Novel use of a high-energy excimer laser catheter for calcified and complex coronary artery lesions

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.

Effectiveness and safety of a novel intravascular lithotripsy system for severe coronary calcification: CALCI-CRACK trial

BACKGROUND

Intravascular lithotripsy is effective and safe for managing coronary calcification; however, available devices are limited, and complex lesions have been excluded in previous studies. This study aimed to investigate the effectiveness and safety of a novel intravascular lithotripsy system for severe calcification in a population with complex lesions.

METHODS

CALCI-CRACK (ChiCTR2100052058) is a prospective, single-arm, multicenter study. The primary endpoint was the procedural success rate. Major safety endpoints included major adverse cardiovascular events (MACE) and target lesion failure (TLF) at 30 days and 6 months, and severe angiographic complications. Calcification morphology was assessed in the optical coherence tomography (OCT) subgroup.

RESULTS

In total, 242 patients from 15 high-volume Chinese centers were enrolled, including 26.45% of patients with true bifurcation lesions, 3.31% with severely tortuous vessels, and 2.48% with chronic total occlusion, respectively. The procedural success rate was 95.04% (95% confidence interval 91.50-97.41%), exceeding the pre-specified performance goal of 83.4% (p<0.001). The 30-day and 6-month MACE rates were 4.13% and 4.55%, respectively. TLF rates at these time-points were 1.24% and 1.65%, respectively. Severe angiographic complications occurred in 0.42% of patients. In the OCT subgroup (n=93), 93.55% of calcified lesions were fractured, and minimal lumen area increased from 1.55 ± 0.55 mm2 to 4.91 ± 1.22 mm2 after stent implantation, with acute gain rate of 245 ± 102%.

CONCLUSIONS

The novel intravascular lithotripsy system is effective and safe for managing severely calcified coronary lesions in a cohort that included true bifurcation lesions, severely tortuous vessels, and chronic total occlusion. (ChiCTR2100052058).

Rotational atherectomy of calcified coronary lesions: current practice and insights from two randomized trials

With growing experience, technical improvements and use of newer generation drug-eluting stents (DES), recent data showed satisfactory acute and long-term results after rotational atherectomy (RA) in calcified coronary lesions. The randomized ROTAXUS and PREPARE-CALC trials compared RA to balloon-based strategies in two different time periods in the DES era. In this manuscript, we assessed the technical evolution in RA practice from a pooled analysis of the RA groups of both trials and established a link to further recent literature. Furthermore, we sought to summarize and analyze the available experience with RA in different patient and lesion subsets, and propose recommendations to improve RA practice. We also illustrated the combination of RA with other methods of lesion preparation. Finally, based on the available evidence, we propose a simple and practical approach to treat severely calcified lesions.

The Role of Intracoronary Imaging for the Management of Calcified Lesions

Interventional cardiologists in everyday practice are often confronted with calcified coronary lesions indicated for percutaneous transluminal coronary angioplasty (PTCA). PTCA of calcified lesions is associated with diverse technical challenges resulting in suboptimal coronary stenting and adverse long-term clinical outcomes. Angiography itself offers limited information regarding coronary calcification, and the adjuvant use of intracoronary imaging such as intravascular ultrasound (IVUS) and Optical Coherence Tomography (OCT) can guide the treatment of calcified coronary lesions, optimizing the different stages of the procedure. This review offers a description of why, when, and how to use intracoronary imaging for PTCA of calcified coronary lesions in order to obtain the most favorable results. We used the PubMed and Google Scholar databases to search for relevant articles. Keywords were calcified coronary lesions, intracoronary imaging, IVUS, OCT, coronary calcium modification techniques, PTCA, and artificial intelligence in intracoronary imaging. A total of 192 articles were identified. Ninety-one were excluded because of repetitive or non-important information.

Can Most Calcified Coronary Stenosis Be Optimized With Coronary Intravascular Lithotripsy?

Intravascular lithotripsy can be used as an effective therapy for lesion preparation in severely calcified lesions. The mechanism, as shown by optical coherence tomography, is calcium fractures. The aforementioned modification is performed with minimal risk of perforation, no-reflow and a low incidence of flow-limiting dissection and myocardial infarctions. Other techniques, such as cutting or scoring balloons and rotational atherectomy have also been shown to increase luminal diameter, but other complications, such as distal embolization, induced by these treatment modalities, are a source of concern. This review describes a single-center study of all-comer patients, including those with complex characteristics. This therapy is very effective, with a very low risk of complications. In this article, we characterize the mechanism of action of the intravascular lithotripsy catheter, its optical coherence tomography validation, clinical applications, and comparison with other calcium-modifying technologies, as well as future directions, which can be used to improve the technology.

