ILUMIEN IV: A Study of OPtical Coherence Tomography (OCT) Guided Coronary Stent IMplantation (OPTIMAL PCI)

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"Volunteer for research at UC Davis and contribute to discoveries that may improve health care for you, your family, and your community!"
Age: 18 years or older
Gender:
Any
Healthy Volunteers: No
Keywords: Coronary Stent Implantation, cardiac stent, angiography
Type: Device study
Target:
10 Participants
Investigator:
Description
Coronary Stent placement is guided by imaging techniques. The most commonly used technique is Coronary Angiography, which uses x-rays. The doctors in your hospital also use OCT (optical coherence tomography). OCT is an imaging technique. It allows for visualization of the stent and artery wall using light, like having a microspic flashlight placed in your heart artery.

The primary purpose of this study is to compare OCT to angiography during coronary stent placement. The physicians participating in this study are experienced users of angiography and OCT in routine clinical practice.

There are two phases of the study. The first phase in a roll-in phase. During this time, up to 3 persons at UC Davis will be enrolled who will have the stenting procedure done using OCT. This roll in phase is to show that the physicians can follow the OCT stent guidance procedures.

The second phase of the study will enroll persons to be randomized to have the stent placed with angiography or OCT. The study physician will let you know at time of consent if you will be part of the roll-in phase or the randomized phase.
This study requires

The study team will make sure you qualify to take part in the study. Qualified participants will receive detailed information about the study. This may include a list of study-related tests and procedures.

Who can participate

Inclusion Criteria (all must be present) 1. Subject must be at least 18 years of age. 2. Subject must have evidence of myocardial ischemia (e.g., stable angina, silent ischemia, unstable angina, or acute myocardial infarction) suitable for elective PCI. 3. Patients undergoing planned XIENCE stent implantation during a clinically indicated PCI procedure meeting one or more of the following criteria: A) High clinical-risk, defined as; i. Medication-treated diabetes mellitus, AND/OR B) High angiographic-risk lesion(s), with at least one target lesion in each target vessel planned for randomization meeting at least one of the following criteria; i. Target lesion is the culprit lesion responsible for either:

  • NSTEMI, defined as a clinical syndrome consistent with an acute coronary syndrome and a minimum troponin of 1 ng/dL (may or may not have returned to normal), and >1 mm ST segment deviation and/or dynamic T wave changes at rest within 7 days, OR

  • STEMI >24 hours from the onset of ischemic symptoms ii. long or multiple lesions (defined as intended total stent length in any single target vessel ≥28 mm), iii. bifurcation intended to be treated with 2 planned stents (i.e. in both the main branch and side branch), and where the planned side branch stent is ≥ 2.5 mm in diameter. iv. angiographic severe calcification (defined as angiographically visible calcification on both sides of the vessel wall in the absence of cardiac motion), v. chronic total occlusion (CTO) (enrolment and randomization in this case performed only after successful antegrade wire escalation crossing and predilatation) vi. in-stent restenosis (all patterns, as long as the lesion is at or within the stent margin(s) and has an angiographically visually-assessed DS ≥70% or DS ≥50% with non-invasive or invasive evidence of ischemia)

  • All target lesions (those lesions to be randomized) must have a visually estimated or quantitatively assessed %DS of either ≥70%, or 50% plus one or more of the following: an abnormal functional test (e.g. fractional flow reserve, stress test) signifying ischemia in the distribution of the target lesion(s) or biomarker positive ACS with plaque disruption or thrombus.
  • All target lesions must be planned for treatment with only ≥2.5 mm and ≤3.5 mm stents and postdilatation balloons based on pre-PCI angiographic visual estimation. The only exception is for long target lesions (visually estimated as >20 mm), in which after implantation of a ≤3.5 mm stent up to half of the stented segment may be post-dilated with balloons >3.5 mm as needed per operator judgment. For example, if there is a 34 mm long LAD lesion spanning the proximal and mid segments, a 38 mm long 3.0 mm diameter Xience stent may be implanted, and the proximal half of the stent may be post-dilated with a 3.75 mm balloon.
  • No more than 2 target lesions requiring PCI are present in any single vessel., and no more than 2 target vessels are allowed. Thus, up to 4 randomized target lesions per patient in a maximum of 2 target vessels are allowed, including branches. The intended target lesions will be declared just prior to randomization. Note: A lesion is defined as any segment(s) of the coronary tree, no matter how long, which is planned to be covered with one contiguous length of stent, whether single or overlapped. A bifurcation counts as a single lesion even if the side branch is planned to be treated. Note: All lesions in a randomized target vessel that are intended to be treated by PCI are designated as target lesions, and at least one target lesion in each randomized target vessel must meet angiographic high-risk inclusion criteria summarized above in 3B). The only exception is for patients who qualify for the trial on the basis of medication-treated diabetes, in which case no target lesion is required to meet angiographic high-risk inclusion criteria.
  • All target lesions intended to be treated by PCI in the target vessel are amenable to OCT-guided PCI (i.e. no lesion-specific angiographic exclusion criteria are present – see Section 5.4.2 below). Example: If a qualifying angiographic high-risk lesion is in the proximal LAD, and there is a second target lesion in the distal LAD which is a focal lesion not otherwise meeting high-risk criteria, both the proximal LAD and distal LAD lesions must be amenable to OCT (e.g. no excessive tortuosity or calcification precluding delivering the OCT catheter), and each lesion must undergo OCT-guided stenting. Otherwise the vessel should be excluded from randomization.
  • For a female subject of childbearing potential, a pregnancy test must be performed with negative results known within 7 days prior to the index procedure per site standard, and pregnancy must not be intended for at least 2 years.
  • For a female subject with a recent birth, subject is not breast-feeding at the time of the screening visit and will not be breast-feeding for up to 2 years following the index procedure.
  • Subject or a legally authorized representative must provide written Informed Consent prior to any study related procedure.

