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21
Figure Legends
Figure 1. Definition process of predicted and actual ablation according to OFDI
before and after rotational atherectomy and a representative case of OFDI
findings following rotational atherectomy.
(A) Definition process of the predicted and actual ablation areas. Cross-sectional
OFDI image (1) before and (2) after RA. (3, 4) Superimposed OFDI images of
before and after RA. The blue dotted line area indicates the predicted ablation area
(P-area). The yellow dotted line indicates the actual ablation area (A-area). White
circle indicates the Rota burr size circle (1.75 mm). (3) The red dotted line indicates
where the P-area and A-area overlapped (O-area). (4) Blue, yellow, and red angles
indicate the P-, R-, and O-angles, respectively. (B) Deep vessel wall injury extending
beyond the media before (1) and after RA (2). Blue area indicates P-area. Yellow
area indicates A-area. White circle indicates the Rota burr size circle (1.50 mm).
Asterisks show deep vessel wall injury extending beyond the media following RA on
above image. (C) Intimal flap outside of P-area (1) before and (2) after RA. White
arrowhead indicates intimal flap outside of the P-area following RA. White circle
indicates the Burr size circle (2.00 mm). OFDI, optical frequency domain imaging;
RA, rotational atherectomy.
Figure 2. Distribution of %Correct-angle.
Figure 3. Distribution of %Correct- and %Error-areas in all cross-sections.
All cross-sections were plotted according to %Correct- and %Error-areas. The
median %Correct- and %Error-areas were 43.1% and 64.2%, respectively. %Correct-
22
area, the ratio of correctness area; %Error-area, the ratio of error area.
Figure 4. Representative angiography and OFDI of good prediction and
irrelevant ablation cases.
(A) Good prediction. (B) Irrelevant ablation. Angiography images with (upper left)
and without contrast (lower left) are shown. OFDI results before and after rotational
atherectomy are shown (right). White double-head arrow indicates target lesions.
White triangles indicate wire position. White circles indicate the circle with Rota
burr dimensions. Blue dotted line indicates the predicted ablation area (P-area).
Yellow dotted line indicates the actual ablation area (A-area). The green dotted area
indicates the P-area with wire-based prediction. (A) In the leftmost cross-sections, Pand A-area were measured as 0.89 mm2 and 0.86 mm2, respectively, and O-area
(where overlapped P- and A-area) was 0.86 mm2. The %Correct- and %Error-area
were calculated to be 96.6% (O-area / P-area×100) and 0% ([A-area − O-area / Aarea]×100), respectively. After conducting similar measurement and calculation on
each cross-section, the mean %Correct-and %Error-area for each lesion were
calculated by the sum of %Correct-and %Error-area for each cross-section divided
by the number of cross-sections of the lesion. The mean %Correct- and %Error-area
were calculated to be 55% and 8%, respectively. (B) The mean %Correctand %Error-areas were 29% and 74%, respectively. OFDI, optical frequency domain
imaging; RA, rotational atherectomy; P-area, predicted ablation area; A-area, real
ablation area.
23
Table 1. Patient, lesion, and procedural characteristics
Overall
Patients, n
Age, yrs
Male, n (%)
Comorbidities
Hypertension, n (%)
Diabetes mellitus, n (%)
Dyslipidemia, n (%)
Chronic kidney disease, n (%)
25
70.5 ± 10.1
20 (80)
20 (80)
14 (56)
19 (76)
15 (60)
Hemodialysis, n (%)
Diagnosis
Stable angina pectoris, n (%)
Acute coronary syndrome, n (%)
Lesion, n
Cross-section, n
Target vessel
LAD, n (%)
LCx, n (%)
RCA, n (%)
6 (24)
25 (100)
0 (0)
26
334
15 (58)
6 (23)
5 (19)
Target lesion
Proximal, n (%)
Mid, n (%)
Distal, n (%)
Approach site
Transfemoral, n (%)
Transradial, n (%)
Guiding catheter type
Judkins, n (%)
Extra back up, n (%)
Amplatzer, n (%)
13 (50)
11 (42)
2 (8)
17 (65)
9 (35)
6 (23)
13 (50)
7 (27)
Rotawire type
Floppy wire, n (%)
Extra-support wire, n (%)
Burr size
1.50 mm, n (%)
16 (62)
10 (38)
15 (58)
24
1.75 mm, n (%)
2.00 mm, n (%)
2.15 mm, n (%)
QCA analysis
Lesion length, mm
Reference diameter, mm
MLD, mm
%Diameter stenosis, %
Burr-to-artery ratio
9 (34)
1 (4)
1 (4)
19.9 (17.5–22.8)
2.77 (2.20–3.18)
1.06 (0.83–1.26)
60.5 (47.5–67.1)
0.47 (0.39–0.53)
Values are expressed as median (interquartile range) or n (%). Abbreviations:
LAD, left anterior descending; LCx, left circumflex; MLD, minimum lumen
diameter; RCA, right coronary artery.
