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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
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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
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Visona A, Liessi G, Bonanome A, Lusiani L, Miserocchi L, Breggion G, Pagnan A. Percutaneous Laser Angioplasty of Peripheral Vessels: Primary Success and Follow-up Results. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449202600804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Excimer laser angioplasty was attempted in 59 patients (43 men, 16 women, mean age sixty-three ± eight years, range thirty-nine to seventy-seven years), affected by peripheral vascular disease. Forty-nine patients had a total occlusion of one superficial femoral artery, 3 of one iliac artery, and 1 of one popliteal artery; 6 patients showed a subocclusive stenosis of a superficial femoral artery. Occlusive and subocclusive stenoses were classified by length: < 10 cm (39 cases), > 10 cm (20 cases). A commercial excimer laser was used at the xenon-chloride wavelength of 308 nm. Successful recanalization was obtained in 53 of 59 patients (90%). Hemodynamic improvement was confirmed by a significant increase of the ankle/ brachial systolic pressure index (from 0.60 ± 0.17 to 0.79 ± 0.20, p < 0.005). The success rate was higher for lesions < 10 cm in length. Early reocclusion was observed in 7 patients and was associated with poor runoff. The cumulative patency rate was 81 % at one month, 67% at six months, and 51 % at one year.
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Affiliation(s)
- Adriana Visona
- Department of Internal Medicine (CLO), University of Padova School of Medicine, Padova
| | - Guido Liessi
- Department of Radiology, OC Castelfranco, Veneto, Italy
| | - Andrea Bonanome
- Department of Internal Medicine (CLO), University of Padova School of Medicine, Padova
| | - Luigi Lusiani
- Department of Internal Medicine (CLO), University of Padova School of Medicine, Padova
| | - Luigi Miserocchi
- Department of Internal Medicine (CLO), University of Padova School of Medicine, Padova
| | | | - Antonio Pagnan
- Department of Internal Medicine (CLO), University of Padova School of Medicine, Padova
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Abela GS, Hage-Korban EE, Tomaru T, Barbeau GR, Abela OG, Friedl SE. Vascular procedures that thermo-coagulate collagen reduce local platelet deposition and thrombus formation: laser and laser-thermal versus balloon angioplasty. Lasers Surg Med 2002; 29:455-63. [PMID: 11891734 DOI: 10.1002/lsm.10000] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVE Exposure of the arterial wall matrix to blood leads to platelet deposition resulting in thrombosis. Because heat alters tissue matrix we proposed that heating reduces platelet deposition. STUDY DESIGN/MATERIALS AND METHODS Sixty arterial homografts (15 dogs) were mounted in an arterio-venous "shunt." Interventions included balloon angioplasty (BA), direct laser (LA), laser-thermal (LTA), and combined LTABA. 111Indium-labeled platelets were circulated, radio activity measured, and homografts processed for histology. RESULTS Radioactivity count (mean+/- SE) at BA sites (13,853+/-3,192 cpm/cm(2)) was greater than LA (7,038+/-981), LTA (5,294 +/-1,145), LTABA (6,176+/-1,571), and control (1,826+/-339), P<0.05. Electron microscopy showed fewer platelets at LA, LTA, and control than BA sites. BA spread the collagen on the arterial lumen while heat gelled collagen and confined it to the arterial media. CONCLUSIONS Heating the artery and gelling collagen during LA, LTA, or LTABA significantly reduced thrombogenicity.
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Affiliation(s)
- G S Abela
- Department of Medicine, Division of Cardiology, Michigan State University, East Lansing, Michigan 48824, USA.