Contemporary percutaneous management of coronary calcification: current status and future directions

Severe coronary artery calcification is one of the greatest challenges in attaining success in percutaneous coronary intervention, limiting acute and long-term results. In many cases, plaque preparation is a critical prerequisite for delivery of devices across calcific stenoses and also to achieve adequate luminal dimensions. Recent advances in intracoronary imaging and adjunctive technologies now allow the operator to select the most appropriate strategy in each individual case. In this review, we will revisit the distinct advantages of a complete assessment of coronary artery calcification with imaging and application of appropriate and contemporary plaque modification technologies in achieving durable results in this complex lesion subset.

Contemporary Interventional Approach to Calcified Coronary Artery Disease

Calcific coronary artery disease is an increasingly prevalent entity in the catheterization laboratory which has implications for stenting and expected outcomes. With new interventional techniques and equipment, strategies to favorably modify coronary calcium prior to stenting continue to evolve. This paper sought to review the latest advances in the management of severe coronary artery calcification in the catheterization laboratory and discuss contemporary percutaneous interventional approaches.

A State-of-the-Art Review: The Percutaneous Treatment of Highly Calcified Lesions

Coronary artery calcification is prevalent in coronary heart disease with its progression being predictive of future adverse cardiac events. Its presence is considered to be a marker of interventional procedural complexity. Several adjunctive percutaneous coronary intervention tools, such as modifying balloons, atherectomy devices and intravascular lithotripsy, now exist to successfully treat calcified lesions. In this state-of-the-art review, a step-wise progression of strategies is described to modify coronary plaque, from well-recognised techniques to techniques that should only be considered when standard manoeuvres have proven unsuccessful. Technology has advanced greatly over the past few decades and we discuss how future technologies might shape percutaneous intervention.

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.

New Advances in the Treatment of Severe Coronary Artery Calcifications

Coronary artery calcifications are always challenging scenarios for interventional cardiologists. Calcium content in coronary tree directly correlates with male sex, age, Caucasian ethnicity, diabetes, and chronic kidney disease. Intracoronary imaging is useful and necessary to understand calcific lesion features and plan the best percutaneous coronary intervention strategy. Thus, accurate evaluation of patient and lesion characteristics is crucial. For this reason, definition of calcific arc, length, and thickness can suggest the best procedure before stenting and final optimization. In our modern era, different devices are available and all are surprisingly promising.

Principles of Intravascular Lithotripsy for Calcific Plaque Modification

A significant proportion of lesions treated with transcatheter interventions in the coronary and peripheral vascular beds exhibit moderate to severe calcific plaques known to portend lower procedural success rates, increased peri-procedural adverse events, and unfavorable clinical outcomes compared with noncalcific plaques. Adapted from lithotripsy technology used for treatment of ureterorenal calculi, intravascular lithotripsy (IVL) is a novel technique for the treatment of severely calcific plaque lesions that uses acoustic shockwaves in a balloon-based delivery system. Shockwaves induce calcium fractures, which facilitate stent expansion and luminal gain. In this review, the authors summarize the physics, preclinical and clinical data on IVL use in the coronary and peripheral vasculature, and future directions of IVL in transcatheter cardiovascular therapies.

Impella-Assisted Intracoronary Lithotripsy of Severely Calcified Left Main Coronary Artery Bifurcation for NSTEMI With Cardiogenic Shock

High calcification of coronary artery plaque is a frequent cause of suboptimal stent expansion, which can result in stent thrombosis and restenosis. Shockwave intravascular lithotripsy (S-IVL) represents a new frontier in the treatment of highly calcified coronary lesions. It can be an excellent alternative to intracoronary atherectomy in extremely high-risk lesions. We present a case of a 57-year-old man with known severe coronary artery disease (CAD) who presented with non-ST segment elevation myocardial infarction (NSTEMI), cardiogenic shock and was successfully treated with impella-assisted shockwave-intravascular lithotripsy permitting successful percutaneous intervention of a high-risk left main coronary artery (LMCA) bifurcation in-stent restenosis.

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.

METHOD

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 <30% stenosis at the end. Periprocedural and in-hospital complications were recorded and verified. Results are presented as numbers and percentages.

RESULTS

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.

CONCLUSION

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.

