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Laser "explosion" technique for treatment of unexpanded coronary stent
... In previous studies, the technique of saline "flush and bathe" was used in order to reduce the risk of coronary dissection induced by high-pressure waves [7,12]. However, in patients with underexpanded stents, ELCA using a contrast or blood medium could assist the achievement of optimized expansion for these lesions by disrupting the underlying plaque [13,14]. In this paper, we evaluated the usefulness of high-energy ELCA using contrast media, in patients with underexpanded stents resistant to high-pressure balloon inflation. ...
... if the optimal ELCA size was selected. However, the application of excimer laser to expand an undilatable stent is limited to case reports [6,10,13,14,16]. In 1998, Goldberg et al. was the first to describe the use of contrast injection during laser angioplasty to amplify the energy and shock waves to successfully expand a stent refractory to balloon dilatation [6]. ...
... When stent underexpansion does occur, few options exist for the management of undilatable coronary stents. Excimer laser coronary atherectomy is reported to have high rates of success with acceptable rates of complications, however centers experienced with this technique are limited [15][16][17][18][19]. Another viable option is stentablation (SA) with rotational atherectomy (RA); although reasonable concerns exist with regard to procedural complications including: no-reflow, strut embolization, and burr entrapment [14,[20][21][22][23]. Until recently, data supporting the non-conventional application of RA as a bailout strategy for SA was limited to case reports [22]. ...
... Inevitably, stent underexpansion will occur and in such cases few options exist for percutaneous intervention. Excimer laser coronary atherectomy is reported to have a favorable safety profile, good rates of procedural success, and acceptable outcomes [15][16][17][18][19]. However, centers experienced with this technology are limited. ...
Introduction:
Coronary stent underexpansion is associated with in-stent restenosis and few interventions are available for the management of undilatable underexpanded stents. Stentablation (SA) with rotational atherectomy (RA) is a unique application and has previously been described with encouraging results. Data regarding SA is limited to case reports and small case series; therefore, reasonable concern persists regarding procedural safety and long-term outcomes.
Methods:
This is a single-center retrospective study analyzing twenty consecutive patients who underwent SA with RA. The primary endpoint was procedural success and secondary endpoints included procedural safety outcomes and major adverse cardiac events (MACE) over a 12-month follow-up period.
Results:
Stentablation and secondary stenting were guided by intravascular ultrasound and procedural success was achieved in all cases. No in-hospital death or MACE was observed. The prevalence of MACE was 5% at 30 days as one patient developed recurrent MI without target lesion revascularization (TLR). At 12 months, MACE had occurred in 40% of patients, however this was strongly driven by a high prevalence of TLR (30%). Only one cardiac death (5%) and one additional NSTEMI were observed during the 11 additional months of follow up.
Conclusion:
Stentablation with RA is a feasible and effective option for the acute management of symptomatic, underexpanded, and undilatable coronary stents. SA is associated with a high rate of procedural success as well as excellent in-hospital and short-term outcomes. However, our study population demonstrated substantial MACE at 12 months which was strongly driven by TLR and associated with minimal mortality.
... The use of contrast injection at the highest fluence and repetition rate (i.e. 80 mJ/ mm2 and 80 Hz for the 0.9 mm catheter) for the treatment of new, very hard calcified coronary lesions is called the "Explosion Technique" [20] ( Fig. 2a, b, c), previously used only for the treatment of under expanded stents. Contrast infusion can enlarge the bubble by up to 2.1 times the diameter of the probe, can focus the light beam towards the vessel wall, can increase the power of the acoustic shock, and achieve a more powerful shock wave of up to 15 kbar. ...
Excimer Laser Coronary Atherectomy (ELCA) is a well-established therapy that emerged for the treatment of peripheral vascular atherosclerosis in the late 1980s, at a time when catheters and materials were rudimentary and associated with the most serious complications. Refinements in catheter technology and the introduction of improved laser techniques have led to their effective use for the treatment of a wide spectrum of complex coronary lesions, such as thrombotic lesions, severe calcific lesions, non-crossable or non-expandable lesions, chronic occlusions, and stent under-expansion. The gradual introduction of high-energy strategies combined with the contrast infusion technique has enabled us to treat an increasing number of complex cases with a low rate of periprocedural complications. Currently, the use of the ELCA has also been demonstrated to be effective in acute coronary syndrome (ACS), especially in the context of large thrombotic lesions.