Exclusion Criteria (none may be present) Clinical exclusion criteria: 1. STEMI ≤24 hours from the onset of ischemic symptoms 2. Creatinine clearance ≤30 ml/min/1.73 m2 (as calculated by MDRD formula for estimated GFR)4 and not on dialysis. Note: chronic dialysis dependent patients are eligible for enrolment regardless of creatinine clearance. 3. Hypotension, shock or need for mechanical support or intravenous vasopressors 4. CHF (Killip class ≥2 or NYHA class ≥3) 5. LVEF ≤30% by the most recent imaging test within 30 days prior to procedure (echo, MRI, contrast left ventriculography or other) 6. Unstable ventricular arrhythmias 7. Inability to take DAPT (both aspirin and a P2Y12 inhibitor) for at least 12 months in the patient presenting with an ACS, or at least 6 months in the patient presenting with stable CAD, unless the patient is also taking chronic oral anticoagulation in which case a shorter duration of DAPT may be prescribed per local standard of care. 8. Planned cardiac or non-cardiac surgery within 24 months after the index procedure 9. Prior PCI within the target vessel within 12 months (unless the target lesion is the prior PCI site - i.e. in-stent restenosis) 10. Any planned PCI within the target vessel(s) within 24 months after the study procedure, other than a planned staged intervention in a second randomized target vessel. Note: Planned staged interventions must be noted at the time of randomization, and the decision to stage may be modified within 24 hours of completion of the index PCI. See Section 6.5.3.7 for more details of multi lesion and vessel treatment. Note: PCI in non-target vessels is permitted >48 hours after the index procedure. 11. Any prior PCI in a non-target vessel within 24 hours before the study procedure, or within previous 30 days if unsuccessful or complicated. Note: Patients requiring non-target vessel PCI may be enrolled and the non-target vessel(s) may be treated in the same index procedure as the randomized lesions (in all cases prior to randomization), as long as treatment of the lesion(s) in the non-target vessel is successful and uncomplicated. Successful and uncomplicated definition for non-target vessel treatment during the index procedure: Angiographic diameter stenosis <10% and TIMI III flow (visually assessed) for all non-target lesions and vessels, without dissection ≥ NHLBI type C, perforation, prolonged chest pain (>5 minutes) or prolonged ST-segment elevation or depression (>5 minutes), or cardiac arrest or need for defibrillation or cardioversion or hypotension /heart failure requiring mechanical or intravenous hemodynamic support or intubation. 12. Subject has known hypersensitivity or contraindication to any of the study drugs (including heparin and all P2Y12 inhibitors, one or more components of the study devices, including everolimus, cobalt, chromium, nickel, platinum, tungsten, acrylic and fluoropolymers, or radiocontrast dye that cannot be adequately pre-medicated. 13. Subject has received any solid organ transplants or is on a waiting list for any solid organ transplants. 14. Subject is receiving immunosuppressant therapy or has known immunosuppressive or severe autoimmune disease that requires chronic immunosuppressive therapy (e.g., human immunodeficiency virus, systemic lupus erythematosus, etc.). Note: corticosteroids are not included as immunosuppressant therapy. 15. Subject has previously received or is scheduled to receive radiotherapy to a coronary artery (vascular brachytherapy), or the chest/mediastinum. 16. Subject has a platelet count <100,000 cells/mm3 or >700,000 cells/mm3 .
17. Subject has a documented or suspected hepatic disorder as defined as cirrhosis or Child-Pugh ≥ Class B. 18. Subject has a history of bleeding diathesis or coagulopathy, or has had a significant gastrointestinal or significant urinary bleed within the past six months. 19. Subject has had a cerebrovascular accident or transient ischemic neurological attack (TIA) within the past six months, or any prior intracranial bleed, or any permanent neurologic defect, or any known intracranial pathology (e.g., aneurysm, arteriovenous malformation, etc.). 20. Subject has extensive peripheral vascular disease that precludes safe 6 French sheath insertion. Note: femoral arterial disease does not exclude the patient if radial access may be used. 21. Subject has life expectancy <2 years for any non-cardiac cause. 22. Subject is in the opinion of the Investigator or designee unable to comply with the requirements of the study protocol or is unsuitable for the study for any reason. 23. Subject is currently participating in another investigational drug or device clinical study that has not yet completed its primary endpoint5 . 24. Subject is part of a vulnerable population who, in the judgment of the investigator, is unable to give Informed Consent for reasons of incapacity, immaturity, adverse personal circumstances or lack of autonomy. This may include: Individuals with mental disability, persons in nursing homes, children, impoverished persons, persons in emergency situations, homeless persons, nomads, refugees, and those incapable of giving informed consent. Vulnerable populations also may include members of a group with a hierarchical structure such as university students, subordinate hospital and laboratory personnel, employees of the Sponsor, members of the armed forces, and persons kept in detention.

Benefits and risks of participating
BENEFITS:

We cannot promise any benefits to you as a result of taking part in this research study.


RISKS:

The study doctor will discuss the risks associated with taking part in this research study.
Compensation
You will not be paid to take part in this research study.
Resources
Schedule
Study duration and period
Persons in the roll-in phase will be in the study for one day (the procedure day). Persons in the randomized phase will be in the study for about 2 years (24 months).
Recruitment period
From Jan. 9, 2019
Location
UC Davis Medical Center
2315 Stockton Boulevard
Sacramento, CA 95817
Research Topic
Conditions:
  • Coronary Artery Disease
  • Coronary Stenosis
  • Atherosclerosis
  • STEMI
  • STEMI - ST Elevation Myocardial Infarction
  • NSTEMI - Non-ST Segment Elevation MI