Excimer laser coronary atherectomy prior to paclitaxel-coated balloon angioplasty for de novo coronary artery lesions

Contrast-enhanced excimer laser stepwise approach during PCI for resistant coronary lesions

BACKGROUND

The treatment of resistant coronary lesions (RCL) is a great challenge for interventional cardiologists. The excimer laser coronary atherectomy (ELCA) is a plaque modification tool based on a main mechanism of photomechanical effect leading to mechanical disruption of the plaque. Contrast dye injection during laser delivery has demonstrated to enhance its power.

AIM

To evaluate the effectiveness and safety of the contrast-enhanced ELCA by a stepwise approach in the treatment of RCLs.

METHODS

We retrospectively examined consecutive patients undergoing contrast-enhanced ELCA-assisted PCI between 2018 and 2021 at two Italian sites. RCLs were defined as novo or in-stent undilatable/uncrossable with conventional balloons (SC/NC balloon). The primary endpoint was ELCA technical success defined as the laser catheter crossing the entire length of the target lesion established by angiographic evidence of the catheter tip in the artery distal to the stenosis.

RESULTS

We enrolled 114 patients who underwent contrast-enhanced ELCA-assisted PCI: 58% of the patients had acute coronary syndrome while the left anterior descending artery was the target vessel in 42.1% of cases. The target lesion was most commonly in-stent (56.2%). The 0.9 mm ELCA catheter tip was employed in 89.5% of cases. The most used frequency/fluency profile was 70/70 (39.5%). The use of contrast-enhanced ELCA was associated with high technical, procedural, and clinical success rates (97.4%, 93.7%, and 90.1%, respectively).

CONCLUSIONS

The contrast-enhanced ELCA seems to be a safe and effective treatment option for the management of both de novo and in-stent-resistant coronary lesions.

Excimer laser coronary angioplasty combined with drug-coated balloon in the treatment of in-stent restenosis

OBJECTIVES

The aim of this study is to investigate the safety and efficacy of excimer laser coronary angioplasty (ELCA) combined with drug-coated balloons (DCBs) in the treatment of in-stent restenosis (ISR), and to explore whether the contrast injection technique would improve the neointimal tissue ablation of ELCA.

METHODS

We studied patients diagnosed with ISR between January 2019 and October 2022 at two medical centers. These patients underwent DCB angioplasty guided by optical coherence tomography (OCT). Based on whether ELCA was performed before DCB treatment, patients were categorized into two groups: the ELCA + DCB group and the DCB group. All patients underwent clinical follow-up 1 year after the procedure. The primary endpoint was the 1-year rate of target lesion revascularization (TLR), which was defined as any repeat percutaneous intervention or bypass surgery on the target vessel conducted to address restenosis or other complications related to the target lesion. The secondary endpoints including immediate luminal gain (ΔMLA, defined as the difference in minimum lumen area before and after the intervention).

RESULTS

A total of 85 lesions in 75 patients were included. The mean age of the study population was 64.2 ± 12.0 years, with 81.3% male. Baseline clinical characteristics were well-balanced, and procedural success was 100% in both groups. The ELCA + DCB group (n = 24) exhibited a greater ΔMLA compared to the DCB group (n = 61) (3.57 ± 0.79 mm² vs. 2.50 ± 1.06 mm², [95% confidence interval, CI: 0.57-1.69], p < 0.001), The reduction in 1-year TLR was more frequently observed in patients from the ELCA + DCB group compared to the DCB group (hazard ratio 0.33 [95% CI: 0.11-0.99]; log-rank p = 0.048). The exploratory analysis showed that ELCA with contrast infusion is associated with greater acute lumen gain compared to ELCA with saline infusion (p < 0.001).

CONCLUSIONS

The combination of ELCA and DCB is a safe and effective treatment strategy for in-stent stenosis. Additionally, compared with saline injection, ELCA with contrast injection is associated with greater acute lumen gain. However, the optimal contrast agent concentration and long-term outcome of the contrast injection technique need confirmation through larger sample sizes and prospective studies.

A novel approach to saline/contrast delivery in excimer laser coronary atherectomy (ELCA) to enhance efficacy: MAXCon ELCA technique

The advent of excimer laser coronary atherectomy (ELCA) nearly four decades ago heralded a novel way to treat complex lesions, both coronary and peripheral, which were previously untraversable and thus untreatable. These complex lesions include heavily calcified lesions, ostial lesions, bifurcation lesions, chronic total occlusions, in-stent restenosis (including stent underexpansion), and degenerative saphenous vein grafts. We discuss the technology of ELCA, its indications, applications, and complications, and suggest the "MAXCon ELCA" technique for better outcomes without increased risk. Lastly, we present a case of MAXCon ELCA effectively treating a complex lesion.

