Integrated backscatter-intravascular ultrasound and modification of plaque during excimer laser coronary angioplasty

This study aims to test the hypothesis that the effect of excimer laser coronary angioplasty (ELCA) not only vaporizes thrombi and their underlying coronary plaque, it also changes their quality. We performed a series of cross-sectional analyses in 52 lesions in 51 patients before and after ELCA with integrated backscatter-intravascular ultrasound (IB-IVUS). The constituent parts of the plaque can be assessed by IB-IVUS (i.e., calcified, fibrous, lipid) according to integrated backscatter values. Minimum lumen diameter, lumen volume and vessel volume expanded after ELCA, while plaque volume did not significantly decrease. There was also a decrease of ‘lipid’ component (35.4–30.3%, P < 0.001) and an increase of IB-IVUS-derived ‘fibrous’ part (34.5–38.3%, P < 0.001). These results may help in understanding plaque change after ELCA. Excimer laser coronary angioplasty seems to contribute to the modification of coronary plaque composition in addition to debulking it.

Excimer Laser Coronary Angioplasty in Coronary Lesions: Use and Safety From the NCDR/CATH PCI Registry

Background: Excimer laser coronary angioplasty (ELCA) uses a ultraviolet laser catheter for the treatment of coronary artery disease. ELCA has been used for various coronary lesions, but current safety and frequency of use are unknown. Methods: We performed a retrospective, registry-based study of ELCA use during coronary interventions reported to the National Cardiovascular Data Registry/CATH percutaneous coronary intervention registry from 2009 to 2018 (n=6 043 596 total interventions evaluated). The primary safety end point was the combination of any perforation, dissection, tamponade, or death. ELCA use per 10 000 interventions was evaluated for the study duration. Subgroups of interest were identified including in-stent restenosis lesions, saphenous vein graft lesions, chronic total occlusions, and thrombotic lesions. Results: A total of 19 688 lesions were identified with ELCA use (0.3% of all lesions). The rate of ELCA use increased across the study period from 14 ELCAs performed per 10 000 interventions in 2009 to 70 ELCAs performed per 10 000 interventions in 2018. The primary safety end point occurred in 4.2% of lesions and was higher than in cases where no ELCA was used (3.0% P <0.001). After adjusting for baseline differences among the subgroups who received ELCA, the in-stent restenosis group had the lowest rate of complications (odds ratio, 0.51 [95% CI, 0.42–0.63]), followed by the saphenous vein graft group (odds ratio, 0.72 [95% CI, 0.5–1]). The chronic total occlusion group had a higher risk for complications (odds ratio, 2.01 [95% CI, 1.61–2.40]). Conclusions: The use of ELCA has remained low but has increased in recent years. Complications are significantly higher when ELCA is used, but this effect is variable with respect to lesion subtype. ELCA is frequently used to treat in-stent restenosis with a low risk of complication. ELCA use during chronic total occlusion interventions is associated with a 2-fold increased risk of complications. Together these findings provide guidance for lesion selection to optimize safety with ELCA use.

Excimer Laser Coronary Angioplasty: Clinical Applications and Procedural Outcome, in a Large-Volume Tertiary Centre

Excimer-laser coronary angioplasty can be used to modify undilatable and uncrossable lesions in native arteries and in-stent restenosis which are increasingly encountered with the ageing population undergoing coronary intervention. We present our laser experience over a 10-year period in a large cardiac tertiary centre. <b><i>Method:</i></b> Retrospective analysis of prospectively collected data on all procedures where laser was used from August 2008 to December 2019. Clinical presentation, demographics, and procedural details were all recorded. Successful procedures were defined as &#x3c;30% stenosis at the end. Periprocedural and in-hospital complications were recorded and verified. Results are presented as numbers and percentages. <b><i>Results:</i></b> A total of 331 patients were identified with 473 lesions treated with laser and an overall total of 637 lesions. Of the 473 lesions treated, 46 (9.9%) were in-stent restenosis, 146 (30.9%) were chronic total occlusions, and the rest were uncrossable or undilatable lesions. The vast majority of procedures (97.0%) were performed with the 0.9-mm laser catheter. The overall success rate was 81.6% (58–87%) from low- to high-volume user. Complications included dissection 3 (0.6%), no-reflow 3 (0.6%), coronary perforation 13 (2.7%), and tamponade in 1 (0.2%). Only 3 (0.6%) of the perforations were seen after the laser catheter passage, the rest were seen later following balloon preparation or stent insertion. <b><i>Conclusion:</i></b> Laser is a valuable tool for treating complex and resistant coronary lesions. Its efficacy and safety are well established and when applied appropriately, it helps to achieve optimal outcomes for our patients.

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.

P2694Early and late restenosis after excimer laser coronary angioplasty and paclitaxel-coated balloon combination therapy for drug-eluting stent restenosis

Background Drug-eluting stent restenosis (DES-ISR) is associated with poorer outcomes than those of bare-metal stent restenosis after treatment with paclitaxel-coated balloon (PCB), and late restenosis after PCB angioplasty for DES-ISR is a residual problem. Excimer laser coronary angioplasty (ELCA) is thought to be advantageous for ISR treatment by removing neointima. However, whether the combination of ELCA and PCB angioplasty is more effective than the use of PCB only angioplasty in DES-ISR has not been studied so far. Purpose We evaluated the efficacy of ELCA and PCB combination therapy for DES-ISR at mid-and late-term after revascularization. Methods From January 2014 to March 2016, 166 DES-ISR lesions were treated with ELCA and no-ELCA prior to PCB. Two serial angiographic follow-ups were planned for the patients (at 6–12 and 18–24 months after procedure). Acute procedural and follow-up angiographic results were assessed by quantitative coronary angiography. ELCA and no-ELCA group included 74 lesions and 92 lesions, respectively. Results There was no significant difference between the two groups in the clinical characteristics except the prevalence of hemodialysis, the rate of first-generation DES (37.9% vs 36.8%, p=0.897), previous stent size (2.90±0.39 mm vs 2.77±0.39 mm, p=0.063), and reference vessel diameter (2.65±0.46 mm vs 2.60±0.65 mm, p=0.593). Early follow-up angiography was performed in 66 lesions (89.1%) of ELCA group, and was done in 76 lesions (82.6%) of no-ELCA group. In the ELCA group, percentage diameter stenosis (%DS) just after procedure and at 6–12 months later were significantly smaller than those of no-ELCA group. Besides, target lesion revascularization (TLR) rate at 6–12 months after procedure was tended to be lower in the ELCA group. Late follow-up angiography was performed for 93 lesions (81.6%) of the remaining 114 lesions (excluding TLR lesion), late restenosis was found 9 lesions (18.6%) in the ELCA group and 11 lesions (24.4%) in the no-ELCA group (p=0.504). Late luminal loss was similar in both groups (0.37±0.71 mm vs 0.24±0.82 mm, p=0.438), and %DS at 12–18 months after revascularization was not different between the two groups. Changes of %DS and TLR rate Conclusions %DS in the ELCA group was smaller at just after procedure and the advantage was kept even after 1-year. However, late restenosis and TLR at 2-year after revascularization for DES-ISR could not be reduced by ELCA and PCB combination therapy.