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Haase KK, Rose C, Duda S, Baumbach A, Oberhoff M, Anthanasiadis A, Karsch KR. Perspectives of coronary excimer laser angioplasty: multiplexing, saline flushing, and acoustic ablation control. Lasers Surg Med 2000; 21:72-8. [PMID: 9228643 DOI: 10.1002/(sici)1096-9101(1997)21:1<72::aid-lsm11>3.0.co;2-b] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Bubble formation, pressure wave generation, and cavitations constitute major factors influencing the outcome of clinical Excimer laser angioplasty. Thus, the rationale of this study was to determine the extent of pressure waves occurring during excimer laser ablation and to discuss possibilities that allow a less traumatic plaque removal in the coronary circulation. STUDY DESIGN/MATERIALS AND METHODS Conventional and experimental Xenon-Chlorid-Excimer lasers emitting light at a wave-length of 308 nm and a pulse duration of 115 ns were used for testing of signals. Whereas the conventional excimer laser light source transmits light through all fibers of a 1.7 mm laser catheter simultaneously, the prototype excimer laser divides the laser beam into several areas of uniform energy fluence by scanning the beam from one section to the other using the intermission between two laser discharges. Hydrophones consisting of piezoelectric films detected the acoustic signals, which were obtained on normal arterial wall and atherosclerotic plaque. RESULTS Multiplexing decreases maximum pressures for both normal arterial wall and calcified plaque significantly, whereas pressure rise time remains comparable. During ablation of pure blood, a linear increase of peak pressures of 1 MPa at 10 mJ/mm2 to 7.5 MPa at 50 mJ/mm2 is found. Contrast media intensifies the extent of pressure wave formation. At 20 mJ/mm2, 60% contrast media added to blood results in an increase of maximum pressures from 1.5 MPa up to 5 MPa. Dilution with saline solution is effective; however, high concentrations of > 90% are required to achieve a significant pressure wave reduction. CONCLUSION Peak pressures of several thousand kPa occur during excimer laser ablation of contrast media, blood, calcified plaque, and normal arterial wall in a decreasing order. Multiplexing and saline flushing are capable of reducing the intensity of the generated acoustic signals during tissue ablation. It has to be taken into consideration, however, that high concentrations of saline solution are necessary to achieve a significant reduction of peak pressures.
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Affiliation(s)
- K K Haase
- Department of Medicine, University of Tübingen, Germany
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Katoh T, Asahara T, Naitoh Y, Nakajima H, Usui M, Rakue H, Amemiya T, Miyagi M, Ibukiyama C. In vivo intravascular laser photodynamic therapy in rabbit atherosclerotic lesions using a lateral direction fiber. Lasers Surg Med 2000; 20:373-81. [PMID: 9142676 DOI: 10.1002/(sici)1096-9101(1997)20:4<373::aid-lsm2>3.0.co;2-n] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE This study was performed to evaluate the possibility of inducing regression of atherosclerotic foci by photodynamic therapy (PDT) using hematoporphyrin derivative (HpD). STUDY DESIGN/MATERIALS AND METHODS Atherosclerotic rabbits were divided into four groups: A (n = 6) and C (n = 6) were given 5 mg/kg of HpD intravenously; Groups B (n = 4) and D (n = 4) were not. Twenty-four hours after HpD administration, the aortae of groups A and B were exposed to 200 mw output argon dye laser beam at 630 nm for 10 minutes; groups C and D were exposed to 400 mw for 5 minutes. Three rabbits from groups A and C and two rabbits from groups B and D were sacrificed immediately after laser photoradiation, being named groups A 0, C 0 and groups B 0, D 0, respectively. Groups A 7, C 7, and Groups B 7, D 7 were sacrificed 7 days after the photoradiation. RESULTS In groups A 7 and C 7, most intimal cells and endothelial cells had become necrotic and disappeared, and a loss of intima was observed. No such changes were found in groups B 7, D 7. CONCLUSION The above data suggest that PDT caused effective regression of the atherosclerotic lesions.
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Affiliation(s)
- T Katoh
- Second Department of Internal Medicine, Tokyo Medical College, Japan
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Affiliation(s)
- S B King
- Andreas Gruentzig Cardiovascular Center, Emory University Hospital, Atlanta, Georgia, USA.