... 12 Except for the ELLEMENT registry, 12 all other instances of successful use of laser for under-expanded stents have been case reports. 14,18,[21][22][23][24] This may be due to the uncommon occurrence of under-expanded stents, or possibly due to the limited availability of excimer laser and the lack of guidelines for the management of under-expanded stents. ...
Under-expanded and under-deployed stents carry a high risk of restenosis and thrombosis, with inherent serious clinical complications. The management of under-expanded stents is a difficult clinical entity.
Method:
A retrospective analysis of prospectively collected data on all under-expanded, under-deployed stents that were managed by excimer laser, with and without contrast, performed at the Freeman Hospital, a large tertiary cardiac center, in the northeast of England.
Results:
Between November 2014 and September 2016, a total of 19 cases were treated with excimer laser with or without contrast, with the initial approach done without contrast. All cases were successful with a stepwise energy-level approach. There were no clinical, procedural, or in-hospital complications, with full expansion of the stents after laser application.
Conclusion:
The use of excimer laser with or without contrast offers a safe and effective method for managing under-expanded and under-deployed stents and potentially avoiding long-term complications of under-expansion.
... Rotablation was not favoured in view of possibility of potential damage to the exposed stent struts. ELCA is an established therapy in patients with mild to moderate calcification resisting full balloon expansion, and in patients with under-expanded stent [6][7][8][9]. ...
Excimer Laser Angioplasty in Calcified Coronary Lesions: Evidence of Calcium Ablation by Optical Coherence Tomography
During percutaneous coronary revascularization, calcified lesions can prove resistant to balloon expansion and cause stent underexpansion. We report on a patient with a calcified resistant lesion in whom adjunctive therapy with excimer laser enabled successful expansion of the stent. We document in this report using optical coherence tomography imaging, the calcium ablator effects of excimer laser, an effect which has not been demonstrated thus far, to our knowledge.
... More studies are needed to demonstrate the safety and efficacy of the "flush and bathe" laser technique for lesion compliance modification in moderate-highly calcified lesions. The new laser "explosion" technique may be applied in this subset of patients to improve procedural success [27]. ...
To assess the efficacy and safety of laser-assisted percutaneous coronary interventions (PCI) in an unselected population.
One hundred consecutive patients, who underwent a laser assisted PCI between January 2008 and March 2012, were included in the present study. Fifty-one patients underwent laser ablation for thrombus vaporization (Group 1), 36 patients for neointima/plaque debulking (Group 2) and 13 patients for lesion compliance modification in calcified lesions (Group 3).
The rate of in-hospital serious events was 2%. The cumulative laser success was 82%, and it was significantly higher for Group 1 and Group 2 in comparison with Group 3 (p = 0.001). Furthermore, the need for repeat revascularization was significantly higher in the Group 3 compared with the others two groups (46% vs. 8% for Group 1 and 11% for Group 2, p = 0.03). The MACE rate was 14%. There was a trend toward a higher MACE rate in the Group 3 compared with others two groups (p = 0.05).
Laser ablation is an effective and safe tool for complex PCI. Patients underwent laser for thrombus vaporization or for neointima/plaque debulking had better immediate success and better outcome at follow-up than patients underwent laser for lesion compliance modification.
Excimer laser coronary atherectomy (ELCA) was introduced in the 1980s for treatment of coronary artery disease, but use was restricted because the ELCA laser was activated with contrast medium still present in the coronary arteries, resulting in unacceptably high rates of dissection and perforation. Lasing in contrast medium leads to intense vapor bubble expansion and implosion, causing forceful dilation and invagination of the adjacent arterial wall after each excimer laser pulse, which can cause dissection and perforation. When the saline flush technique was applied in the 2000s, the use of ELCA spread because of the reduced rate of complications compared with the earlier attempts. In addition, the introduction of a smaller profile 0.9 mm ELCA catheter allowed treatment of a wider spectrum of coronary artery lesions, such as tortuous lesions, chronic total occlusions (CTOs), and balloon-uncrossable lesions. Unlike plain old balloon angioplasty and stenting, ELCA has three unique mechanisms of action: photoablation, photothermal, and photomechanical. Through these mechanisms of action, ELCA vaporizes plaque in complex coronary anatomies containing thrombus, soft atheroma, fibrous tissue, and calcium. In addition, laser energy is capable of suppressing platelet aggregation as a pleiotropic effect. The current clinical indications for ELCA are saphenous vein grafts, acute coronary syndrome, in-stent restenosis, bifurcation lesions, ostial lesions, moderately calcified lesions, CTOs, balloon-uncrossable lesions, and stent underexpanded lesions.
