1
|
Sung JG, Lo ST, Lam H. Contemporary Interventional Approach to Calcified Coronary Artery Disease. Korean Circ J 2023; 53:55-68. [PMID: 36792557 PMCID: PMC9932225 DOI: 10.4070/kcj.2022.0303] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 11/22/2022] [Indexed: 01/09/2023] Open
Abstract
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.
Collapse
Affiliation(s)
| | - Sidney Th Lo
- Department of Cardiology, Liverpool Hospital, Sydney, Australia
| | - Ho Lam
- Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong, China.
| |
Collapse
|
2
|
Bamford P, Collins N, Boyle A. A State-of-the-Art Review: The Percutaneous Treatment of Highly Calcified Lesions. Heart Lung Circ 2022; 31:1573-1584. [PMID: 36150953 DOI: 10.1016/j.hlc.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/28/2022] [Accepted: 08/04/2022] [Indexed: 12/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- Paul Bamford
- Cardiology Department, John Hunter Hospital, Newcastle, NSW, Australia; Cardiology Department, University of Newcastle, Newcastle, NSW, Australia.
| | - Nicholas Collins
- Cardiology Department, John Hunter Hospital, Newcastle, NSW, Australia; Cardiology Department, University of Newcastle, Newcastle, NSW, Australia
| | - Andrew Boyle
- Cardiology Department, John Hunter Hospital, Newcastle, NSW, Australia; Cardiology Department, University of Newcastle, Newcastle, NSW, Australia
| |
Collapse
|
3
|
Sharma N, Asrress KN, O'Kane P, Pyo RT, Redwood SR. Laser, Rotational, Orbital Coronary Atherectomy, and Coronary Intravascular Lithoplasty. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
|
4
|
Adikari DH, Giles RW, Jepson NS, Pitney MR. Initial experience of a single referral centre using excimer laser coronary atherectomy-assisted expansion in undilatable stents: Excimer laser in undilatable stents. ASIAINTERVENTION 2022; 8:32-41. [PMID: 35350795 PMCID: PMC8922468 DOI: 10.4244/aij-d-21-00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 11/22/2021] [Indexed: 06/14/2023]
Abstract
AIMS Undilatable stents with severe peri-stent calcification are an important cause of target lesion failure and therapeutic options are limited. We report our initial experience with the safety and efficacy of excimer laser coronary atherectomy (ELCA)-assisted expansion of undilatable stents. METHODS AND RESULTS ELCA was performed with saline, blood and contrast-enhanced trains. All lesions were post-dilated at high pressures and treated with a drug-eluting balloon. Thirty-one lesions with undilatable stents were included at a single centre with experienced operators from March 2016 to February 2021. The mean number of prior procedures for in-stent restenosis was three and 14 lesions had multiple layers of stent. Procedural success (>50% increase in minimal stent diameter [MSD]) and adequate stent expansion (MSD >70% of reference vessel diameter) was achieved in all lesions. At six-month follow-up (N=26 lesions), there were six periprocedural myocardial infarctions due to slow flow, two cardiac deaths and one target lesion revascularisation. There were no perforations. CONCLUSIONS Our niche experience at a centre with experienced operators demonstrated that ELCA led to larger final lumen and stent dimensions in highly selected patients with undilatable stents and recurrent restenosis at the cost of relatively frequent slow flow.
