Determinants and Clinical Impact of Direct Stenting in Optical Coherence Tomography-Guided Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction　- An ATLAS-OCT Substudy.

BACKGROUND

Direct stenting (DS) is a simplified strategy for primary percutaneous coronary intervention (PCI); however, its role in the era of advanced intravascular imaging remains incompletely defined. We aimed to identify determinants of DS use and its impact on procedural efficiency and optical coherence tomography (OCT)-defined stent implantation quality in ST-elevation myocardial infarction (STEMI).

METHODS AND

RESULTS

The ATLAS-OCT trial was a prospective multicenter nationwide study mandating OCT guidance in Japan. In this subanalysis, clinical characteristics, angiographic and OCT findings, procedural metrics, and clinical outcomes were compared between patients undergoing DS and those treated with balloon predilatation. Among 436 patients, DS was performed in 32.1% (n=140), with marked interinstitutional variability (0-68.3%; P<0.01), suggesting a strong influence of operator preference. DS use was not associated with angiographic features or OCT-defined culprit plaque morphology. DS significantly reduced contrast volume and procedure time. Post-PCI OCT showed a trend towards a larger minimum stent area and greater stent expansion index with DS. These benefits were not associated with in-hospital or 1-year outcomes.

CONCLUSIONS

In contemporary OCT-guided primary PCI for STEMI, DS appears to be driven primarily by operator preference rather than lesion characteristics. In this study, DS was associated with improved procedural efficiency without significantly compromising OCT-assessed stent implantation quality or mid-term clinical safety.