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Oberhoff M, Baumbach A, Herdeg C, Hassenstein S, Xie DY, Blessing E, Hanke H, Haase KK, Betz E, Karsch KR. Smooth excimer laser coronary angioplasty (SELCA) and conventional excimer laser angioplasty: Comparison of vascular injury and smooth muscle cell proliferation. Lasers Med Sci 1997; 12:328-35. [PMID: 20803272 DOI: 10.1007/bf02767155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/1997] [Accepted: 05/29/1997] [Indexed: 10/22/2022]
Abstract
Although the excimer laser, which utilizes 'non-thermal ablation effects', has achieved encouraging results in early clinical trials, the long-term results have failed to show any advantage over conventional percutaneous transluminal coronary angioplasty (PTCA).A new system, Smooth Excimer Laser Coronary Angioplasty (SELCA), has been developed to reduce the tissue damage in the vessel wall caused by shock waves and vapour bubbles.SELCA (wavelength 308 nm, pulse duration 115 ns, repetition rate 150 Hz and energy density 50 mJ mm(-2)) lowers the amount of shock wave formation and pressure peak amplitude in the surrounding tissue by about eight times when compared to the conventional 308 nm excimer laser (ELCA). In this preclinical evaluation, this new system was compared to ELCA. Fifty New Zealand White rabbits were stimulated by repeated weak DC impulses for a period of 28 days in order to form an atherosclerotic plaque in the right carotid artery. The vessels were excised 3, 7,14 and 28 days after laser irradiation for immunohistochemical analysis.SELCA and ELCA laser treatment lead to a decrease in maximal intimal wall thickness 3 days after intervention (control: 177+/-4 microm; SELCA: 131+/-22microm; ELCA: 120 +/-33microm). In the period between 3 and 28 days, a moderate increase in intimal wall thickness was observed after SELCA treatment compared to a significant increase after ELCA (28 days after intervention: SELCA: 157+/-22microm; ELCA: 274 +/-28microm). Bromodeoxyuridine (BrdU) was applied 18 and 12 h before excision of the vessels in order to determine the percent of cells undergoing DNA synthesis. The percent of BrdU labelled SMC in the intima (control: 13 +/- 2 cells mm(-2)) increased in both groups after 3 days (SELCA: 248 +/- 107 cells mm(-2); ELCA: 162 +/- 41 cells mm(-2)) and 7 days (SELCA: 162+/- 55 cells mm(-2); ELCA: 279 +/- 119 cells mm(-2)).The present results demonstrate that vascular wall injury and increase in intimal wall thickness following SELCA are reduced in comparison to the results achieved with the conventional technique. Further trials are necessary to assess whether these improvements will lead to more favourable long-term results after excimer laser angioplasty.
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Affiliation(s)
- M Oberhoff
- Department of Medicine, Division of Cardiology, Otfried Müller Str. 10, D-72076, Tübingen, Germany
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Larrazet FS, Dupouy PJ, Dubois Rande JL, Ducot B, Kvasnicka J, Geschwind HJ. Angioscopy variables predictive of early angiographic outcome after excimer laser-assisted coronary angioplasty. Am J Cardiol 1997; 79:1343-9. [PMID: 9165155 DOI: 10.1016/s0002-9149(97)00137-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study attempted to determine whether anatomic findings at angioscopy were associated with adverse early angiographic outcomes following excimer laser-assisted coronary angioplasty. Predictive factors of either coronary abrupt vessel closure or early (< or =24 hours) restenosis after percutaneous coronary angioplasty, including clinical and angiographic variables, have been widely evaluated. The role of angioscopic findings may contribute to identification of patients at risk for early poor outcome. Thirty-seven patients with severe lesions, including 23 total occlusions which underwent successful percutaneous transluminal coronary angioplasty (PTCA) with laser irradiation and adjunctive balloon dilatation (n = 35), or stand alone laser (n = 2), had concomitant angioscopic imaging of the target vessel. All patients had a 24-hour angiographic follow up. Early unfavorable outcome (n = 15) was defined as abrupt vessel closure or restenosis (> or = 50% stenosis) at 24 hours. By multivariate logistic regression analysis, immediate post-PTCA residual percent stenosis was associated with a poor outcome (restenosis: 33 +/- 22% vs no restenosis: 21 +/- 14%, p = 0.05). Angioscopic red thrombus aspect was the most significant correlate for early closure or restenosis (7 of 15 patients with unfavorable outcome vs 2 of 22 patients with favorable outcome, odds ratio, 22.9; p < 0.01) and was associated with a significantly higher early minimal lumen diameter loss (1 +/- 0.8 mm in the presence of a red thrombus vs 0.3 +/- 0.5 mm without thrombus, p < 0.005). Red thrombus appearance is associated with an unfavorable early angiographic outcome in patients who undergo laser-assisted coronary angioplasty.