Collapse
Affiliation(s)
- Dona H Adikari
- Cardiology Department, The Prince of Wales Hospital, Sydney, Australia
| | - Robert W Giles
- Cardiology Department, The Prince of Wales Hospital, Sydney, Australia
| | - Nigel S Jepson
- Cardiology Department, The Prince of Wales Hospital, Sydney, Australia
| | - Mark R Pitney
- Cardiology Department, The Prince of Wales Hospital, Sydney, Australia
| |
Collapse
|
5
|
Asrress KN, O'Kane P, Pyo R, Redwood SR. Laser, Rotational, and Orbital Coronary Atherectomy. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kaleab N. Asrress
- Department of Cardiology; St Thomas’ Hospital, and King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital; London UK
| | - Peter O'Kane
- Dorset Heart Centre; Royal Bournemouth Hospital; Bournemouth UK
| | - Robert Pyo
- Montefiore Medical Center; Albert Einstein College of Medicine; New York NY USA
| | - Simon R. Redwood
- Department of Cardiology; St Thomas’ Hospital, and King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital; London UK
| |
Collapse
|
6
|
Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
7
|
Fernandez JP, Hobson AR, McKenzie D, Shah N, Sinha MK, Wells TA, Levy TM, Swallow RA, Talwar S, O’Kane PD. Beyond the balloon: excimer coronary laser atherectomy used alone or in combination with rotational atherectomy in the treatment of chronic total occlusions, non-crossable and non-expansible coronary lesions. EUROINTERVENTION 2013; 9:243-50. [DOI: 10.4244/eijv9i2a40] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
8
|
McKenzie D, Talwar S, Jokhi P, O’Kane P. How should I treat severe coronary artery calcification when it is not possible to dilate a balloon or deliver a RotaWire™? EUROINTERVENTION 2011; 6:779-83. [DOI: 10.4244/eijv6i6a132] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
9
|
Fernandez JP, Hobson AR, McKenzie DB, Talwar S, O’Kane P. Treatment of calcific coronary stenosis with the use of excimer laser coronary atherectomy and rotational atherectomy. Interv Cardiol 2010. [DOI: 10.2217/ica.10.83] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
10
|
Wilson JM, Ferguson JJ, Hall RJ. Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
11
|
Bittl JA, Chew DP, Topol EJ, Kong DF, Califf RM. Meta-Analysis of randomized trials of percutaneous transluminal coronary angioplasty versus atherectomy, cutting balloon atherotomy, or laser angioplasty. J Am Coll Cardiol 2004; 43:936-42. [PMID: 15028347 DOI: 10.1016/j.jacc.2003.10.039] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2003] [Accepted: 10/09/2003] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We conducted a systematic overview (meta-analysis) of randomized trials of balloon angioplasty versus coronary atherectomy, laser angioplasty, or cutting balloon atherotomy to evaluate the effects of plaque modification during percutaneous coronary intervention. BACKGROUND Several mechanical approaches have been developed that ablate or section atheromatous plaque during percutaneous coronary interventions to optimize acute results, minimize intimal injury, and reduce complications and restenosis. METHODS Sixteen trials (9,222 patients) constitute the randomized controlled experience with atherectomy, laser, or atherotomy versus balloon angioplasty with or without coronary stenting. Each trial tested the hypothesis that ablative therapy would result in better clinical or angiographic results than balloon dilation alone. RESULTS Short-term death rates (<31 days) were not improved by the use of ablative procedures (0.3% vs. 0.4%, odds ratio [OR] 0.94 [95% confidence interval 0.46 to 1.92]), but periprocedural myocardial infarctions (4.4% vs. 2.5%, OR 1.83 [95% CI 1.43 to 2.34]) and major adverse cardiac events (5.1% vs. 3.3%, OR 1.54 [95% CI 1.25 to 1.89]) were increased. Angiographic restenosis rates (6,958 patients) were not improved with the ablative devices (38.9% vs. 37.4%, OR 1.06 [95% CI 0.97 to 1.17]). No reduction in revascularization rates (25.2% vs. 24.5%, OR 1.04 [95% CI 0.94 to 1.14]) or cumulative adverse cardiac events rates up to one year after treatment were seen with ablative devices (27.8% vs. 26.1%, OR 1.09 [95% CI 0.99 to 1.20]). CONCLUSIONS The combined experience from randomized trials suggests that ablative devices failed to achieve predefined clinical and angiographic outcomes. This meta-analysis does not support the hypothesis that routine ablation or sectioning of atheromatous tissue is beneficial during percutaneous coronary interventions.
Collapse
Affiliation(s)
- John A Bittl
- Ocala Heart Institute, Munroe Regional Medical Center, 1511 SW 1st Avenue, Ocala, Florida 34474, USA.
