Artificial Intelligence-based Approaches for Characterizing Plaque Components From Intravascular Optical Coherence Tomography Imaging: Integration Into Clinical Decision Support Systems

Intravascular optical coherence tomography (IVOCT) is emerging as an effective imaging technique for accurately characterizing coronary atherosclerotic plaques. This technique provides detailed information on plaque morphology and composition, enabling the identification of high-risk features associated with coronary artery disease and adverse cardiovascular events. However, despite advancements in imaging technology and image assessment, the adoption of IVOCT in clinical practice remains limited. Manual plaque assessment by experts is time-consuming, prone to errors, and affected by high inter-observer variability. To increase productivity, precision, and reproducibility, researchers are increasingly integrating artificial intelligence (AI)-based techniques into IVOCT analysis pipelines. Machine learning algorithms, trained on labelled datasets, have demonstrated robust classification of various plaque types. Deep learning models, particularly convolutional neural networks, further improve performance by enabling automatic feature extraction. This reduces the reliance on predefined criteria, which often require domain-specific expertise, and allow for more flexible and comprehensive plaque characterization. AI-driven approaches aim to facilitate the integration of IVOCT into routine clinical practice, potentially transforming this technique from a research tool into a powerful aid for clinical decision-making. This narrative review aims to (i) provide a comprehensive overview of AI-based methods for analyzing IVOCT images of coronary arteries, with a focus on plaque characterization, and (ii) explore the clinical translation of AI to IVOCT, highlighting AI-powered tools for plaque characterization currently intended for commercial and/or clinical use. While these technologies represent significant progress, current solutions remain limited in the range of plaque features these methods can assess. Additionally, many of these solutions are confined to specific regulatory or research settings. Therefore, this review highlights the need for further advancements in AI-based IVOCT analysis, emphasizing the importance of additional validation and improved integration with clinical systems to enhance plaque characterization, support clinical decision-making, and advance risk prediction.