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Affiliation(s)
- F S Larrazet
- Department of Cardiology, University Hospital Bicêtre; Kremlin-Bicêtre, INSERM U 292, University of Paris, France
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Schofer J, Kresser J, Rau T, Kunze KP, Kühn CR, Mathey DG. Recanalization of chronic coronary artery occlusions using laser followed by balloon angioplasty. Am J Cardiol 1996; 78:836-8. [PMID: 8857495 DOI: 10.1016/s0002-9149(96)00434-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Excimer laser angioplasty with adjunctive percutaneous transluminal coronary angioplasty of chronic coronary artery occlusions was performed using the Litvack 1.3 Z laser catheter in 80 patients in whom the occlusion could be passed by a guidewire; success rate was 89%. Angiographic follow-up revealed a restenosis rate of 33% and a reocclusion rate of 20%, and clinical follow-up showed a significant symptomatic improvement. It is concluded that laser angioplasty is a promising method for the treatment of chronic coronary artery occlusions.
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Affiliation(s)
- J Schofer
- Center for Cardiology Othmarschen, Hamburg, Germany
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Quan KJ, Hodgson JM. Comparison of tissue disruption caused by excimer and midinfrared lasers in clinical simulation. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1996; 38:50-5. [PMID: 8722858 DOI: 10.1002/(sici)1097-0304(199605)38:1<50::aid-ccd11>3.0.co;2-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Laser coronary angioplasty is a useful therapy for selected complex coronary lesions. Laser-induced acoustic trauma is postulated to be a cause of dissection and acute vessel occlusion. Controversy exists regarding the relative degree of photoacoustic effects of midinfrared and excimer lasers in clinical practice. To date, these systems have not been compared at clinical energy doses and with clinical pulsing strategies. Therefore, we studied the photoacoustic effects of both midinfrared and excimer lasing at clinically accepted doses. Human atherosclerotic iliofemoral artery segments were obtained at autopsy (n = 36) and placed lumen side up in a saline bath. Clinical laser catheters were advanced over an 0.018" guide wire, perpendicular to the tissue. A 10-g down force was applied to the catheter for full-thickness lasing. Pulsing strategies were, for midinfrared laser: 5 pulses, 1-sec pause, 5 pulses, 1-sec pause, 5 pulses, withdraw; for excimer: 5 sec of pulses, wait 10 sec, 5 sec of pulses. Several clinically acceptable energy levels were used; for excimer: 25 mJ/mm2, 40 mJ/mm2, 60 mJ/mm2; for midinfrared: 3 W (400 mJ/mm2), 3.5 W (467 mJ/mm2). Photoacoustic effect was assessed histologically by determining the number of lateral cleavage planes (dissections) arising from the lased crater border and extending into the surrounding tissue. In normal tissue, midinfrared lasing produced less acoustic damage than excimer lasing (2.79 +/- 0.78 vs. 5.27 +/- 0.75 cleavage planes, mean +/- SD, P < 0.05, data for lowest energy for each system). The same was true in noncalcified atheroma (2.48 +/- 0.71 vs. 6.43 +/- 1.09, P < 0.05) and calcified atheroma (2.47 +/- 1.21 vs. 6.27 +/- 1.13, P < 0.05). This effect was similar at all energy levels, with a trend for more damage at higher energies in both systems. This study demonstrates that midinfrared lasing causes less acoustic damage than excimer lasing when using clinical catheters, energy levels, and pulsing strategies. This effect is independent of tissue-type but tends to be dose-related. These findings may explain, in part, the differences in dissection rates seen clinically.