| | | | | | | | | |
Collapse
|
12
|
Strikwerda S, Montauban van Swijndregt E, Foley DP, Boersma E, Umans VA, Melkert R, Serruys PW. Immediate and late outcome of excimer laser and balloon coronary angioplasty: a quantitative angiographic comparison based on matched lesions. J Am Coll Cardiol 1995; 26:939-46. [PMID: 7560621 DOI: 10.1016/0735-1097(95)00278-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study sought to compare acute lumen changes and late lumen narrowing during and after excimer laser-assisted balloon angioplasty, measured by quantitative coronary angiography, with the immediate and long-term outcome of balloon angioplasty alone. BACKGROUND Although excimer laser coronary angioplasty is used as an adjunct or alternative to balloon angioplasty, limited comparative data exist regarding the immediate and long-term efficacy of excimer laser-assisted balloon angioplasty versus balloon angioplasty alone. METHODS A series of 53 lesions in 47 consecutive patients successfully treated with excimer laser-assisted balloon angioplasty were individually matched after completion of 6-month follow-up angiography with 53 successfully treated balloon angioplasty lesions according to vessel location, preprocedural minimal lumen diameter and reference diameter. Immediate and long-term angiographic results were assessed by an automated lumen contour detection algorithm. RESULTS Before intervention in the laser and balloon angioplasty groups, respectively, minimal lumen diameter (mean +/- SD) was 0.73 +/- 0.47 and 0.74 +/- 0.46 mm, and reference diameter was 2.71 +/- 0.42 and 2.72 +/- 0.41 mm. Laser angioplasty was followed by adjunctive balloon dilation in 50 lesions. Mean balloon diameter at maximal inflation was similar in both treatment groups (2.61 +/- 0.32 and 2.65 +/- 0.38 mm, respectively), resulting in similar minimal lumen diameters after intervention of 1.77 +/- 0.41 and 1.78 +/- 0.34 mm, respectively. At follow-up angiography, minimal lumen diameter after excimer laser-assisted balloon angioplasty was 1.17 +/- 0.63 mm, and that after balloon angioplasty alone was 1.46 +/- 0.67 mm (p = 0.02). The angiographic restenosis rates at follow-up using the 50% diameter stenosis cutoff criterion were 57% and 34%, respectively (p = 0.02). CONCLUSIONS Quantitative angiographic analysis of a matched group of 106 successfully treated coronary lesions showed a similar immediate outcome but reduced long-term efficacy of excimer laser-assisted balloon angioplasty compared with that after balloon angioplasty alone.
Collapse
Affiliation(s)
- S Strikwerda
- Cardiac Catheterization Laboratory, Thoraxcenter, University Hospital Dijkzigt, Erasmus University, Rotterdam, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
13
|
Strikwerda S, van Swijndregt EM, Melkert R, Serruys PW. Quantitative angiographic comparison of elastic recoil after coronary excimer laser-assisted balloon angioplasty and balloon angioplasty alone. J Am Coll Cardiol 1995; 25:378-86. [PMID: 7829791 DOI: 10.1016/0735-1097(94)00378-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Coronary lumen changes during and after excimer laser-assisted balloon angioplasty were measured by quantitative coronary angiography, and the results were compared with the effects of balloon angioplasty alone. BACKGROUND Reduction of atherosclerotic tissue mass by laser ablation in the treatment of coronary artery disease may be more effective in enlarging the lumen than balloon angioplasty alone. METHODS A series of 57 consecutive coronary lesions successfully treated by xenon chloride excimer laser-assisted balloon angioplasty were individually matched with 57 coronary artery lesions successfully treated by balloon angioplasty alone. The following variables were measured by quantitative coronary analysis: 1) ablation by laser, 2) stretch by balloon dilation, 3) elastic recoil, and 4) acute gain. RESULTS Matching by stenosis location, reference diameter and minimal lumen diameter resulted in two comparable groups of 57 lesions with identical baseline stenosis characteristics. Minimal lumen diameter before excimer laser-assisted balloon angioplasty and balloon angioplasty alone were (mean +/- SD) 0.73 +/- 0.44 and 0.74 +/- 0.43 mm, respectively. Laser ablation significantly improved minimal lumen diameter by 0.56 +/- 0.44 mm before adjunctive balloon dilation. In both treatment groups, similar-sized balloon catheters (2.59 +/- 0.35 and 2.56 +/- 0.40 mm, respectively) were used. After laser-assisted balloon angioplasty, elastic recoil was 0.84 +/- 0.30 mm (32% of balloon size), which was identical to that after balloon angioplasty alone, namely, 0.82 +/- 0.32 mm (32%). Consequently, both interventions resulted in similar acute gains of 1.02 +/- 0.52 and 1.00 +/- 0.56 mm, respectively. Minimal lumen diameter after intervention was equal in both groups: 1.75 +/- 0.35 and 1.75 +/- 0.34 mm, respectively. The statistical power of this study in which a 25% difference in elastic recoil (0.2 mm) between groups was considered clinically important was 95%. CONCLUSIONS In matched groups of successfully treated coronary lesions, xenon chloride excimer laser ablation did not reduce immediate elastic recoil after adjunctive balloon dilation or improve the final angiographic outcome compared with balloon angioplasty alone using similar-sized balloon catheters.
