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visible rotating sensor. A summary of the characteristics of the OCT systems is shown in Table 9.1. The Dragonfly OpStar imaging catheter has recently been redesigned with enhanced features. The catheter has a restructured lens for improved brightness and visibility of the EEM and plaque. The lens marker is now immediately proximal to the imaging lens. The newly designed shaft improves pushability through tortuous anatomy and a tapered three‐layer guide wire rail tip assists with lesion crossability. The reinforced guidewire port and straightened guidewire exit improve trackability.

Table 9.1 Comparison of optical coherence tomography systems.

	IVUS	HD ‐ IVUS	Ilumien Optis	Lunawave Terumo
Energy wave	Ultrasound	Ultrasound	Near‐infrared	Near‐infrared
Wavelegth (μm)	35–80	35–80	1.3	1.3
Axial resolution (μm)	100–150	100–150	10–15	10–20
Lateral resolution (μm)	150–300	150–300	20–30	20
Tissue penetration (mm)	4–8	4–8	1.5–2	1–2
Frame rate (frames/s)	30	30	180	158
Pullback speed (mm/s)	0.5–2	0.5–1	18 or 36	Up to 40
Maximal length pullback(mm)/duration (sec)	10/200	100	54/3 or 75/2.1	Up to 150 mm

Catheter preparation, calibration, image acquisition and fluoroscopic co‐localization

Purging with contrast is an essential step of catheter preparation. Because of the difficulty to inject the highly viscous contrast through the long thin hole around the probe, a high‐pressure syringe is provided. After connection and testing, calibration is the next essential step and must be performed when the catheter is already inserted at the start‐point of the pullback to correct for changes in length of the optic fiber caused by bending of the imaging wire and proximity to the vessel wall [6]. The rapid OCT pullback should be started only after optimal blood clearance that can be achieved via a manual injection through the guiding catheter or, better, using an automatic injector (ACIST Bracco, Italy; Medrad, Bayer, Germany). While the injection rate is similar or slightly higher than the customary 3 mL/s for the RCA and 4 mL/s for the LCA, the contrast volume should be increased to 15–20 mL to ensure full clearance throughout the pullback. High volume users mainly prefer manual selection of the pullback to avoid a too early start often observed, relying on the automatic system triggering. The use of contrast to replace blood is very efficient because it avoids swirling of blood when less viscous fluids are used but is contraindicated in patients with severe renal insufficiency. In most patients it is possible to obtain all the required information performing 2–3 imaging runs (before stenting and after stent optimization) sparing contrast in avoiding multiple views not required when the full three‐dimensional anatomy of the vessel can be clarified with OCT, especially in combination with coregistration that also eliminates the need of injections for balloon and stent positioning. The substitution of contrast with dextran or saline may offer a future solution for all these problems.

      If an angiographic acquisition is performed throughout the pullback, efficient built‐in software is available to follow the imaging tip during pullback and allow accurate matching of OCT with angiographic images. This facilitates accurate ballon/stent positioning during fluoroscopy at the desired sites. The AptiVue software upgrade has new features that will assist in achieving optimization targets as it was designed to follow the ILUMIEN IV protocol (NCT03507777). The software permits automated and rapid determination of stent expansion and apposition. The stent expansion analysis offers two modes: dual and tapered. In both, the stent is automatically detected, rendered, and divided in half to account for natural vessel tapering. It is important to note that all areas should be checked and manually corrected by the operator, when needed, prior to any treatment.

      Artifacts

Interpretation of OCT data and their application in clinical situations is limited by image artifacts (Figure 9.1). Blood contamination usually results from inadequate flushing and can be prevented by using power injection through a pump at a speed greater than the maximal coronary flow. Residual red blood cells disturb the OCT light beam, reducing the visibility and brightness of the vessel wall (Figure 9.1b); blood swirling along the vessel wall can be mistaken for thrombus. Physiologic phenomena such as cardiac motion, vessel pulsatility, or, to a lesser extent, catheter movement and respiratory movements are associated with typical artifacts (Figure 9.1c). Dense objects such as guidewires, metallic stent struts (Figure 9.1a) completely obstruct the OCT signal, leading to a loss of signal and no visualization behind them. Compensation algorithms are been tested to reduce shadowing and improve signal from the deepest tissues [7]. “Sew‐up” artifacts appear as a result of rapid vessel movement during imaging, but they are less prominent than in the much slower IVUS pullbacks and have become clinically irrelevant at the high pullback speeds of the newest OCT systems. Imaging modalities that use a mechanically rotated endoscopic probe to scan an artery often suffer from image degradation caused by a variation in the rotational speed of rotating optical components during image acquisition [8]. This occurs in the presence of acute angulations, tight hemostatic valve, kinking of the imaging sheath, a defective catheter, or while the catheter crosses a tight stenosis. Saturation artifact occurs when the signal from a highly reflective surface exceeds the dynamic range of the detector (Figure 9.1d). Tangential signal dropout happens when the beam strikes the tissue with a near parallel angle, a signal‐poor area with diffuse borders, covered by a thin signal‐rich layer arises (Figure 9.1e), and mimics a lipid‐rich plaque with a fibrous cap [9].

Figure 9.1 Frequent artifacts in optical coherence tomography imaging. (a) Shadowing of guidewire (asterisk) and stent struts. (b) Residual blood. (c) Motion artifact (“sew‐up”). (d) Saturation

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