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Affiliation(s)
- K J Quan
- Department of Medicine, University Hospitals of Cleveland, Ohio, USA
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de Marchena E, Larrain G, Posada JD, Tang S, McGhee V, Mallon S. Holmium laser-assisted coronary angioplasty in acute ischemic syndromes. Clin Cardiol 1996; 19:315-9. [PMID: 8706372 DOI: 10.1002/clc.4960190407] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND AND HYPOTHESIS Initial studies have shown holmium laser to be effective in ablation of coronary atheroma, and small studies that it may be helpful in ablation of thrombotic stenoses. Therefore, holmium laser-assisted coronary angioplasty was studied in 85 consecutive patients with acute ischemia syndromes. METHODS Indications for therapy were acute myocardial infarction (MI) in 7 patients (8%), post-MI ischemic in 32 patients (38%), and crescendo angina pectoris in 46 patients (54%). Coronary morphology characteristics by multivessel angioplasty prognosis group criteria were Type A in 9 (10%), Type B1 in 15 (18%), Type B2 in 44 (52%), Type C in 17 patients (20%). RESULTS Angiographic evidence of thrombus was seen in 37 (44%) of patients. The laser successfully crossed the total length of the coronary narrowing in 76 patients (89%). Procedure/clinical success was 92% for the total study population, 100% for patients with acute MI, 94% for post-MI ischemia patients, and 89% for patients with crescendo angina. Lesions with and without thrombus had identical procedure success rates. Major complication rate was 3.5%, (deaths 0%, Q-wave MI 0%, and emergent bypass surgery 3.5%). Six-month angiographic restenosis rate (> 50% stenosis) was 45%. CONCLUSION Holmium laser-assisted balloon angioplasty appears promising in the treatment of acute ischemic syndromes and thrombotic coronary lesions.
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Affiliation(s)
- E de Marchena
- University of Miami School of Medicine, Department of Medicine, Florida, USA
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PIZZULLI LUCIANO, JUNG WERNER, PFEIFFER DIETRICH, FEHSKE WOLFGANG, LÜDERITZ BERNDT. Angiographic Results and Elastic Recoil Following Coronary Excimer Laser Angioplasty with Saline Perfusion. J Interv Cardiol 1996. [DOI: 10.1111/j.1540-8183.1996.tb00590.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Tomaru T, Nakamura F, Yanagisawa-Miwa A, Fujimori Y, Omata M, Kawai S, Okada R, Uchida Y. Reduced vasoreactivity and thrombogenicity with pulsed laser angioplasty: comparison with balloon angioplasty. J Interv Cardiol 1995; 8:643-51. [PMID: 10159755 DOI: 10.1111/j.1540-8183.1995.tb00914.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- T Tomaru
- Second Department of Internal Medicine, University of Tokyo, Japan
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Rechavia E, Federman J, Shefer A, Macko G, Eigler NL, Litvack F. Usefulness of a prototype directional catheter for excimer laser coronary angioplasty in narrowings unfavorable for conventional excimer or balloon angioplasty. Am J Cardiol 1995; 76:1144-6. [PMID: 7484899 DOI: 10.1016/s0002-9149(99)80324-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We report clinical and angiographic results in 53 patients with 57 significant coronary or saphenous vein graft narrowings treated with directional excimer laser angioplasty. The target vessels were the left main (1%), anterior descending (32%), circumflex (19%), right coronary artery (39%), and vein grafts (9%). Lesions were morphologic class B1 (18%), B2 (79%), or C (3%), with 40 de novo and 17 restenotic lesions. Adjunctive balloon angioplasty was used in 53 lesions (93%). Mean pre- and postprocedural minimal lumen diameters were 0.6 +/- 0.3 and 1.9 +/- 0.7 mm (p < 0.001), corresponding to a mean diameter stenosis of 72 +/- 20% and 27 +/- 16%. Procedural success rate was 91%. Cumulative risk of death, Q-wave myocardial infarction, or emergency bypass operation was 9% (5 patients). Of patients who had a successful laser procedure, 28 (60%) with 30 lesions underwent angiographic follow-up at 6 +/- 3 months after the procedure. Restenosis rates (> 50% diameter restenosis or acute gain loss) were 37% and 23%, respectively. Four patients underwent bypass, 3 angioplasty, and 1 patient died from cancer. This study demonstrates the feasibility of directional application of laser energy to selected unfavorable narrowings for conventional excimer laser or balloon angioplasty. Further evaluation of this device using the now standard saline infusion technique is necessary to establish its ultimate role as a primary interventional device.