Objectives:
Coronary stent underexpansion is a known risk factor for in-stent restenosis and stent thrombosis. There are limited options once noncompliant balloons have failed to achieve optimal stent expansion. Excimer Laser Coronary Angioplasty with contrast medium injection is one possibility, but not readily available. Rotational atherectomy is an alternative, and has been described in case reports, but concerns exist regarding safety.
Methods:
All consecutive patients undergoing rotational atherectomy for symptomatic in-stent restenosis due to stent underexpansion resistant to noncompliant balloon postdilatation between January 2005 and December 2015 were analysed.
Results:
A total of 16 patients underwent treatment during the study period and the procedure was successful in 14 cases (87.5%). The mean postprocedural minimal lumen diameter increased by 2.3 ± 0.8 mm and percentage diameter stenosis decreased from 82.17% ± 17.2% to 11.9% ± 9.1%. Intraprocedural complications occurred in two patients (burr entrapment successfully managed percutaneously and periprocedural myocardial infarction). At 1-year follow-up, the incidence of target lesion revascularisation was 13.3% (2 out of 15 patients), and one patient died from noncardiac death.
Conclusion:
In this small series of underexpanded stents, rotational atherectomy was an effective treatment for resistant stent underexpansion with acceptable outcomes. © 2016 Wiley Periodicals, Inc.
Stent underexpansion is a risk factor for in-stent restenosis (ISR) and stent thrombosis. Although excimer laser coronary atherectomy (ELCA) with contrast medium was shown to be effective to improve stent underexpansion in undilatable lesions, precise mechanism of this technique was not well understood. We report a case of ISR with stent underoptimal implantation within a circumferential calcified atherosclerotic plaque beneath the stent strut that could not be dilated by repeated high-pressure balloon inflations. After rotational atherectomy, the mechanism of the underexpanded lesion could be obtained by optical frequency domain imaging (OFDI). High-pressure balloon could not dilate the underexpanded stent. Since ELCA with saline flush only gave intimal erosions and minor dissections, additional high-pressure balloon was also ineffective. Finally ELCA with contrast medium could disrupt the calcific lesion beneath the underexpanded stent. The angiographic and OFDI findings confirmed the full stent expansion could be accomplished by further balloon dilatation with an ordinary pressure. ELCA with contrast medium is feasible to improve stent underexpansion by disrupting the calcified plaque behind the stent strut. This article is protected by copyright. All rights reserved.
© 2015 Wiley Periodicals, Inc.
Although the importance of monocyte trans-endothelial migration in early atherogenesis is well recognized, it is unclear whether and how one transmigration event affects endothelium to facilitate subsequent ones. In this study, we tested the hypothesis that monocyte transmigration alters endothelial junctional organization to facilitate subsequent transmigration.
When human monocytes were added twice at intervals of ≈30 min to IL-1beta-prestimulated human umbilical vein endothelial cells in vitro, significant augmentation of transmigration was observed at the second addition (≈1.5-fold, analyzed from a total of 231 monocytes in 3 experiments). Endothelial surface expressions of two major junctional molecules, PECAM-1 and VE-cadherin, increased and decreased respectively, in response to monocyte addition, which could facilitate subsequent transmigration. To further investigate spatiotemporal dynamics of the increasing molecule, PECAM-1, we constructed a PECAM-1-GFP expression system and found that monocyte transmigration induced local accumulation of endothelial PECAM-1 around the transmigration spot, which was followed by transmigration of subsequent monocyte around the same location. Detailed analysis revealed that within the defined region around one transmigration event, 50% of later transmigrating monocytes used the same or similar location as the previous one (10 out of 20 transmigrating monocytes in 11 experiments).