Restenosis after excimer laser coronary atherectomy and drug-coated balloon dilation in Takayasu's arteritis: a case report and review of the literature

Takayasu's arteritis (TAK) is a rare chronic granulomatous arteritis that mainly affects the aorta and its major branches. Coronary artery (CA) involvement can be observed in 10-25% of TAK patients. We report a 21-year-old young female who was previously diagnosed with TAK and severe left main coronary artery (LMCA) stenosis and underwent numerous percutaneous coronary interventions (PCIs) in our hospital due to in-stent restenosis (ISR). This time, an excimer laser coronary atherectomy (ELCA) and drug-coated balloon (DCB) dilation was taken at the LMCA for the ISR. The blood flow was smooth after the operation, and she was symptom-free after discharge. Unfortunately, 5 months later, severe intimal hyperplasia was still seen in the stent of LMCA and left anterior descending (LAD) coronary artery. A coronary artery bypass graft surgery (CABG) was performed, and she has been symptom-free ever since. ELCA plus DCB is one of the novel ways we first reported. However, ensuring long-term inflammation control is equally important to restore blood flow. The combination of revascularization and anti-inflammation/immunosuppression is recommended to improve the outcomes of TAK patients with CA involvements.

Review on Laser Technology in Intravascular Imaging and Treatment

Blood vessels are one of the most essential organs, which nourish all tissues in our body. Once there are intravascular plaques or vascular occlusion, other organs and circulatory systems will not work properly. Therefore, it is necessary to detect abnormal blood vessels by intravascular imaging technologies for subsequent vascular treatment. The emergence of lasers and fiber optics promotes the development of intravascular imaging and treatment. Laser imaging techniques can obtain deep vascular images owing to light scattering and absorption properties. Moreover, photothermal and photomechanical effects of laser make it possible to treat vascular diseases accurately. In this review, we present the research progress and applications of laser techniques in intravascular imaging and treatment. Firstly, we introduce intravascular optical coherent tomography and intravascular photoacoustic imaging, which can obtain various information of plaques. Multimodal intravascular imaging techniques provide more information about intravascular plaques, which have an essential influence on intravascular imaging. Secondly, two laser techniques including laser angioplasty and endovenous laser ablation are discussed for the treatment of arterial and venous diseases, respectively. Finally, the outlook of laser techniques in blood vessels, as well as the integration of laser imaging and treatment are prospected in the section of discussions.

Excimer laser coronary atherectomy for a severe calcified coronary ostium lesion: A case report

BACKGROUND

Percutaneous coronary intervention can be challenging for ostial coronary artery lesions due to calcium burden and elastic fiber content. Excimer laser coronary atherectomy (ELCA) is a less common treatment for severe calcified coronary ostium lesions.

CASE SUMMARY

An 81-year-old male presented to the Cardiology Department of Qingdao Municipal Hospital with a 1-year history of chest pain. Coronary angiography showed severe calcific stenosis (approximately 90%) in the right coronary artery ostium. The right coronary artery ostium was unable to be advanced using a 2.5 mm × 12.0 mm balloon (NC Sprinter, Medtronic, United States) or dilated using a 2.0 mm × 12.0 mm balloon (Sprinter, Medtronic, United States). The patient underwent successful ELCA and balloon dilation of the calcified coronary ostium lesion.

CONCLUSION

ELCA appears to be a safe and effective treatment for the management of severe calcified coronary ostium lesions.

Impact of small diameter and low level of emission laser coronary atherectomy in patients with acute myocardial infarction

Excimer laser coronary atherectomy (ELCA) is an effective treatment to remove intracoronary thrombi. In the present study, we compared in-hospital mortality in patients with acute myocardial infarction (AMI) who underwent conventional treatment and conventional treatment plus ELCA. Among 656 patients who were admitted to our hospital through the Tokyo CCU Network, 104 patients with AMI who were treated by percutaneous coronary intervention between January 2013 and December 2016 met inclusions criteria and underwent conventional treatment with ELCA (ELCA group) and 89 underwent conventional treatment alone (conventional group). We retrospectively evaluated in-hospital mortality within 30 days and used propensity score (PS) matching to reduce assignment bias and multivariate analysis to detect the predictors of in-hospital mortality. In-hospital mortality rate was significantly lower in the ELCA group before and after PS matching (2.9% vs. 13.5%, p = 0.006 before PS matching, and 2.8% vs. 14.1%, p = 0.016 after PS matching). After PS matching, β-blocker or statins use, incidence of shock, Killip classification, and door-to-balloon time were not significantly different. A multivariate logistic regression analysis identified ELCA, dyslipidemia, shock, and left ventricular ejection fraction as independent predictors of in-hospital mortality (odds ratio (OR), 0.147, 95% confidence interval [CI], 0.022–0.959, p = 0.045; OR, 0.077, 95% CI, 0.007–0.805, p = 0.032; OR, 6.494, 95% CI, 1.228–34.34, p = 0.028; OR, 0.890, 95% CI, 0.828–0.957, p = 0.002, respectively). Our data indicate that ELCA with the small diameter and low level emission may reduce the in-hospital mortality compared to conventional methods in patients with AMI in drug-eluting stent era.