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Artis zee
OPTIS™ Integrated Angio Co-Registration (AC-R) WorkflowErnest Horsley
Cath Lab RadiographerHeart & Stroke Unite Netcare Blaauwberg Hospital
March 2016
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OPTIS™ Integrated Onboarding Program Erasmus MC Rotterdam Rotterdam March 7th and 8th 2016
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Optical Coherence TomographyCo-Registration Integration
The OPTIS™ workflow consists of acquiring and selecting a dedicated X-ray image to be used for co-registration, determining the vessel centreline, and performing of the pullback
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Limitations of Angiography
It’s a Lumenogram of contrast media Flat 2D image of a 3D vessel Limited information about - Type of Plaque
- Generalised Disease- Vessel Wall- Stent Placement- Stent Deployment
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Architecture Outlines
OPTIS™ Integrated System Architecture Dragonfly™ OPTIS™ Imaging Catheter features OPTIS™ Integrated System Settings Injector Pump Settings X-Ray Equipment Settings
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OPTIS™ Integrated System Architecture
Tableside Controller
OPTIS™SystemCabinet
Drive-motor & Optical Controller (DOC)
Dragonfly™ OPTIS™Imaging Catheter
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OPTIS™ Integrated System ArchitectureTableside Controller
Wi-Box™FFR
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OPTIS™ Integrated System ArchitectureTableside Controller
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OPTIS™ Integrated System ArchitectureDrive-motor & Optical Controller (DOC)
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Dragonfly™ OPTIS™Imaging Catheter
Outer Diameter 2.7 Fr (0.90mm) Distal 280mmLow-profile tip
Delivery Rapid Exchange MonorailDual lumen
Working Length 135cmCoating Hydrophilic coating
Min Guiding Cath 6 Fr Guide Catheter 100cmNo Sideholes
Max Guide Wire 0.014”
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Dragonfly™ OPTIS™Imaging Catheter
PreparationFlush 3.0 ml Undiluted ContrastWipe Heparinised SalineImaging Catheter for OPTIS™ Integrated System
ILUMIEN™ OPTIS™ILUMIEN™ PCI Optimization™ Systems
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Dragonfly™ OPTIS™ Imaging Catheter
Imaging Catheter
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Scan Length
Survey High *Resolution
75 mm 54mmLesion Survey
Stent Survey
Triger Manual AutomaticAcquire Angio Yes No*
OPTIS™ Integrated System Setting
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Pullback type Survey High Resolution*Pullback length 75 mm 54mm**Pullback speed180 frames/sec
36 mm/sec5 fpmm
18 mm/sec10 fpmm
Pullback time 2,1 sec 3,0 secPullback file size 375 MB 540 MB
OPTIS™ Integrated System Setting
* Default ** Stent Evaluation
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Automatic Pullback Injector Pump Settings
Contrast Strength 300 – 400 mg I/mlContrast Pressure 600 PSI minimum
> 450 PSI Acist > 300 PSI Medrad
Rise Time No Rise 0.0 SecContrast Volume* 14ml @4ml/s = 3.5 sec
12ml @3ml/s for RCA
It takes < 2 seconds to fill the artery to the distal pointIt takes 2,1 second for a pull back at 75mm/sec (Survey Mode 75mm @ 5fpmm)
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Manual Pullback Injector Pump Settings
Contrast Strength 300 – 400 mg I/mlContrast Pressure 600 PSI minimum
> 450 PSI Acist > 300 PSI Medrad
Rise Time No Rise 0.0 SecContrast Volume* 35ml @3ml/s = 11.6 sec
40ml @4ml/s = 10 sec
3ml/s for Regular Coronary Angiogram4ml/s for CABG & Large vessels12 – 18 ml Contrast use should be achieved
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X-ray Equipment Settings
Frame rate of 30fps > 15fps Un-subtracted image (DA not DSA) Co-Registration on A-Plane only (Bi-Plane)
Co-Registration software needs to register the OCT imaging catheter position
Start Acquisition Before Pull Back initiated End Acquisition After Pull Back has ceased
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Procedure Outlines
Key Benefits of AC-R Good AC-R Practice
Co-Registration Workflow
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Key Benefits of Angio Co-Registration
Facilitates OCT-guided PCI therapy Collects key clinical vessel information with 1 angio Reduces learning curve to assess location of OCT Increases confidence in position of OCT features Improves workflow efficiency into PCI Reduction in contrast & radiation wrt OCT wo AC-R
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Artery Selection
