Optical Coherence Tomography-Guided PCI for ISHLT Grade 3 Cardiac Allograft Vasculopathy: A 1 -Year Follow-Up Case Report

Background: International Society for Heart and Lung Transplantation (ISHLT) Grade 3 cardiac allograft vasculopathy (CAV) poses challenges for revascularization due to diffuse fibrotic lesions and neovascularization. While optical coherence tomography (OCT) enables high-resolution imaging, evidence for OCT-guided percutaneous coronary intervention (PCI) in high-risk patients with comorbidities like chronic kidney disease (CKD), chronic hepatitis B (CHB), or metabolic dysfunction remains limited. Case Presentation: A 39-year-old male with ISHLT Grade 3 CAV, CKD stage 3b, (eGFR 42.5 mL/min/1.73 m²), CHB, and severe hyperglycemia (HbA1c 15.7%) underwent OCT-guided PCI. Coronary angiography(CAG) revealed diffuse stenosis in the left anterior descending (LAD) and right coronary artery (RCA). OCT identified fibrotic-neovascular plaques in the LAD and fibrotic-lipidic plaques in the RCA, prompting implantation of sirolimus-eluting stents (SES) to address CAV-specific neointimal hyperplasia. To mitigate CKD-related risks, iso-osmolar contrast, pre-procedural hydration, aspirin and clopidogrel were used for antiplatelet therapy. At 6-month follow-up, CAG/OCT showed patent stents with minimal neointimal hyperplasia and a Type B dissection in the proximal RCA, which was successfully managed with additional SES implantation. At 1-year, coronary computed tomography angiography (CCTA) confirmed sustained stent patency without new stenosis; renal function remained stable (eGFR 47.88 mL/min/1.73 m²), improved glycemic control(HbA1c 8.3%), and no major adverse events occurred. Conclusion: This case shows OCT-guided SES implantation is feasible in high-risk CAV patients with complex conditions, highlighting OCT’ s role in precise lesion assessment and risk-adaptive strategies that led to stable outcomes at 1 year. Despite its single-case nature, it underscores the need for larger studies to confirm long-term benefits.