Excimer Laser Atherectomy in Percutaneous Coronary Intervention: A Contemporary Review

Excimer laser coronary atherectomy (ELCA) during percutaneous coronary intervention (PCI) has been in use for more than twenty years. While early experiences were not favorable over balloon angioplasty alone, with improvement in operator technique, patient selection and technology, ELCA has established its own niche in contemporary PCI as a safe and effective atherectomy strategy. With growing experience in complex coronary interventions worldwide, ELCA has become one of the essential atherectomy tools offering unique advantages over other atherectomy devices. In the modern era, ELCA is commonly used for patients with in-stent restenosis, stent under expansion, balloon uncrossable lesions and chronic total occlusions. Technical success rates are reported to be >80% in most situations while procedural complication rates such as vessel dissection and perforation among others are reported to average 9% over the past 25 years with improvement over time. In this review, we provide a comprehensive systematic review of the ELCA system, its practical use, indications, and procedural techniques in the contemporary PCI era.

Management of Calcific Coronary Artery Lesions: Is it Time to Change Our Interventional Therapeutic Approach?

Patients with obstructive coronary lesions with a high calcium content (LHCC) have an exaggerated clinical risk, because the presence of calcification is associated with more extensive coronary atheroma and higher burden of comorbidities. Treatment of LHCC using percutaneous techniques is complex because of an increased risk of incomplete lesion preparation with suboptimal stent deployment and higher rates of acute and chronic stent failure. Rotational atherectomy has been the predominant technology for treatment of high-grade LHCC, but novel devices/technologies have entered clinical practice. It seems likely that combining enhanced intravascular imaging, which allows definition of the patterns of calcification with these new technologies, will herald a change in procedural algorithms for treatment of LHCC. This review provides an overview about LHCC with special focus on existing and emergent technologies. We also provide a proposed procedural algorithm to facilitate optimal use of technology according to specific features of LHCC and coronary anatomy.

Using the coronary lithotripsy system for coronary artery disease

Severe coronary artery calcification increases percutaneous treatment complexity and the risk of intraprocedural complications, affecting acute and long-term outcomes. Current use of specialty balloons and atherectomy technologies is limited due to the higher risk of complications, degree of technical difficulty and operator experience. Intravascular lithotripsy (IVL) is a novel technology for severe calcified coronary artery disease that facilitates vessel preparation, enhancing vessel compliance. IVL system emits sonic waves that penetrate through vascular layers and disrupt both superficial and deep calcium, leaving the soft tissue unharmed. The purpose of the present review is to provide a summary of the evidence currently available on this therapy, including a practical description of the components and function of the shockwave coronary IVL system.

Treatment of In-Stent Restenosis Using Excimer Laser Coronary Atherectomy and Bioresorbable Vascular Scaffold Guided by Optical Coherence Tomography

The rate of in-stent restenosis (ISR) has become increasingly prevalent with the exponential growth in stent implantation due to an aging population and a higher life expectancy, in addition to the high rates of obesity and diabetes. In this prospective, single operator, all-comer study, we sought to analyze the performance of ELCA followed by bioresorbable vascular scaffold (BVS) placement in patients undergoing percutaneous coronary intervention (PCI) for ISR. A total of 13 patients had ISR treated with a combination of ELCA and BVS, with 9 patients having matched OCT pre, post ELCA and post BVS. Mean age was 65 ± 11.22 and 83% of the patients were male. Hypertension and dyslipidemia were present in 100% of the patients and smoking and diabetes in 50%. After the procedure, we did not detect residual stenosis over 10% in any patient, resulting in a technical success of 100%. No patients had MACE during their hospital stay or within the next six months, resulting in a procedure success of 100%. The mean lumen area increased 0.35 mm² from pre procedure to post ELCA and 3.58 mm² from post ELCA to post BVS. The final difference, from pre procedure to post BVS, was a 3.93 mm² lumen area gain. The mean lumen diameter increased 0.11 mm from baseline to ELCA, 0.95 mm from post laser to BVS implantation and 1.06 mm from pre procedure to post BVS. The NIH area reduced 0.48 mm² from pre to post ELCA, 1.13mm² from post ELCA to BVS implantation and 1.61 mm² from baseline to post BVS implantation. We conclude that ELCA is a safe and feasible debulking method to approach ISR, with high rates of post-procedural BVS success, within six months follow-up.