Lesion Length Suitable Landing zone beyond stenosis
Reasonable Calibre Not Excessively Torturous
Eccentricity Collaterals Reference Vessel Diameter – MLA >4.0 mm2
OCT > IVUS stenosis severity in vessels <3.0 mm
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Good Angio Co-Registration PracticeGood Angio Acquisition is key for successful AC-RAcquisition The cine recording must encompass the
entire OCT pullback, Start to End
Field of View X-ray equipment must be Stationery From the Guiding Catheter tip to the
radiopaque section of the Guidewire
Views Avoid vessel Foreshortening Overlapping branches *(Spider view) Radiopaque structures (clips, devices)
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Good Angio Co-Registration PracticeGood Angio Acquisition is key for successful AC-RSoftware Designed for Coronary Angio (Dist-Prox)
Guide Cath• Good engagement in vessel ostium• Stable • No Sideholes
Workflow • One person co-ordinates workflow• Talk the Procedure
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Good Angio Co-Registration PracticeIf you can see the imaging catheter radiopaque marker band on the angio, so can the software
Proximal Guide Catheter Radiopaque MarkerGood engagement
Distal Guidewire Radiopaque Marker
OCT Lens
Software reads image from Distal (Inferior) to Proximal (Superior)
Avoid vessel foreshortening & overlapping branches
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Co-Registration Workflow
In the Patient Summary menu (or after adding a new patient),click + New OCT Recording at the bottom of the screen
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Dragonfly™ OPTIS™ Imaging Catheter
Remove Imaging Catheter from the sterile packaging & place it onto the sterile field, along with the DOC cover and 3 ml syringe
Gently remove the Imaging Catheter from its hoop
Wipe the shaft with gauze moistened with heparinized saline to activate the hydrophilic coating
Gently purge the catheter through the side port with supplied 3 ml syringe filled with 100% contrast until 3 to 5 drops exit tip. Leave syringe attached for repeat purging in vivo prior to each imaging pullback
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Drive-motor & Optical Controller
Insert the DOC into the sterile bag
Remove the cap from the catheter
Align hub tabs with notches, push the hub into the DOC until it cannot go any further, and twist slightly clockwise until it locks
Observe that the LED lights flash as the DOC connects, and that the system performs an automatic calibration
Establish that the OPTIS™ system has recognized the appropriate imaging catheter on the monitor
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Load the imaging catheter onto the guidewire.
Confirm the recording settingsPullback TypeTrigger TypeAcquire Angio etc. – in the upper left hand corner of the screen
And Pump Injector settings check
Ensure that the imaging catheter is not rotating, if necessaryClick on Standby View or press the Live View button on the DOC
Dragonfly™ OPTIS™ Imaging Catheter
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Under fluoroscopic guidance, advance the catheter to the target area, so that the Lens Marker and Proximal Marker will frame the area of interest
Ensure Acquire Angio is selected if co-registration is desired and then press the Live View button on the DOC or click on Live View on the screen to start live-scan imaging
Confirm that the imaging core is still purged of bloodPlace system in Standby View to purge againAfterwards, return to Live View to confirm
Dragonfly™ OPTIS™ Imaging Catheter
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Dragonfly™ OPTIS™ Imaging Catheter
Confirm that the imaging core is still purged of bloodPlace system in Standby View to purge againAfterwards, return to Live View to confirm
Blood in Lumen Clear Lumen
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Click Auto Calibrate on the screen or the Enable button on the DOC to auto calibrate the catheter
Inject a small puff of contrast through the guide catheter to determine adequate blood clearance of the distal vessel
This will help determine guide catheter alignment and position prior to image acquisition
Dragonfly™ OPTIS™ Imaging Catheter
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Automatic OCT PullbackOnce ready to coordinate the cine, flush, and OCT pullback, click Enable Pullback
Step on the cine pedal and begin the flush protocol to start the pullbackThe flush protocol is the same as all OCT recordings
Step off the cine pedal after the OCT pullback has completed.