25
Table 2. OFDI measurements before and after rotational atherectomy according
to cross-section-based analysis
Overall
Pre/post-operative lumen measurements
n=334
Pre minimum lumen diameter, mm
1.62 (1.19–2.08)
Pre mean lumen diameter, mm
1.90 (1.53–2.48)
Pre lumen area, mm²
2.84 (1.84–4.88)
Burr/pre lumen ratio
0.88 (0.65–1.09)
Post minimum lumen diameter, mm
2.01 (1.67–2.28)
Post mean lumen diameter, mm
2.39 (2.01–2.71)
Post lumen area, mm²
4.48 (3.17–5.76)
Morphology of calcification
n=334
Arc of calcium, °
154.9 (97.3–257.4)
Minimum depth of calcium, µm
800 (540–1080)
Circumferential calcification, n (%)
104 (31.1)
Eccentric calcification, n (%)
123 (36.8)
Nodular calcification, n (%)
107 (32.0)
Location of myocardial site, n (%)
157 (68.2)
Location of pericardial site, n (%)
73 (31.8)
RA-related measurement
Angle-based analysis
n=311
P-angle, ˚
127.1 (65.3–218.7)
A-angle, ˚
102.9 (70.6–142.3)
O-angle, ˚
64.6 (23.9–118.1)
%Correct-angle, %
55.3 (22.6–90.1)
Area-based analysis
n=334
P-area, mm²
0.47 (0.20–0.74)
A-area, mm²
0.54 (0.28–0.99)
O-area, mm²
0.18 (0.05–0.35)
%Correct-area, %
43.1 (14.9–69.4)
%Error-area, %
64.2 (31.4–90.4)
OFDI and wire position
n=334
Minimum distance between the OFDI catheter and intima, mm
0.001 (0–0.155)
Minimum distance between the wire and intima, mm
0.20 (0.10–0.33)
Minimum distance between the OFDI catheter and wire, mm
26
0.02 (0–0.05)
OFDI findings following RA
n=334
Deep vessel wall injury extending beyond media, n (%)
14 (4.2)
Intimal flap outside of the P-area, n (%)
26 (7.8)
Values are expressed as median (interquartile range) or n (%). Burr/lumen ratio was calculated
by dividing the Rota burr size by the mean lumen diameter. %Correct-angle was calculated as
O-angle divided by P-angle. %Correct-area was calculated as O-area divided by P-area. %Errorarea was calculated as A-area minus O-area divided by A-area. Abbreviations: RA, rotational
atherectomy; OFDI, optical frequency domain imaging; P-area, predicted ablation area; A-area,
actual ablation area; O-area, overlap ablation area; P-angle, angle of predicted ablation area; Aangle, angle of actual ablation area; O-angle, angle of overlap ablation area; %Correct-angle
(area), percentage of correct ablation angle (area); %Error-area, percentage of error ablation
area.