The Use and Clinical Outcomes of Single-Burr Rotational Atherectomy: The Experience of a Local Hospital in Taiwan

Background

Treating heavily calcified lesions is a challenge and is associated with high re-stenosis and target lesion revascularization (TLR). Before stent implantation, lesions must be adequately prepared using rotational atherectomy (RA), which has shown favorable results. The study aims to report our hospital's clinical outcomes when using rotational atherectomy on complex and heavily calcified coronary lesions with a single-burr strategy.

Methods

We retrospectively analyzed 58 patients who underwent percutaneous coronary interventions with RA at our center between December 2006 and April 2017. Data on immediate post-procedural events and major adverse cardiovascular events were collected during follow-up, including cardiovascular death, myocardial infarction, TLR, target vessel revascularization (TVR) and stroke.

Results

Of the 58 patients and 90 lesions treated over 10 years, 88 lesions (97.8%) used only one burr. The intervention procedure success rate was 100%. During a mean follow-up of 41.2 months, 6 patients experienced acute coronary syndrome, 12 required TLR, 2 needed TVR, and 6 died due to a cardiovascular event. We divided lesions into 5 categories. The prevalence of lesions and the burr size most commonly used were: category 1 (ostial lesion, 8.9%, 1.75 mm), category 2 (focal lesion, 20%, 1.75 mm), category 3 (intermediate lesion, 13.3%, 1.5 mm), category 4a (long, looser lesion, 26.7%, 1.5 mm), and category 4b (long, rigid lesion, 31.1%, 1.25 mm).

Conclusions

Rather than a routine step-by-step strategy for RA, this study shows convincing evidence supporting the use of this device to treat complex calcified coronary lesions using a single-burr strategy.

Contemporary Approach to Heavily Calcified Coronary Lesions

Percutaneous treatment of heavily calcified coronary lesions still represents a challenge for interventional cardiology, with higher risk of immediate complications, late failure due to stent underexpansion and malapposition, and consequently poor clinical outcome. Good characterisation of calcium distribution with multimodal imaging is important to improve the successful treatment of these lesions. The use of traditional or new dedicated devices for the treatment of calcified lesions allows better lesion preparation; therefore, it is important that we know the different mechanisms and technical features of these devices.

The Excimer Laser: Science Fiction Fantasy or Practical Tool?

Nearly 20 years ago, in vitro experiments left no doubt about the fact that laser light can ablate atherosclerotic plaque. The initial enthusiastic results with the technology, particularly in coronary arteries, were followed by reports showing unacceptably high restenosis and complication rates. These poor results were due to the premature application of an underdeveloped technology, a lack of understanding of laser/tissue interaction, and the use of incorrect lasing techniques. Consequently, and without discrimination, all lasers were banned from the catheterization laboratories for nearly a decade. Technological enhancements of the excimer laser, combined with refined catheter lasing techniques, resulted in greater debulking of atherosclerotic material in long superficial femoral artery occlusions. These results triggered the application of the excimer laser technique as an atherectomy tool in more complex lesions below the knee. The multicenter Laser Atherectomy for Critical Ischemia study clearly demonstrated that the excimer laser technology resulted in limb salvage rates >90% in patients with critical limb ischemia (CLI). Furthermore, new clinical results indicate that the excimer laser is very effective in dissolving thrombotic obstructions, redirecting this technology to the coronary field.

The results of the excimer laser in CLI validate the role of the cool laser in treating complex peripheral vascular disease. The results suggest a larger indication for this technology and support a more aggressive use of these interventional techniques in the treatment of this large patient cohort. However, all lasers are not equally effective in debulking atherosclerotic material. Only the athermic process associated with the excimer laser produces a safe and effective endovascular ablation of obstructive atherosclerotic and/or thrombotic material. The appropriate and safe utilization of the equipment and lasing techniques, combined with correct indications and patient selection, will contribute to the successful application of laser-assisted atherectomy in complex peripheral and coronary artery obstructive disease. Unfortunately, little consistent scientific data has been generated to convince the interventional community of the usefulness of excimer laser ablation.

Extended use of the GuideLiner in complex coronary interventions

AIMS

Challenging coronary anatomies including chronic total occlusions (CTO), extreme vessel tortuosity, diseased bypass grafts, and anomalous coronary arteries pose difficulties in coronary interventions. The GuideLiner is a monorail catheter originally developed to facilitate delivery of stents to target lesions in tortuous vessels. We conducted a study on the feasibility and safety of utilising this catheter in a wider array of complex coronary interventions.

