Use of Excimer Laser for Thrombus Containing Lesion

Primary percutaneous coronary intervention without stenting using excimer laser and manual thrombectomy in STEMI with duodenal ulcer perforation: a case report

Background

ST-segment elevation myocardial infarction (STEMI) and peptic ulcer perforation are both medical emergencies that require urgent intervention. In case that these time-sensitive medical emergencies present concomitantly, it remains unclear which one should be treated first.

Case summary

An 85-year-old man with melaena, epigastric pain, and severe anaemia was transferred to our emergency department and diagnosed as having inferior STEMI based on electrocardiogram. Emergency coronary angiography (CAG) revealed severe stenosis with thrombus in the proximal right coronary artery. Immediate oesophagogastroduodenoscopy and abdominal computed tomography detected the presence of duodenal ulcer perforation. Primary percutaneous coronary intervention (PCI) without stenting using excimer laser coronary angioplasty and manual thrombectomy was performed under intravascular ultrasound (IVUS) guidance to avoid dual antiplatelet therapy (DAPT). After successful PCI, the perforated viscus was surgically repaired with a laparoscopic omental patch. On Day 7, endoscopic haemostasis treated the oozing of blood from the duodenal ulcer. On Day 21, follow-up CAG and IVUS showed residual stenosis with organized thrombus in the culprit lesion, in which a drug-coated stent was directly implanted. He was discharged with a favourable clinical course on Day 23.

Discussion

We judged that PCI should take precedence over the surgical repair of perforated duodenal ulcer in our case since STEMI was an immediate life-threatening compared to the perforated viscus which had no active exsanguination. Excimer laser coronary angioplasty with manual thrombectomy might be an adequate option to avoid stent deployment and subsequent DAPT in such complex scenarios.

Excimer Laser Coronary Angioplasty in Acute Myocardial Infarction

We evaluated the short-term results of percutaneous excimer laser angioplasty in acute myocardial infarction. Of the 18 patients studied, 2 were female and 16 male with a mean age of 56.6 ± 12.1 years. Thrombolysis in myocardial infarction grades 0, 1, and 2 flow was observed in 10, 5, and 3 cases, respectively, prior to the procedure. The degree of stenosis was 97.9% ± 5.1%. The lesion was crossed with a laser catheter in all cases, using a mean number of 808 ± 384 laser pulses. Type C dissection developed in only 1 case (6%). Except for this case, distal flow was grade 3 in all the patients. Following the procedure, ST segment resolution exceeding 70% was achieved in 14 cases (78%) within the first 90 minutes. The success rate of laser ablation was 94% (17 patients). Stent implantation was performed in all the cases. In conclusion, laser angioplasty is an effective and reliable treatment for acute myocardial infarction.