Collapse
Affiliation(s)
- S Strikwerda
- Catheterization Laboratory, Thoraxcenter, University Hospital Dijkzigt, Erasmus University, Rotterdam, The Netherlands
| | | | | | | |
Collapse
|
14
|
Initial clinical experience with a modified excimer laser for coronary angioplasty. Lasers Med Sci 1994. [DOI: 10.1007/bf02594180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
15
|
Strikwerda S, Koolen JJ, de Feyter PJ, Sprangers RL, Tijssen JG, Serruys PW. Excimer laser coronary angioplasty in The Netherlands: preamble for a randomized study. Am Heart J 1993; 125:838-47. [PMID: 8438713 DOI: 10.1016/0002-8703(93)90179-d] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The immediate outcome of ELCA by XeCl excimer laser radiation is described in 53 patients who were selected to undergo ELCA from December 1990 to September 1991 in two centers that are currently performing ELCA in the Netherlands. Immediate success rates on the basis of visual assessment of the angiogram were as follows. Laser success (> 20% reduction of diameter stenosis after ELCA alone) was observed in 77% of patients, procedural success (< 50% residual stenosis after ELCA with or without adjunctive balloon dilatation [PTCA]) in 91%, and clinical success (procedural success without clinical complications) in 83% of patients. Quantitative coronary angiography by automated contour detection was performed in 31 patients who underwent ELCA in the Thoraxcenter. The minimal luminal diameter (mean +/- SD) of the treated coronary segments increased from 0.77 +/- 0.41 mm to 1.24 +/- 0.25 mm after ELCA and further to 1.67 +/- 0.29 mm after adjunctive PTCA in 25 patients. The present experience is put in perspective of results initially reported by other centers and compared with data from multicenter registries of ELCA. Finally, a short description is given of the design of a prospective, randomized trial of ELCA versus conventional PTCA (AMRO trial).
Collapse
Affiliation(s)
- S Strikwerda
- Department of Cardiology, University Hospital Dijkzigt, Erasmus University, Rotterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|
16
|
Chatelain P, Meier B, de la Serna F, Moles V, Pande AK, Verine V, Urban P. Success with coronary angioplasty as seen at demonstrations of procedure. Lancet 1992; 340:1202-5. [PMID: 1359269 DOI: 10.1016/0140-6736(92)92900-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
To assess the real-life results of coronary angioplasty, unidentified participants made notes on 104 cases demonstrated live at twelve international angioplasty courses in 1991. The initially planned procedure was successful in 73% with crossover to another device in 20% for an ultimate success rate of 93%. Interventions lasted an hour on average and two devices on average were used per artery tackled. Rates of success and of complication necessitating reintervention were, for balloon angioplasty (57 cases) 81% and 19%, for directional atherectomy (16 cases) 75% and 0%, for the Rotablator (12 cases) 42% and 42%, for stent implantation (10 cases) 100% and 0%, for excimer laser angioplasty (6 cases) 17% and 33%, and for Rotacs recanalisation (3 cases) 67% and 0%, respectively. The complications were occlusions (threatened, acute, or delayed) and they were usually treated by balloon angioplasty or a stent. No death or myocardial infarction was reported. The observer attending the demonstration tended to take a less favourable view of the outcome than the clinician doing the procedure and in general the results of coronary angioplasty seemed inferior to those reported in journals. Interventions done before an audience will be unusually stressful but this will be outweighed by the fact that difficult cases with a low probability of success are rarely tackled during live courses. This survey suggests that conventional balloon angioplasty, complemented by stent implantation in selected cases, is the treatment of choice.