These findings show that monocyte trans-endothelial migration alters endothelial junctional organization to a more monocyte-permeable state (increased PECAM-1 and decreased VE-cadherin), resulting in the augmented transmigratory activity at a later stage. This positive feedback mechanism is partially associated with monocyte transmigration-induced local accumulation of endothelial PECAM-1, which promotes transmigration of following monocytes at the same location.
Objectives.We sought to evaluate whether intracoronary saline infusion during excimer laser coronary angioplasty decreases the incidence of significant laser-induced coronary artery dissections.Background.Despite procedural success rates >90%, coronary artery dissections occur in 17% to 27% of excimer laser coronary angioplasty procedures. Excimer laser irradiation of blood results in vapor bubble formation and acoustomechanical trauma to the vessel wall. Saline infusion into a coronary artery may minimize blood irradiation and consequent arterial wall damage.Methods.In this prospective, randomized, controlled study, consecutive patients undergoing excimer laser coronary angioplasty were randomly assigned to conventional laser irradiation in a blood medium or to laser irradiation with blood displacement by intracoronary saline infusion. In the patients randomized to intracoronary saline infusion, prewarmed normal saline was injected through the coronary artery guide catheter at a rate of 1 to 2 ml/s using a power injector. The incidence and severity of dissection after excimer laser ablation were evaluated in a core laboratory by angiographers with no knowledge of treatment assignment. The severity of coronary artery dissection was rated on an ordinal scale of 1 to 5. Dissections of grade 2 or higher were considered significant.Results.The mean (±SE) dissection grade after laser angioplasty in patients treated with intracoronary saline infusion was 0.43 ± 0.13 compared with 0.91 ± 0.26 in patients undergoing laser angioplasty in a blood medium. The incidence of significant dissection was 7% in saline-treated patients compared with 24% in conventionally treated patients (p < 0.05). No significant complications were associated with saline infusion.Conclusions.Intracoronary saline infusion should be incorporated into all excimer laser coronary angioplasty procedures.
All authors to papers in the International Journal of Cardiology must adhere to the following principles: 1. That the corresponding author has the approval of all other listed authors for the submission and publication of all versions of the manuscript. 2. That all people who have a right to be recognised as authors have been included on the list of authors and everyone listed as an author has made an independent material contribution to the manuscript. 3. That the work submitted in the manuscript is original and has not been published elsewhere and is not presently under consideration of publication by any other journal other than in oral, poster or abstract format. 4. That the material in the manuscript has been acquired according to modern ethical standards and has been approved by the legally appropriate ethical committee. 5. That the article does not contain material copied from anyone else without their written permission. 6. That all material which derives from prior work, including from the same authors, is properly attributed to the prior publication by proper citation. 7. That the manuscript will be maintained on the servers of the Journal and held to be a valid publication by the Journal only as long as all statements in these principles remain true. 8. That if any of the statements above ceases to be true the authors have a duty to notify the Journal as soon as possible so that the manuscript can be withdrawn. (C) 2010 Published by Elsevier Ireland Ltd.
Excimer laser coronary atherectomy (ELCA) has been an FDA-approved treatment for coronary artery disease since 1992 and is commonly used as an adjunct treatment to balloon angioplasty. While ELCA presents a good therapeutic option for lesions non-dilatable or uncrossable with balloon angioplasty, historically the technique was not able to manage heavily calcified lesions. The advent of a smaller (0.9 mm tip diameter) excimer laser coronary catheter (Point 9, Spectranetics Corporation), capable of delivering higher energy densities and repetition rates, has proven effective and safe in the treatment of complex calcified lesions1-3. However, there is still a need for a smaller laser catheter for use in small vessels in other anatomical locations, balloon-resistant lesions, and for primary crossing of CTOs. We recently developed a new, even smaller over-the-wire (OTW) laser catheter (Point 7) capable of accessing the most distal vasculature and providing an additional margin of safety in treating complex lesions. Combined with a simple guidewire steering element this device could possibly be used to traverse the proximal cap of CTOs and assist in the primary crossing of the blockage.