27
Table 3. Univariate and multivariate logistic regression analyses according to the good prediction group
Variables
Univariate
Multivariate
OR
95% CI
P value
OR
95% CI
P value
LAD
Floppy wire
1.99
1.86
1.21 – 3.29
1.12 – 3.09
0.007
0.016
2.59
1.45 – 4.62
0.001
Judkins type guiding catheter
Pre lumen area
Burr / lumen ratio
Distance between the OFDI catheter and intima
Distance between the wire and intima
Distance between the OFDI catheter and wire
Myocardial site calcification
0.89
0.70
8.17
0.00
0.18
0.03
0.69
0.49 – 1.61
0.60 – 0.81
3.61 – 18.5
0.00 – 0.03
0.05 – 0.65
0.001 – 0.61
0.43 – 1.08
0.692
<0.001
<0.001
<0.001
0.008
0.024
0.104
4.12
0.01
1.71 – 10.1
0.00 – 0.16
0.002
0.001
Arc of calcium
Thickness of calcium
1.00
0.72
1.00 – 1.01
0.43 – 1.22
0.006
0.22
1.00
1.00 – 1.01
0.006
Abbreviation: LAD, left anterior descending; OFDI, optical frequency domain imaging.
28
Table 4. Univariate and multivariate logistic regression analyses according to the irrelevant ablation group
Variables
Univariate
Multivariate
OR
95% CI
P value
OR
95% CI
P value
LAD
Extra-support wire
0.49
1.38
0.31 – 0.79
0.86 – 2.21
0.003
0.18
0.54
0.33 – 0.89
0.016
Judkins type guiding catheter
Pre lumen area
Burr / lumen ratio
Distance between the OFDI catheter and intima
Distance between the wire and intima
Distance between the OFDI catheter and wire
Myocardial site calcification
1.25
1.26
0.13
154.7
7.46
206.7
0.97
0.70 – 2.23
1.12 – 1.42
0.05 – 0.31
19.6 – 1221
2.36 – 23.5
11.5 – 3279
0.62 – 1.53
0.45
<0.001
<0.001
<0.001
0.001
<0.001
0.903
30.4
4.05
44.3
2.92 – 316.4
1.15 – 14.3
3.67 – 534.1
0.004
0.03
0.003
Arc of calcium
Thickness of calcium
1.00
1.47
0.99 – 1.003
0.87 – 2.49
0.53
0.15
Abbreviation: LAD, left anterior descending; OFDI, optical frequency domain imaging.
29
Figure 1.
30
Figure 2.
31
Figure 3.
32
Figure 4.
33
Supplementary Table 1. OFDI measurements before and after rotational
atherectomy according to lesion-based analysis.
n=26
Pre/post-operative lumen measurements
Pre minimum lumen diameter, mm
0.97 (0.83–1.19)
Pre minimum lumen area, mm2
1.59 (1.30–2.15)
Post minimum lumen diameter, mm
1.61 (1.45–1.77)
Post minimum lumen area, mm2
1.98 (1.87–2.16)
Morphology of calcification
Length of calcification, mm
21.9 (14.8–33.6)
Circumferential calcification, n (%)
9 (34.6)
Eccentric calcification, n (%)
9 (34.6)
Nodular calcification, n (%)
8 (30.8)
RA-related measurement
Angle-based analysis
P-angle, ˚
120.0 (78.0–174.6)
A-angle, ˚
80.4 (62.4–139.4)
O-angle, ˚
49.6 (32.0–112.4)
%Correct-angle, %
43.0 (28.0–51.0)
Volume-based analysis
P-volume, mm3
6.08 (3.52–10.59)
A-volume, mm3
6.39 (3.54–12.36)
O-volume, mm3
2.11 (1.14–4.55)
%Correct-volume, %
50.3 (29.0–57.0)
%Error-volume, %
67.0 (50.0–77.0)
OFDI and wire position
Minimum distance between the OFDI catheter and intima, mm
0.08 (0.04–0.13)
Minimum distance between the wire and intima, mm
0.25 (0.22–0.29)
Minimum distance between the OFDI catheter and wire, mm
0.04 (0.01–0.07)
Values are expressed as median (interquartile range) or n (%). All variables were calculated as
averages at each cross-section per lesion. %Correct-angle was calculated as O-angle divided by
P-angle. %Correct-area was calculated as O-area divided by P-area. %Error-area was calculated
as A-area minus O-area divided by A-area. P-, A-, and O-volume was calculated by integrating
P-, A-, and O-area each cross-section, respectively. %Correct-volume was calculated as Ovolume divided by P-volume. %Error-volume was calculated as A-volume minus O-volume
34
divided by A-volume. Abbreviations: RA, rotational atherectomy; OFDI, optical frequency
domain imaging; P-area (volume), predicted ablation area (volume); A-area (volume), actual
ablation area (volume); O-area (volume), overlap ablation area (volume); P-angle, angle of
predicted ablation area; A-angle, angle of actual ablation area; O-angle, angle of overlap ablation
area; %Correct-angle (volume), percentage of correct ablation angle (volume); %Error-volume,
percentage of error ablation volume.
