Impact of in-stent tissue characteristics on excimer laser coronary angioplasty prior to drug-coated balloon treatment

Debulking With Excimer Laser Coronary Angioplasty Versus Balloon Angioplasty in Patients With in Stent Restenosis (ELDISR Study): A Randomized Controlled Trial

OBJECTIVES

Excimer laser coronary angioplasty (ELCA) is a safe and effective method for lesion preparation. However, its impact on clinical outcomes in patients with in-stent restenosis (ISR) undergoing drug-coated balloon (DCB) angioplasty remains unclear. This study aims to evaluate the effect of ELCA-based lesion preparation on the clinical outcomes of ISR patients treated with standard DCB angioplasty.

METHODS

In this prospective, single-center, randomized controlled trial, patients with ISR were randomized 1:1 to either ELCA (+) or ELCA (-). The ELCA (+) group received ELCA for lesion preparation followed by standard DCB angioplasty, while the ELCA (-) group received standard DCB angioplasty alone. The primary endpoint was the rate of target lesion revascularization (TLR) within 1 year. Safety was also evaluated.

RESULTS

A total of 110 patients were randomized to either the ELCA (+) group (n = 55) or the ELCA (-) group (n = 55). The mean age of the study participants was 64.5 years, 89 (80.9%) were men and 51 (46.4%) had diabetes mellitus. The procedure was successful in all patients. The primary endpoint event occurred in five patients (cumulative incidence, 9.1%) in the ELCA (+) group and in 13 patients (cumulative incidence, 23.6%) in the ELCA (-) group (HR, 0.38; 95% CI, 0.15-0.95; p = 0.038).

CONCLUSIONS

Lesion preparation with ELCA before DCB angioplasty is a safe and effective strategy for patients with ISR, associated with a lower incidence of TLR compared to standard DCB angioplasty alone. However, due to the limited sample size and single-center design, these findings should be considered hypothesis-generating. Future validation requires confirmation through multicenter studies with larger patient populations.

TRIAL REGISTRATION

Unique identifier: ChiCTR2300068962.

Drug-coated balloons for coronary artery disease: An updated review with future perspectives

Since the advent of coronary stents, two of the most common long-term complications after percutaneous coronary intervention (PCI) are in-stent restenosis (ISR) and stent thrombosis (ST). Although the rates of ST have been nearly abolished and ISR rates have declined with the current gold-standard second-generation drug-eluting stents (DES), late ISR of DES remains a valid concern in the field of interventional cardiology. The drug-coated balloon (DCB) is a non-stent technology that relies on the concept of targeted homogeneous drug delivery from an inflated balloon to restore luminal vascularity, treat atherosclerosis, and overcome some limitations of PCI, including ISR and prolonged dual antiplatelet therapy to prevent ST by leaving nothing behind. Most clinical evidence on coronary DCBs predominantly comes from small, randomized data and registries using paclitaxel DCBs for ISR and de novo lesions in the coronary space. Since 2014, outside the United States, DCBs have been approved for the treatment of ISR, with a class I recommendation by the European Society of Cardiology. The Food and Drug Administration very recently approved the Agent DCB to treat ISR in patients with coronary artery disease in the US. Additionally, recent randomized clinical data also showed DCB's safety and efficacy for the treatment of de novo small-vessel disease and high-bleeding-risk patients, while their role for other clinical situations including acute coronary syndrome, large-vessel disease, bifurcation lesions, and long-diffuse distal lesions is currently under investigation. Herein, we review the evidence-based role of DCBs in the treatment of coronary lesions and offer future perspectives.

Excimer laser coronary atherectomy with distal protection for neoatherosclerosis rupture: a case report

Background

Neoatherosclerosis, a prominent contributor to in-stent restenosis (ISR), persists as a formidable challenge during percutaneous coronary intervention. Excimer laser coronary atherectomy (ELCA) and embolic protection devices may help reduce coronary flow disturbance from procedure-related distal embolization.

Case summary

A 71-year-old man experienced in-stent neoatherosclerosis rupture-related non-ST segment elevation myocardial infarction. Multidisciplinary intracoronary imaging, including intravascular ultrasound and optical coherence tomography (OCT), suggested that the ISR was caused by a neoatherosclerosis rupture that can potentially lead to distal embolization. Excimer laser coronary atherectomy (fluence, 45 mJ/mm2 and frequency, 25 pulse/s) using a 1.7 mm concentric catheter was performed with distal protection using Filtrap (Nipro Corporation, Tokyo, Japan), which significantly reduced the volume of the neoatherosclerosis. However, subsequent ELCA on the highest setting (fluence, 60 mJ/mm2 and frequency, 40 pulse/s) led to a filter no-reflow phenomenon, although OCT revealed a further effective vaporization of the neoatherosclerosis and an apparent reduction of soft tissue compatible with the thrombus. After removing the embolic protection device, drug-coated balloon angioplasty provided optimal results without coronary flow disturbance.

Discussion

Excimer laser coronary atherectomy reduces soft plaque and thrombus burden, which can reduce the occurrence of distal embolization in select cases. In the case of this patient, procedure-related distal embolization may have been induced by the heightened photomechanical effects resulting from the use of the highest setting in ELCA under increased intracoronary arterial pressure caused by continuous saline injection during ELCA. Concomitant distal protection during ELCA may be more feasible for preventing coronary flow disturbance in patients with a large amount of neoatherosclerosis.