Late thrombosis occurring after bare metal stent (BMS) implantation is a rare complication. However, it is often associated with poor outcome. Mechanisms underlying BMS thrombosis may differ from those underlying drug eluting stent thrombosis. In particular, severe instent restenosis may trigger thrombus formation. This case report describes a very late thrombosis of BMS occurring on an in-stent restenosis. After failure of manual thrombectomy, the case was successfully faced by Excimer Laser Coronary Angioplasty (ELCA). Cases like this may be successfully treated by devices like ELCA combining debulking and thrombus removal capabilities.
Target lesion calcium is a marker for significant coronary artery disease and a determinant of the success of transcatheter therapy.
Eleven hundred fifty-five native vessel target lesions in 1117 patients were studied by intravascular ultrasound (IVUS) and coronary angiography. The presence, magnitude, location, and distribution of IVUS calcium were analyzed and compared with the detection and classification (none/mild, moderate, and severe) by angiography. Angiography detected calcium in 440 of 1155 lesions (38%): 306 (26%) moderate calcium and 134 (12%) severe. IVUS detected lesion calcium in 841 of 1155 (73%, P < .0001 versus angiography). The mean arc of lesion calcium measured 115 +/- 110 degrees; the mean length measured 3.5 +/- 3.7 mm. Target lesion calcium was only superficial in 48%, only deep in 28%, and both superficial and deep in 24%. The mean arc of superficial calcium measured 85 +/- 108 degrees; the mean length measured 2.4 +/- 3.4 mm. Three hundred seventy-three of 1155 reference segments (32%) contained calcium (P < .0001 compared with lesion site). The mean arc of reference calcium measured 42 +/- 80 degrees; the mean length measured 1.7 +/- 3.6 mm. Only 44 (4%) had reference calcium in the absence of lesion calcium. Angiographic detection and classification of calcium depended on arcs, lengths, location, and distribution of lesion and reference segment calcium. By discriminant analysis, the classification function for predicting angiographic calcium included the arc of target lesion calcium, the arc of superficial calcium, the length of reference segment calcium, and the location of calcium within the lesion. This model correctly predicted the angiographic detection of calcification in 74.4% of lesions and the angiographic classification (none/moderate/severe) of calcium in 62.8% of lesions.
IVUS detected calcium in > 70% of lesions, significantly more often than standard angiography. Although angiography is moderately sensitive for the detection of extensive lesion calcium (sensitivity, 60% and 85% for three- and four-quadrant calcium, respectively), it is less sensitive for the presence of milder degrees.
Recently, a series of shared molecular pathways have emerged that have in common a significant role in the pathogenesis and progression of both atherosclerosis and cancer. Oxidative stress and the cellular damage that results from it have been implicated in a wide variety of disease processes including atherogenesis and neoplasia. Toxic metabolites produced by cigarette smoking and increased dietary fat intake are implicated in the pathogenesis of both diseases. It has been hypothesized that atherosclerosis may begin when an injury or infection mutates or transforms a single arterial smooth muscle cell in the progenitor of a proliferative clone similar to the most widely held theory of carcinogenesis. Cell proliferation regulatory pathways including genes involved in the GIS checkpoint (p53, pRb, p15, p16, and cyclins A, D, E, and cdk 2,4) have been associated with plaque progression, stenosis and restenosis after angioplasty as well as in cancer progression. Alterations in cell adhesion molecules (integrins, cadherin-catenins) have been linked to plaque formation and thrombosis as well as to tumor invasion and metastasis. Altered expression of proteases associated with thrombolysis has been implicated in atherosclerotic plaque expansion and hemorrhage and in the invasion and metastasis of malignancy. Ligand-growth factor receptor interactions (tyrosine kinases) have been associated with early atherosclerotic lesions as well as cancer development and spread. Nuclear transcription factors such as NFkappaB have been associated with progression of both diseases. Angiogenesis modulators have recently been linked to plaque expansion and restenosis of atherosclerotic lesions as well as local and metastatic tumor expansion. Common disease treatments, such as the use of growth factor inhibitors and radiation treatment, established anticancer treatments, were recently introduced into atherosclerosis therapeutic strategies to prevent restenosis after angioplasty and endarterectomy. In conclusion, a series of molecular pathways of disease development and progression common to atherosclerosis and cancer support that the world's two most common diseases are far more closely aligned than previously believed and that emerging anti-inflammatory and antiproliferative therapeutic strategies may ultimately be efficacious in both conditions.
