The fiber optic catheter/endoscope required alignment of two optical fibers with 8 μm cores (one rotating) across free space.

The first intravascular in vivo imaging was in rabbit (1998), but blood (opaque to infrared light) needed to be displaced out of the field of view.[4] Index matching media (such as saline or contrast) was proposed to displace blood (i.e., red blood cells) from the arterial lumen.[5] The initial few years of the millennium did not see in vivo human imaging as only a few groups were capable. Researchers at Massachusetts General Hospital achieved first in human in vivo imaging in 2003.[6]

However, despite this important milestone, time-domain OCT required slow acquisitions (20-30 second long) which required the use of balloon occlusion techniques, preventing for several years a broader adoption. Sweep source lasers allowed for the development of Fourier-Domain OCT (FD-OCT). This enabled for the first time rapid acquisitions of a long coronary segment in a few seconds, allowing non occlusive brief contrast injections to clear the arterial lumen from blood. Initial demonstration of FD-OCT for coronary imaging was achieved in 2008-2009[7][8] which significantly accelerated clinical adoption starting in 2009.

Cardiovascular Medicine Applications

Following regulatory clearances in the major geographies between 2009 and 2012 of fast acquisition Fourier domain OCT, the use of intracoronary OCT rapidly increased.

In the last decade, clinical benefits of coronary OCT images have been investigated. Several studies have correlated the use of intravascular imaging such as IVUS and OCT to better stent expansion, a metric strongly correlated to better clinical outcomes in patients suffering from coronary artery disease and myocardial infarction.[9] [10] [11] [9] [12]

Recently, larger randomized clinical trials have been undertaken. In 2023, a double-blind prospective trial demonstrated improvement in morbidity and mortality in coronary bifurcation interventions: "Among patients with complex coronary-artery bifurcation lesions, OCT-guided PCI was associated with a lower incidence of MACE at 2 years than angiography-guided PCI."[13] Although not every study showed significant results[14], to date, several studies demonstrated the benefits in patient outcomes of using intravascular imaging during coronary arteries interventions.[15][16]

Data published in late 2016 showed that approximately 100,000 intracoronary optical coherence tomography procedures are performed every year, and its adoption is rapidly growing at a rate of ~ 20% every year.[17]

Assessment of artery lumen morphology is the cornerstone of intravascular imaging criteria to evaluate disease severity and guide intervention. The high-resolution of OCT imaging allows to assess with high accuracy vessel lumen area, wall microstructure, intracoronary stent apposition and expansion.[18][19] OCT has an improved ability with respect to intravascular ultrasound to penetrate and delineate calcium in the vessel wall that makes it well suited to guide complex interventional strategies in vessels with superficial calcification. OCT has the capability of visualize coronary plaque erosion and fibrotic caps overlying atheromas.[2]

Technology

The technology of most interest to clinicians and non-physicians are the catheter, technology for faster imaging (SS-OCT versus TD-OCT), the light source, and the potential for a guidewire. The most critical technological advance (besides identifying the optimal wavelength) was the catheter. The fiber optic catheter/endoscope required rapid alignment of two optical fibers with 8 μm cores (one rotating) across free space. The fiber itself is 120 microns so can be made into a guidewire unlike IVUS. The distal end has a focusing component (GRIN lens typically) and light directing component (usually prism). The fiber is fragile and needs external casing as a recent study using a Lightlab catheter in a joint had a high breakage rate.[20]

State-of-the-art intracoronary optical coherence tomography uses a swept-source laser to make OCT images at high-speed (i.e., approximately 80,000 kHz - A-scan lines per second) to complete acquisition of a 3D OCT volume of coronary segments in a few-seconds.[21] The first intravascular FD-OCT was introduced to the market in 2009 (EU and Asia) and in 2012 (US). In 2018, two intracoronary OCT catheters are clinically available for use in the coronary arteries, having a size in diameter between 2.4F and 2.7F. [citation needed]

The axial resolution of state-of-the-art commercial systems is less than 20 micrometers, which is decoupled from the catheter lateral resolution. The highest resolution of OCT allows for the in vivo imaging of vessel microstructural features at an unprecedented level, enabling visualization of vessel wall atherosclerosis, pathology, and interaction with therapeutic devices at a microscopic level.[22][citation needed]