Collapse
Affiliation(s)
- P Chatelain
- Cardiology Centre, University Hospital, Geneva, Switzerland
| | | | | | | | | | | | | |
Collapse
|
17
|
Krause PB, Schaer GL, Parrillo JE, Klein LW. Excimer laser ablation before autoperfusion balloon inflation: a novel therapeutic approach to high grade stenoses in vessels supplying substantial myocardium at risk. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1992; 27:202-8. [PMID: 1423576 DOI: 10.1002/ccd.1810270309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The utility of a novel approach employing excimer laser ablation to form a channel for subsequent autoperfusion balloon angioplasty is presented. Two important advantages of this strategy are highlighted: (1) applicability to severe stenoses in vessels supplying substantial myocardium at risk and (2) ability to allow prolonged inflation time to minimize procedure related ischemia and optimize revascularization of the heart. We prospectively selected and studied five patients and performed excimer laser coronary angioplasty using either a 1.3 mm or 1.6 mm laser catheter followed by autoperfusion balloon dilatation. Procedural success was documented by a significant reduction in mean percent diameter stenosis from 89 +/- 4% (S.D.) to 53 +/- 4% after laser angioplasty (p < 0.0001) and subsequently to 20 +/- 4% after autoperfusion balloon angioplasty (p < 0.0001). Clinical success was attained and characterized by resolution of anginal symptoms for at least 4 weeks after hospital discharge. There were no major acute complications encountered; however, restenosis has occurred in 2 out of 5 patients. We therefore recommend this novel pre-dilation strategy with excimer laser followed by autoperfusion balloon angioplasty in selected patients with an extensive amount of myocardium at risk.
Collapse
Affiliation(s)
- P B Krause
- Department of Medicine, Rush Medical College, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612
| | | | | | | |
Collapse
|
18
|
Haase KK, Baumbach A, Hanke H, Voelker W, Mauser M, Karsch KR. Success rate and incidence of restenosis following coronary excimer laser angioplasty: results of a single center experience. J Interv Cardiol 1992; 5:15-23. [PMID: 10150948 DOI: 10.1111/j.1540-8183.1992.tb00818.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The initial single center experience of percutaneous coronary excimer laser angioplasty is described for the first three series of 147 patients. Sixty patients were treated with a prototype 1.4-mm laser catheter, 40 patients with improved transmission devices, and the third series of 47 patients with an increased pulse width of the laser system allowing improved energy transmission. In 17 patients (12%) laser angioplasty could not be initiated due to inability to cross the lesion with the guidewire or to place the catheter coaxially within the vessel. In 32 patients (58%) of series 1, 11 patients (31%) of series 2, and 17 patients (43%) of series 3, additional balloon dilatation following laser treatment was necessary due to vessel closure (24%) or due to an insufficient angiographic result (35%). There was one death in series 1 (2%) and 2 (3%) each, one perforation in series 2 (3%), two transmural myocardial infarctions in series 1 (4%), and one myocardial infarction in series 2 (3%). During the 6-month follow-up period one patient in series 2 (2%), and one patient in series 3 (3%) died. Angiographic restenosis was found in 22, 12, and 11 patients of series 1 (40%), 2 (34%), and 3 (27%), respectively. No patient developed a transmural myocardial infarction. Thus, percutaneous coronary excimer laser angioplasty can be performed as a safe and feasible procedure in patients with coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- K K Haase
- Division of Cardiology, Medical Clinic III, Tübingen, Germany
| | | | | | | | | | | |
Collapse
|
19
|
Baumbach A, Haase KK, Karsch KR. Direct Laser Ablation of Coronary Atherosclerotic Plaque in Humans — The German Experience. RESTENOSIS AFTER INTERVENTION WITH NEW MECHANICAL DEVICES 1992. [DOI: 10.1007/978-94-011-2650-2_29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
|
20
|
Abstract
Preliminary clinical experience with excimer laser coronary angioplasty shows that it is a safe and effective means of achieving nonsurgical coronary revascularization in selected patients but specific indications for its use are as yet undefined. In the present report a specific indication is proposed for the use of the excimer laser: to facilitate balloon inflation in a rigid stenosis that fails to dilate despite high balloon inflation pressures.