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Automatic OCT PullbackOnce ready to coordinate the cine, flush, and OCT pullback, click Enable Pullback
Step on the cine pedal and begin the flush protocol to start the pullbackThe flush protocol is the same as all OCT recordings
Step off the cine pedal after the OCT pullback has completed.
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Manual OCT PullbackOnce ready to coordinate the cine, flush, and OCT pullback, click Enable Pullback
Step on the cine pedal and Begin the flush protocol Start the pullback
Pullback stopsEnd the flush protocolStep off the cine pedal
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OCT-Angio Co-RegistrationClick on the Co-Register button in the lower right-hand corner of the screen to start the co-registration workflow
Choose the frame of angiography that will display the entire vessel best
Note if Imaging Catheter is disconnected the buttons at the bottom of the screen swap
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OCT-Angio Co-RegistrationAfter choosing the best frame, plot at least 2 control points within the target vessel where the OCT pullback was performed
The first control point should be placed near or on the radiopaque portion of the guidewire, within the target vessel, by clicking once to place it
At least one more control point needs to be placed within the target vessel, closer to the distal tip of the guide catheter
The user may choose to place several more control points to ensure that the software tracks along the pullback, but these additional points also need to be selected from distal to proximal
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OCT-Angio Co-RegistrationTips for good control point placement
Control points must be placed from distal to proximal on the guidewire
Ensure the control points are within the target vessel
The first and last control points must encompass the OCT pullback between them
Do not place a control point in the contrast cloud/reflux into the aorta
Do not double back – Restart
Verify that the path displayed on the OCT pullback aligns with the target vessel. Click on Confirm
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OCT-Angio Co-RegistrationReview the software tracking the Lens Marker in the left image and the entire pullback traced in the right image and if accurate, click on Accept
Verify the accuracy of the co-registered pullback by moving the Current Frame Indicator to a location that displays a visible anatomical landmark and see if this correlates with the location of the lens on the angiography
The lens is represented by a small white rectangle if the software is certain of the pullback tracking – red if not.
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OCT-Angio Co-RegistrationPrior to starting any measurements or opening the Lumen Profile, the software will prompt a calibration verification step when using Dragonfly™ Imaging Catheter or Dragonfly™ Duo Catheter
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OCT-Angio Co-RegistrationWhen complete, click End Review to return to the Patient Summary screen
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Unload DOCDisconnecting Imaging Catheter from DOC
Always press the Eject button before removing the Imaging Catheter, failure to do so can damage the DOC
Unloading Imaging Catheter
Ensure that the imaging catheter is not rotating, if necessary press the Live View button on the DOC
Press Eject button on the DOCThe probe retracting is audible and the Pullback motion LEDs blink
When LEDs stop blinking disconnect the imaging catheter by turning it anti-clockwise
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Despite the overall attractiveness of OCT, some drawbacks include
• Need for extra contrast• Limited ability to image very large vessels given limited depth of penetration (imaging
>4.5 mm diameter vessels is difficult)• Difficulty to image true aorto-ostial disease (IVUS is preferred in this scenario)• Blood pool artefact (this occurs when the lumen is not devoid of blood because of
inadequate contrast injection – the erythrocytes cause a severe scatter of light)• Stitch artefact (usually only subtle and not a major issue; this artifact relates mostly to
catheter movement within the vessel and appears as an abrupt step in the vessel wall)• If the catheter does not sit coaxially within the vessel then an oblique cut may be made
through the lumen and vessel wall• Given the imaging catheter remains in the artery, there may be a tendency to straighten
the vessel, cause vessel concertina and perhaps even distort stents of questionable longitudinal Strength
• In the early phases of operator inexperience, there can be difficulty identifying calcium and differentiating it from lipid rich plaque
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Acknowledgements
Slides And Resources
Jurgen Ligthart, Erasmus MC RotterdamFelipe Hernandes, MadridMuhammad Naveed Saeed, Riyadh
THANK YOU
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