Factors leading to subacute stent thrombosis after percutaneous coronary intervention (PCI) have not been well established. We assessed the pre- and post-PCI intravascular ultrasound (IVUS) characteristics of subacute stent thrombosis.
We analyzed 7484 consecutive patients without acute myocardial infarction who were treated with PCI and stenting and underwent IVUS imaging during the intervention. Twenty-seven (0.4%) had angiographically documented subacute closure <1 week after PCI (median time to subacute closure, 24 hours). Subacute closure lesions were compared with a control group (selected to be 3 times the abrupt closer group) matched by procedure date (within 6 months), age, gender, stable or unstable angina, lesion location, and additional treatment (balloon angioplasty or atherectomy). Postintervention IVUS did not identify a cause in 22% and did identify at least 1 cause for abrupt closure in 78% of patients (versus 33% in matched lesions, P=0.0002). In 48% of the patients, there were multiple causes in 48% (versus 3% in matched lesions, P<0.0001). Causes included dissection (17%), thrombus (4%), and tissue protrusion within the stent struts leading to lumen compromise lumen (4%). A total of 83% of patients with >1 of these abnormal morphologies also had reduced lumen dimensions post-PCI (final lumen <80% reference lumen). Preprocedural lesion characteristics were not different from matched lesions.
Subacute stent thrombosis is infrequently related to the preintervention lesion characteristics. Inadequate postprocedure lumen dimensions, alone or in combination with other procedurally related abnormal lesion morphologies (dissection, thrombus, or tissue prolapse), contribute to this phenomenon.
Patients who develop acute myocardial infarction due to occlusion in a saphenous vein graft (SVG) constitute a revascularization challenge. Excimer laser angioplasty may have a potential advantage in the treatment of SVGs, since its 308 nanometer wavelength is avidly absorbed by both atherosclerotic plaque and thrombus. The data presented herein support the notion that excimer laser angioplasty is a technology that has a potential role in achieving adequate revascularization outcomes in this selected, high-risk patient population.
A 40 year old patient presented with acute anterior wall infarction. A non-calcified lesion was stented directly without significant expansion of the stent. Rotational atherectomy successfully removed parts of the maldeployed stent and resistant arterial wall substance allowing full dilatation of the lesion.
Treatment of in-stent restenosis (ISR) with conventional percutaneous transluminal coronary angioplasty (PTCA) causes significant recurrent neointimal tissue growth in 30-85%. Therefore, laser ablation of intrastent neointimal hyperplasia before balloon dilation can be an attractive alternative. However, the long-term outcomes of such treatment have not been studied thoroughly enough. This prospective case-control study evaluated angiographic and clinical outcomes of PTCA alone and a combination of excimer laser coronary angioplasty (ELCA) and adjunct PTCA in 125 patients with ISR. ELCA was performed before balloon dilation in 67 patients, PTCA alone was performed in 58 patients. Basic demographic and clinical data were comparable in both groups. Lesions included in ELCA group were longer (17.1+/-9.9 vs 13.6+/-9.1 mm; p = 0.034), more complex (36.5% type C stenoses vs 14.3%; p = 0.006), and more frequently had reduced distal blood flow (TIMI <3: 18.9% vs 4.8%; p = 0.025) compared to lesions in the PTCA group. Immediate angiographic results of PTCA and ELCA + PTCA appeared to be comparable. PTCA alone was successful in 57 patients (98.3%), ELCA + PTCA, in 66 patients (98.5%). The rates of hospital complications were comparable (3.0% in ELCA group vs 8.6% in PTCA group). The 1-year follow-up showed that the rates of major adverse cardiac events (MACE) were comparable in the 2 groups (37.3% in ELCA group vs 46.6% in PTCA group). The rates of target vessel revascularization (TVR) within 1 year after the intervention were also similar in the 2 groups (32.8% vs 34.5%). The data mean that ELCA in patients with complex ISR is efficient and safe. Despite a higher complexity of lesions in the ELCA group, no increase in the rate of complications was registered.