Collapse
Affiliation(s)
- D H Israel
- Department of Medicine, Mount Sinai Medical Center, New York, New York
| | | | | |
Collapse
|
21
|
Excimer laser coronary angioplasty: Initial experience at St. Thomas' Hospital. Lasers Med Sci 1991. [DOI: 10.1007/bf02030891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
22
|
Cook SL, Eigler NL, Shefer A, Goldenberg T, Forrester JS, Litvack F. Percutaneous excimer laser coronary angioplasty of lesions not ideal for balloon angioplasty. Circulation 1991; 84:632-43. [PMID: 1860207 DOI: 10.1161/01.cir.84.2.632] [Citation(s) in RCA: 106] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Excimer laser coronary angioplasty is a new, investigational technique for treating coronary artery stenoses. Initial reports have demonstrated acute efficacy and relative safety of this procedure, but have not addressed the effect of lesion type on acute success and complication rates. METHODS AND RESULTS In the first 100 patients undergoing percutaneous excimer laser coronary angioplasty at our institution, acute laser success was obtained in 84% and procedural success was obtained in 94%. There were six acute closures during laser angioplasty and one myocardial infarction. Two patients required emergency coronary bypass surgery. Sixty-five percent of patients had lesions not ideal for balloon angioplasty because of lesion morphology (tubular, diffuse, or chronic total occlusion) or ostial location. There were 10 tubular stenoses, 29 diffuse lesions, 18 chronic total occlusions, and eight ostial lesions, including five aorto-ostial lesions. In this nonideal subgroup, the acute success rate with laser was 86% (72% of chronic total occlusions and 91% of non-totally occluded lesions), and the procedural success rate was 94%. There were three acute occlusions during laser angioplasty but no myocardial infarctions, emergency bypass surgeries, or deaths. One coronary artery perforation occurred without clinical sequelae. Laser angioplasty was successful in four of six lesions (67%) in which balloon angioplasty had failed. Laser success was obtained in 10 of 11 (91%) moderately or heavily calcified stenoses. Eight eccentric lesions and two lesions on bends were successfully treated without dissection or perforation. No side branch occlusions occurred in the 15 patients in whom one or more major branches originated within the lesion treated. Adjunctive balloon angioplasty was performed in 47% of cases, usually to obtain a larger final luminal diameter. Need for adjunctive balloon angioplasty decreased to 36% after a larger (2.0 mm) laser catheter became available. Twenty-eight percent of the 105 lesions treated were American College of Cardiology/American Heart Association classification type A, 47% were type B, and 25% were type C. Laser and procedural successes were obtained in 83% and 97% of type A, 88% and 96% of type B, and 85% and 88% of type C lesions, respectively. CONCLUSIONS In our initial experience, excimer laser angioplasty was found to be acutely effective and safe therapy for lesions identified as not ideal for balloon angioplasty. This technique may provide a useful adjunct or alternative to balloon angioplasty in selected patients.
Collapse
Affiliation(s)
- S L Cook
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048
| | | | | | | | | | | |
Collapse
|
23
|
Sanborn TA, Bittl JA, Hershman RA, Siegel RM. Percutaneous coronary excimer laser-assisted angioplasty: initial multicenter experience in 141 patients. J Am Coll Cardiol 1991; 17:169B-173B. [PMID: 2016475 DOI: 10.1016/0735-1097(91)90954-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Initial multicenter clinical experience with percutaneous coronary excimer laser-assisted angioplasty is described for 158 lesions in 141 patients. Using a xenon chloride (308 nm) excimer laser generator and 1.5 to 1.75 mm catheters, excimer laser angioplasty was attempted at 135 ns pulse width, 25 to 40 Hz repetition rate, 2 to 5 s laser delivery time and 30 to 60 mJ/mm2 energy fluence. Laser success (greater than 20% improvement in luminal diameter) was achieved in 138 (87%) of 158 lesions, with a reduction to less than 50% stenosis noted in 77 lesions (49%). Overall, laser-assisted balloon angioplasty success (less than 50% residual stenosis without major complication) was observed in 129 (91%) of 141 patients. Procedural complications (abrupt closure 1.3%, side branch occlusion 1.9%, intimal dissection 6.3%, embolization 1.3%, filling defect 1.3%, perforation 1.9% and spasm 1.3% and major complications (non-Q wave myocardial infarction 4.8%, emergency coronary bypass surgery 3.5% and death 0%) were infrequent and predominantly related to subsequent balloon angioplasty. In the early follow-up period (range 1 to 10 months, mean 7), 111 (79%) of the 141 patients remain asymptomatic, whereas symptoms have recurred in 27 (19%) and 3 patients (2.1%) have died. Thus, percutaneous coronary excimer laser angioplasty appears to be a feasible and safe procedure. Assessment of the impact of this technology on the acute complications of and restenosis rates after angioplasty awaits further follow-up analysis.