METHODS AND RESULTS

Consecutive patients undergoing coronary or peripheral interventions where a GuideLiner was used were recruited into this study. Patient demographics, lesion and vessel characteristics, procedural details and outcomes were prospectively entered into our database and analysed. From September 2009 to October 2011, 54 consecutive patients underwent coronary intervention in our institution using a GuideLiner; 21 out of 54 coronary applications were motivated by the need to increase support to cross CTOs, predominantly of the RCA. Anomalous or angulated take-off of the treatment vessels (31%), previously deployed proximal stents (15%), heavy proximal calcification (9%) and tortuosity (7%) accounted for the remaining reasons. One patient had successful renal denervation with the aid of a GuideLiner catheter. Procedural success was 98% in our series with no device-related periprocedural complications such as ostial dissection or myocardial necrosis.

CONCLUSIONS

The use of a GuideLiner facilitates the approach to complex coronary interventions including chronic total occlusion and saphenous vein graft intervention by providing greater back-up support and easier engagement of coronary ostia.

Coronary Intervention with the Excimer Laser: Review of the Technology and Outcome Data

Excimer laser coronary atherectomy (ELCA) is a long-established adjunctive therapy that can be applied during percutaneous coronary intervention (PCI). Technical aspects have evolved and there is an established safety and efficacy record across a number of clinical indications in contemporary interventional practice where complex lesions are routinely encountered. The role of ELCA during PCI for thrombus, non-crossable or non-expandable lesions, chronic occlusions and stent under-expansion are discussed in this review. The key advantage of ELCA over alternative atherectomy interventions is delivery on a standard 0.014-inch guidewire. Additionally, the technique can be mastered by any operator after a short period of training. The major limitation is presence of heavy calcification although when rotational atherectomy (RA) is required but cannot be applied due to inability to deliver the dedicated RotaWire^TM (Boston Scientific), ELCA can create an upstream channel to permit RotaWire passage and complete the case with RA - the RASER technique.

Successful retrieval of an entrapped guide wire between a deployed coronary stent and severely calcified vessel wall using excimer laser coronary atherectomy

We report the successful retrieval of an entrapped interventional guide wire between a newly deployed coronary stent and severely calcified vessel wall. Using a buddy wire technique, the stent was deployed at high pressure in a culprit lesion of the left anterior descending (LAD) artery. The buddy wire in the LAD artery was entrapped between the deployed stent and severely calcified vessel wall, as it was not removed before stent deployment, and could not be retrieved. Neither balloon catheters nor a microcatheter were able to be advanced behind the stent over the entrapped guide wire. Excimer laser coronary atherectomy (ELCA) was performed within the stent to modify and soften the calcification behind the deployed stent. Consequently, the entrapped guide wire was retrieved successfully and safely. This case illustrates that ELCA can be utilized to retrieve an entrapped guide wire between a deployed stent and calcified vessel wall.

Immediate and midterm follow-up results of excimer laser application in complex percutaneous coronary interventions: Report from a single center experience

OBJECTIVE

To assess the efficacy and safety of laser-assisted percutaneous coronary interventions (PCI) in an unselected population.

METHODS

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).

RESULTS

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).

CONCLUSIONS

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.

How should I treat severe calcific coronary artery disease?

BACKGROUND

An 80-year-old man with limiting angina pectoris.

INVESTIGATION

Physical examination, laboratory tests, echocardiography, exercise ECG, coronary arteriography, pressure wire assessment.

DIAGNOSIS

Single severe calcific coronary artery disease.

TREATMENT

Elective percutaneous coronary intervention (PCI) for calcific mid-vessel stenosis with rotational and excimer laser atherectomy.

The use of excimer laser for complex coronary artery lesions

Excimer laser coronary atherectomy (ELCA) has been used for coronary intervention for more than 20 years. Advances in delivery systems for laser energy using the xenon-chlorine pulsed laser catheter deliver higher energy density with lower heat production. The Spectranetics CVX-300 (Spectranetics, Colorado Springs, CO, USA) excimer laser catheter system has been used for the treatment of complex coronary lesions. We report our experience with the use of this advanced system for stenoses for which were unsuitable for standard percutaneous coronary intervention; for example, balloon-resistant lesions, chronic total occlusions, and for underexpanded stents in calcified lesions. ELCA may also be valuable for thrombus-containing lesion. We find ELCA to be indispensable in the catheterization laboratory for specific complex or calcified lesions. Its role should be explored in a large randomized trial of thrombus containing lesions and saphenous vein grafts.