35
Supplementary Table 2. Multiple linear regression analyses for %Correct- and %Error-volume
Variables
%Correct-volume
%Error-volume
Standard B
95% CI
P value
Standard B
95% CI
P value
Age
0.08
-0.86 – 1.10
0.790
-0.08
-1.47 – 1.10
0.760
Male
-0.04
-21.3 – 17.8
0.849
0.19
-14.1 – 37.3
0.346
LAD
0.13
-15.2 – 23.7
0.646
-0.27
--38.5 – 12.6
0.291
Floppy wire
-0.12
-21.3 – 13.2
0.617
-0.36-
-40.3 – 5.11
0.117
Judkins type guiding catheter
0.13
-15.3 – 25.1
0.607
0.15
-18.1 – 35.0
0.501
Pre minimum lumen area
-0.01
-14.6 – 14.1
0.968
0.23
-10.2 – 27.5
0.338
Burr / artery ratio
-0.07
-57.2 – 45.9
0.817
-0.20
-91.3 – -44.4
0.465
Mean distance between the OFDI catheter and intima
0.21
-118.1 – 221.8
0.519
-0.26
-315.1 – 131.9
0.390
Mean distance between the wire and intima
-0.17
-114.9 – 62.2
0.529
-0.34
-193.5 – 39.3
0.175
Mean distance between the OFDI catheter and wire
-0.66
-147.6 – 6.0
0.068
0.41
-37.0 – 164.9
0.193
Mean arc of calcium
0.23
-0.08 – 6.69
0.381
0.10
-0.14 – 0.21
0.667
Mean thickness of calcium
-0.38
-46.7 – 6.69
0.128
0.31
-10.7 – 59.6
0.156
Abbreviation: LAD, left anterior descending; OFDI, optical frequency domain imaging.
36
Supplementary Table 3. Univariate and multivariate logistic regression analyses according to the over ablation group
Variables
Univariate
Multivariate
OR
95% CI
P value
OR
95% CI
P value
LCx
Extra-support wire
2.52
2.80
1.24 – 5.01
1.53 – 5.11
0.01
0.001
2.21
1.17 – 4.16
0.014
Judkins type guiding catheter
Pre lumen area
Burr / lumen ratio
Distance between the OFDI catheter and intima
Distance between the wire and intima
Distance between the OFDI catheter and wire
Myocardial site calcification
1.13
1.23
0.16
7.81
0.24
0.11
2.01
0.53 – 2.41
1.07 – 1.41
0.05 – 0.52
0.78 – 78.6
0.04 – 1.33
0.003 – 3.87
1.10 – 3.68
0.747
0.003
0.002
0.081
0.103
0.23
0.024
Arc of calcium
Thickness of calcium
1.00
1.92
1.00 – 1.001
0.96 – 3.84
0.183
0.065
Abbreviation: LCx, left circumflex; OFDI, optical frequency domain imaging.
37
Supplementary Figure 1. Patient flowchart.
38
Supplementary Figure 2. Distributions of OFDI findings following rotational
atherectomy.
(A) Presence of deep vessel wall injury extending beyond the media following
rotational atherectomy. The cross-section with deep vessel wall injury was more
frequently observed in the over ablation group (9.6% of cross-sections, 5 of 52 crosssections, χ² test: P = 0.60). (B) Presence of intimal flap outside of the P-area following
rotational atherectomy. Cross-sections with intimal flap outside the P-area were more
frequently observed in the irrelevant ablation group than the other groups (18.1% of
cross-sections, 21 of 116 cross-sections, χ² test: P <0.001). OFDI, optical frequency
domain imaging.
39
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