Collapse
Affiliation(s)
- T A Sanborn
- Department of Medicine, Mount Sinai Medical Center, New York, New York 10029
| | | | | | | |
Collapse
|
24
|
Blanche C, Segalowitz J, Czer LS, Wong S, Matloff JM. Excimer laser angioplasty during aortocoronary bypass grafting. Ann Thorac Surg 1991; 51:670-2. [PMID: 2012432 DOI: 10.1016/0003-4975(91)90339-r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Laser coronary angioplasty using the 308-nm Excimer laser was successfully performed intraoperatively during coronary artery bypass grafting. It achieved a reduction of the left anterior descending artery stenosis from 99% to 25% as seen on angioscopy, without evidence of vascular perforation or intimal disruption. The Excimer laser offers the opportunity for intraoperative endovascular remodeling and recanalization and has a potential role as an adjunct to existing standard coronary artery bypass grafting protocol.
Collapse
Affiliation(s)
- C Blanche
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California 90048
| | | | | | | | | |
Collapse
|
25
|
|
26
|
Fischell TA, Stadius ML. New technologies for the treatment of obstructive arterial disease. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1991; 22:205-33. [PMID: 2013086 DOI: 10.1002/ccd.1810220311] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The well-known limitations of balloon angioplasty include unpredictable abrupt closure, chronic total occlusion, diffuse disease, and restenosis, among other factors. These limitations have prompted the development of new technologic approaches to angioplasty including laser applications for plaque ablation, mechanical device applications for plaque removal/debridement, and stent devices for structural maintenance of vascular lumen patency. Devices which directly apply laser energy for ablation of plaque material include a balloon-centered laser angioplasty system, excimer laser ablation catheter systems, and a fluorescence-guided spectral feedback laser system. Experience with these devices indicates that plaque can be successfully ablated by using laser energy. Vessel perforation and dissection are complications reported with these devices and the effects of laser angioplasty on restenosis remain unclear. Indirect application of laser energy has been tested by using a "hot tip" catheter and a laser balloon angioplasty system. Although the hot tip device has received FDA approval for use in peripheral arteries, it appears to have very limited applications in the coronary arteries. Laser balloon angioplasty appears to be beneficial in the setting of threatened acute closure; the device continues to be evaluated for potential beneficial impact on restenosis. Mechanical atherectomy catheters are designed to remove atherosclerotic plaque from the arterial system and include the AtheroCath, the Transluminal Extraction Catheter (TEC), and the Pullback Atherectomy Catheter (PAC). The Rotablator is an atheroablation device which debrides the obstructing plaque material with distal embolization of the particulate debris. Successful removal/debridement of atherosclerotic plaque has been demonstrated with the AtheroCath, Rotablator, and the TEC device. Pre-clinical studies demonstrate successful removal of plaque material with the PAC device. Despite the theoretic advantage of removing plaque material when performing angioplasty with these devices, there has been little or no reduction in restenosis rates based on a significant experience with the AtheroCath and the Rotablator. Intravascular stent devices including one self-expanding device design and two balloon-expandable device designs have been employed successfully in the elective setting to treat recurrent restenosis lesions. Two of the devices have been successfully tested in the setting of threatened acute closure. Early follow-up studies suggest some improvement in restenosis rates in certain clinical settings following intravascular stenting. Acute and subacute thrombosis remain substantial problems for stent devices and very aggressive anticoagulation regimens are necessary to minimize the adverse events. In summary, a number of a new technologic approaches for treatment of atherosclerotic lesions have been developed and are undergoing significant clinical evaluation.(ABSTRACT TRUNCATED AT 400 WORDS)
Collapse
Affiliation(s)
- T A Fischell
- Division of Cardiovascular Medicine, Stanford University, California
| | | |
Collapse
|
27
|
