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. 2024 Sep 1;36(2):137–157. doi: 10.37616/2212-5043.1387

Table 2.

Consensus statements on the clinical use of intracoronary imaging.

Section Statements Quality of Evidence
I. Intracoronary imaging and PCIs outcomes 1. ICI-guided PCI demonstrates superior safety, efficacy, and enhanced patient outcomes compared to angiography-guided PCI, especially in complex lesions. The clinical benefit of imaging guidance of PCI mainly depends on baseline planning and stent optimization. High
2. Each catheterization laboratory in Saudi Arabia should be equipped with high-resolution ICI system (s) that corresponds to catheterization lab needs. The lab should also be equipped with staff trained in image acquisition, interpretation, and measurement. High
3. ICI-guided PCI is recommended in patients with complex coronary lesions and left-main interventions due to a reduction in MACE, revascularization, and stent thrombosis. Both IVUS and OCT-guided PCI provide comparable short and long-term benefits on stent expansion, MACE, revascularization, and stent thrombosis. The choice between both techniques should be based on the operator’s expertise, patient characteristics, and clinical scenarios. High
4. In heavily calcified and bifurcation lesions, OCT provides valuable additional information, such as calcium thickness and three-dimensional stent views, that can better guide the step-by-step PCI optimization. When compared to standard IVUS devices, OCT may be preferred for detecting lumen or stent-related features with potential clinical impact in heavily calcified coronary lesions. Moderate
5. In patients with renal failure undergoing PCI, IVUS is preferred over OCT. This preference is primarily driven by the significant concern of contrast-induced nephropathy in this patient population. Moderate
II. Patient selection 6. ICI-guided PCI is recommended for patients with:

  1. Unprotected left main coronary lesions

  2. Ostial lesions

  3. True bifurcation lesions with side branch diameter ≥2.5 mm.

  4. Chronic total occlusions with duration ≥3 months

  5. Severely calcified lesions (requiring a calcium modification)

  6. ACS culprit lesion and/or non-culprit ambiguities

  7. Long lesions (implanted stent length ≥28 mm)

  8. Multi-vessel PCI (≥2 major epicardial coronary vessels treated at one PCI session) or multiple stent implantation (3 or more stents per patient)

  9. Stent thrombosis and In-stent restenosis (ISR) lesion

  10. Any time an unexplained complication happens during PCI

 High
7. Routine ICI-guided PCI may be considered in patients presenting with non-complex disease, especially those with diffuse disease, to allow lesion preparation, optimize stent expansion and apposition, and improve short and long-term outcomes. Low
III. Principles of Imaging Acquisition 8. The availability and use of co-registration of ICI with coronary angiography (angio co-registration) should be considered to facilitate imaging-guided PCI. Moderate
IV. Plaque composition 9. ICI-guidance prior to stent implantation is recommended to assess plaque composition and distribution (calcification, lipid-rich plaque), allow plaque modification, and facilitate the choice of stent size (diameter and length). High
10. The low sensitivity of coronary angiography to identify high calcium content in native vessels and cases of ISR increases the risk of stent under-expansion and malapposition. Thus, pre-stenting imaging is recommended for plaque assessment in all calcified lesions or in undilatable coronary stenosis. ICI images of calcium distribution (circumferential and longitudinal) and thickness guide the selection of the calcium modification technique, allowing for better lesion preparation and stent expansion. High
V. Assessment of angiographically indeterminate coronary artery stenosis 11. IVUS is recommended over OCT for the evaluation of angiographically indeterminate ostial left main. Either modality can be used for distal or shaft disease of the left main artery. Low
12. In indeterminate LMCA disease, a mean luminal diameter (MLD) < 2.8 mm and mean luminal area (MLA) < 5.9 mm2 correlate with significant lesions. Lesions with MLA >7.5 mm2 are not hemodynamically significant. Lesions with MLA of 6–7.5 mm2 require further physiological assessment. These cutoffs should be used cautiously and with other clinical factors to guide practice. Further studies are needed to validate these cutoffs and establish more robust criteria for identifying hemodynamically significant lesions using ICI. Moderate
13. There are ethnic differences in coronary atherosclerosis morphology. The optimal MLA cutoff to determine significant lesions is still unknown in the Arab ethnicity, which requires future research. Moderate
14. In non-LMCA disease, MLA <4 mm2 may be significant but requires additional physiological assessment. Lesions with MLA of >4 mm2 and MLD > 2 mm are not hemodynamically significant. These cutoffs should be used cautiously and with other clinical factors to guide practice. Further studies are needed to validate these cutoffs and establish more robust criteria for identifying hemodynamically significant lesions using ICI. Moderate
VI. Stent failure 15. An ICI analysis of stent restenosis and stent thrombosis is strongly recommended to understand failure mechanisms, including stent malappostion, stent underexpansion and extent of neointimal hyperplasia. Moderate