Recent developments included the combination of OCT with spectroscopy and fluorescence in a single imaging catheter[23][24] and miniaturization of the imaging catheter.[25]

Safety

Safety of intravascular imaging, including intracoronary OCT and intravascular ultrasound, has been investigated by several studies. Recent clinical trials reported a very low rate of self-limiting, minor complications on over 3,000 patients where in all cases no harm or prolongation of hospital stay was observed. Intracoronary optical coherence tomography was demonstrated to be safe among heterogeneous groups of patients presenting varying clinical setting.[26]

Other intravascular applications: Neurovascular

In the last decade, significant advances have been made in the endovascular treatment of stroke, including brain aneurysms, intracranial atherosclerosis and ischemic stroke.[27] Intravascular OCT has been proposed has a key technology that can improve current procedure and treatments.[28] However, current intracoronary OCT catheters are not designed for navigation and reliable imaging of tortuous cerebrovascular arteries.[29]

Recently, refined OCT catheters have been proposed specifically designed for the human cerebrovasculature,[30] neuro optical coherence tomography (nOCT). A first clinical study to investigate safety and possibility conducted.[31] Initial applications for the treatment of brain aneurysms and intracranial atherosclerosis have been demonstrated[32][33][34] showing future potential.[35][36]

See also

References

  1. ^ Bezerra HG, Costa MA, Guagliumi G, Rollins AM, Simon DI (November 2009). "Intracoronary optical coherence tomography: a comprehensive review clinical and research applications". JACC. Cardiovascular Interventions. 2 (11): 1035–1046. doi:10.1016/j.jcin.2009.06.019. PMC 4113036. PMID 19926041.
  2. ^ a b c Brezinski ME, Tearney GJ, Bouma BE, Izatt JA, Hee MR, Swanson EA, et al. (March 1996). "Optical coherence tomography for optical biopsy. Properties and demonstration of vascular pathology". Circulation. 93 (6): 1206–1213. doi:10.1161/01.CIR.93.6.1206. PMID 8653843.
  3. ^ Brezinski ME, Tearney GJ, Weissman NJ, Boppart SA, Bouma BE, Hee MR, et al. (May 1997). "Assessing atherosclerotic plaque morphology: comparison of optical coherence tomography and high frequency intravascular ultrasound". Heart. 77 (5): 397–403. doi:10.1136/hrt.77.5.397. PMC 484757. PMID 9196405.
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  18. ^ Ughi GJ, Adriaenssens T, Onsea K, Kayaert P, Dubois C, Sinnaeve P, et al. (February 2012). "Automatic segmentation of in-vivo intra-coronary optical coherence tomography images to assess stent strut apposition and coverage". The International Journal of Cardiovascular Imaging. 28 (2): 229–241. doi:10.1007/s10554-011-9824-3. PMID 21347593.
  19. ^ Yabushita H, Bouma BE, Houser SL, Aretz HT, Jang IK, Schlendorf KH, et al. (September 2002). "Characterization of human atherosclerosis by optical coherence tomography". Circulation. 106 (13): 1640–1645. doi:10.1161/01.CIR.0000029927.92825.F6. PMID 12270856.
  20. ^ Martin S, Rashidifard C, Norris D, Goncalves A, Vercollone C, Brezinski ME (December 2022). "Minimally Invasive Polarization Sensitive Optical Coherence Tomography (PS-OCT) for assessing Pre-OA, a pilot study on technical feasibility". Osteoarthritis and Cartilage Open. 4 (4): 100313. doi:10.1016/j.ocarto.2022.100313. PMC 9576017. PMID 36263247.
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  22. ^ Brezinski ME, Tearney GJ, Bouma BE, Izatt JA, Hee MR, Swanson EA, et al. (March 1996). "Optical coherence tomography for optical biopsy. Properties and demonstration of vascular pathology". Circulation. 93 (6): 1206–1213. doi:10.1161/01.CIR.93.6.1206. PMID 8653843.
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  35. ^ Cooney E (2024-05-15). "To detect risk of stroke, tiny probe acts 'like a microscope' inside brain's blood vessels". STAT. Retrieved 2024-05-17.
  36. ^ ""Snake-like" Probe Images Arteries from Within - IEEE Spectrum". spectrum.ieee.org. Retrieved 2024-05-17.
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