Percutaneous coronary excimer laser-assisted balloon angioplasty: initial clinical and quantitative angiographic results in 50 patients. J Am Coll Cardiol 1991; 17:94-9. [PMID: 1987246 DOI: 10.1016/0735-1097(91)90709-i] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The initial clinical experience and quantitative angiographic results of percutaneous coronary excimer laser-assisted balloon angioplasty are described for 55 lesions in 50 patients. With use of a xenon chloride (308 nm) excimer laser generator and 1.5 to 1.75 mm catheters, excimer laser angioplasty was attempted at 135 ns pulse width, 25 to 40 Hz repetition rate, 2 to 5 s laser delivery time and 30 to 60 mJ/mm2 energy fluence. Laser success (greater than 20% reduction in absolute percent diameter stenosis) was achieved in 41 (75%) of 55 lesions, with 100% subsequent balloon angioplasty success (less than 50% residual stenosis). By quantitative digital caliper technique, the percent diameter stenosis (mean +/- SE) was reduced from 81 +/- 1% to 50 +/- 3% after excimer laser angioplasty (p less than 0.001) and to 20 +/- 1% after balloon angioplasty (p less than 0.001); minimal luminal diameter increased from 0.56 +/- 0.04 to 1.46 +/- 0.08 mm (p less than 0.001) and 2.03 +/- 0.07 mm (p less than 0.001), respectively. By videodensitometric techniques, the percent area stenosis decreased from 86 +/- 2% to 54 +/- 3% after excimer angioplasty (p less than 0.001) and to 26 +/- 3% after balloon angioplasty (p less than 0.001). There were no perforations, need for emergency bypass surgery or deaths. The overall incidence of abrupt closure (3.6%), dissection (1.8%), embolization (1.8%), filling defect (6%), myocardial infarction (5.5%), side branch occlusion (3.6%) or spasm (3.6%) was infrequent and more related to subsequent balloon angioplasty than to the laser procedure.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
|
28
|
Litvack F, Eigler NL, Margolis JR, Grundfest WS, Rothbaum D, Linnemeier T, Hestrin LB, Tsoi D, Cook SL, Krauthamer D. Percutaneous excimer laser coronary angioplasty. Am J Cardiol 1990; 66:1027-32. [PMID: 2220626 DOI: 10.1016/0002-9149(90)90499-q] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
To determine the efficacy of percutaneous excimer laser coronary angioplasty as an adjunct or alternative to conventional balloon angioplasty, 55 patients were studied in a multicenter trial. These patients underwent the procedure using a modification of conventional balloon angioplasty technique. A first-generation, 1.6-mm diameter catheter constructed of 12 individual silica fibers concentrically arranged around a guidewire lumen was used. Catheter tip energy density varied from 35 to 50 mJ/mm2. The mean number of pulses delivered at 20 Hz was 1,272 +/- 1,345. Acute success was defined as a greater than or equal to 20% increase in stenotic diameter and a lumen of greater than or equal to 1 mm in diameter after laser treatment. Acute success was achieved in 46 of 55 (84%) patients. Adjunctive balloon angioplasty was performed on 41 patients (75%). The percent diameter stenosis as determined by quantitative angiography decreased from a baseline of 83 +/- 14 to 49 +/- 11% after laser treatment and to 38 +/- 12% in patients undergoing adjunctive balloon angioplasty. The mean minimal stenotic diameter increased from a baseline of 0.5 +/- 0.4 to 1.6 +/- 0.5 mm after laser treatment and to 2.1 +/- 0.5 mm after balloon angioplasty. There were no deaths and no vascular perforations. One patient (1.8%) required emergency coronary bypass surgery. These data suggest that excimer laser energy delivered percutaneously by specially constructed catheters can safely ablate atheroma and reduce coronary stenoses.
Collapse
Affiliation(s)
- F Litvack
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California 90048
| | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Affiliation(s)
- J M Isner
- Department of Medicine (Cardiology), St. Elizabeth's Hospital, Tufts University School of Medicine, Boston, MA 02135
| | | | | |
Collapse
|
30
|
Abstract
The current status of new techniques for percutaneous arterial recanalization, including laser, thermal and mechanical angioplasty techniques, is described. The reported results, potential advantages and possible future developments are discussed.
Collapse
Affiliation(s)
- J A Michaels
- Department of Surgery, University College and Middlesex School of Medicine, London, UK
| |
Collapse
|