Results for standard revascularization therapies in acute myocardial infarction (AMI) have been limited in part by distal embolization, a process which might be reduced by the application of ultraviolet laser light. The aim was to assess feasibility and safety of excimer laser coronary angioplasty (ELCA) in a randomized study in AMI.
Twenty-seven consecutive patients with ST-segment elevation AMI (aged 57.8+/-9.2 years) were randomized either to balloon angioplasty and stent implantation alone (n=13) or adjunct ELCA (n=14). Quantitative coronary angiography was analyzed by an independent core laboratory.
ELCA was feasible and safe in all cases. No procedure-associated complications were observed. Similar results were found for main parameters in laser (L) and control (C) patients: diameter stenosis decreased from 94.3+/-9.6 to 20.7+/-10.3% (L) and from 82.7+/-16.8 to 18.9+/-5.5% (C) (p=ns; L vs. C). TIMI flow increased from 0.7+/-1.2 to 2.8+/-0.4 and from 1.7+/-1.5 to 3.0+/-0 (p=ns; L vs. C), respectively. The post-procedural myocardial blush score did not differ between the groups (2.1+/-1.3 and 2.7+/-1.0; p=ns; L vs. C) and the final corrected TIMI frame count (cTFC) was also similar in both groups (23+/-7 and 22+/-4; p=ns; L vs. C), but the cTFC gain was higher in the laser group (53+/-14% and 35+/-20%; p<0.05; L vs. C).
Laser angioplasty is feasible and safe for the treatment of patients with ST elevation AMI. Procedural results were at least on par with conventional treatment. Further randomized controlled trials are needed to assess the benefit of laser angioplasty in AMI.
Pulsed-wave ultraviolet excimer laser light at 308 nm can vaporise thrombus, suppress platelet aggregation, and, unlike other thrombectomy devices, ablates the underlying plaque.
To evaluate both safety and efficacy of laser ablation in patients presenting with Acute Myocardial Infarction (AMI) complicated by persistent thrombotic occlusion.
From May 2003 to October 2006, we enrolled 66 AMI patients (age 59+/-11 years; 57 men) presenting complete thrombotic occlusion of the infarct related vessel. All patients were treated with laser. Primary acute angiographic end-points was corrected TIMI frame count. Secondary echocardiographic end-point was left ventricular remodeling defined as an increase in end-diastolic volume >/=20% 6 months after infarction. Tertiary clinical endpoint was event-free survival at 6 months follow-up.
There were no intra-procedural death or coronary perforation. One primary angiographic failure was observed during lasing. Major dissection occurred in 1 (1.5%) and distal embolization in 4 patients (6%). Corrected TIMI frame count was 100 at baseline, 29+/-0.6 after lasing and 22+/-3 after stenting. At 6-months follow-up, left ventricular remodeling occurred in 8% patients. Event-free survival was 95% at 6-months follow-up.
Laser angioplasty is feasible, safe and effective for the challenging treatment of patients with AMI and thrombus-laden lesions. The acute effects on coronary epicardial and myocardial reperfusion are excellent.
Balloon refractory calcific coronary plaques remain a technical challenge. Stent underexpansion is known as a major cause of restenosis and thrombosis. We report a case of in-stent restenosis 5 months after stent suboptimal implantation in a noncompliant calcific atherosclerotic plaque which could not be disrupted by repeated prolonged high-pressure balloon inflations. High-energy excimer laser use altered underlying lesion morphology, allowing full stent apposition. Advances in equipment and technique have allowed more frequent use of high energy excimer laser technology during percutaneous coronary angioplasty with very low rates of complications. Laser technology represents a useful tool to overcome resistant lesions during percutaneous coronary interventions.
International Invasive Cardiology Research Group. Current role of laser angioplasty of restenotic coronary stents.
- Batyraliev T.A.
- Pershukov I.V.
- Niyazova-Karben Z.A.
Batyraliev TA, Pershukov IV, Niyazova-Karben ZA, et al. International Invasive Cardiology Research Group. Current role of laser angioplasty of restenotic coronary stents. Angiology 2006;57(1):21–32.