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Affiliation(s)
- E Rechavia
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA
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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.
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Affiliation(s)
- S Strikwerda
- Cardiac Catheterization Laboratory, Thoraxcenter, University Hospital Dijkzigt, Erasmus University, Rotterdam, The Netherlands
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Timms ID, Tomaszewski JE, Shlansky-Goldberg RD. Effect of nonanticoagulant heparin (Astenose) on restenosis after balloon angioplasty in the atherosclerotic rabbit. J Vasc Interv Radiol 1995; 6:365-78. [PMID: 7647438 DOI: 10.1016/s1051-0443(95)72825-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
PURPOSE To determine whether intravenous administration of Astenose, a high-molecular-weight nonanticoagulant heparin, can reduce restenosis following balloon angioplasty in a rabbit model. MATERIALS AND METHODS Focal atherosclerosis was induced in 54 rabbits (89 vessel), and angioplasty was performed after animals were randomized into five groups. Group 1 vessels (control) were treated with lactated Ringer solution for 28 days (n = 19); group 2, Astenose at 0.10 mg/kg per hour for 28 days (n = 16); group 3, Astenose at 0.33 mg/kg per hour for 28 days (n = 16); group 4, Astenose at 0.60 mg/kg per hour for 28 days (n = 17); and group 5, Astenose at 0.33 mg/kg per hour for 14 days (n = 21). Arteriograms were obtained to measure minimal luminal diameters before, immediately after, and 28 days after angioplasty, and the rabbits were killed for histologic analysis. RESULTS Angiographically demonstrated restenosis was significantly reduced in groups 3 (18.9% +/- 3.7, P = .04) and 4 (20.2% +/- 3.1, P = .04) compared with the control group (32.4% +/- 4.8). Group 5 showed a nonsignificant trend toward reduced restenosis (23.1% +/- 2.9, P = .09), and group 2 showed restenosis similar to that in group 1 (31.0% +/- 2.5, P = .80). However, quantitative histopathologic analysis detected no differences among the groups in absolute plaque area. Medial area was significantly smaller in groups 2 and 5 (P < or = .002) than in group 1, and there was a nonsignificant trend toward reduced medial area in groups 3 and 4 (P = .12). CONCLUSION Long-term intravenous Astenose therapy resulted in a modest but statistically significant reduction in angiographically demonstrated restenosis after angioplasty in this atherosclerotic rabbit model.
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Affiliation(s)
- I D Timms
- Department of Radiology, Hospital of the University of Pennsylvania, University of Pennsylvania, School of Medicine, Philadelphia 19104, USA
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Ruygrok PN, de Feyter PJ, de Jaegere PP. New devices in interventional cardiology: a European perspective. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1995; 25:162-168. [PMID: 7605301 DOI: 10.1111/j.1445-5994.1995.tb02831.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Affiliation(s)
- P N Ruygrok
- Catheterization Laboratory, Thoraxcenter, Rotterdam, The Netherlands
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19
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Wright G, Michalis LK, Rolfe P. Insularity and professional protectionism or matrixing and professional security in the provision of perfusion services. Perfusion 1995; 10:89-92. [PMID: 7647381 DOI: 10.1177/026765919501000204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- G Wright
- WE Dunn Unit of Cardiology, Department of Biological Sciences, Keele University, Staffordshire, UK
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20
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Ragosta M, Gertz SD, Sarembock IJ, Deckelbaum LI, Haber HL, Powers ER, Gimple LW. Effect of midinfrared holmium: YAG laser angioplasty with and without balloon angioplasty on acute outcome and restenosis in atherosclerotic femoral arteries in rabbits. Lasers Surg Med 1995; 16:235-45. [PMID: 7791497 DOI: 10.1002/lsm.1900160305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVE Pulsed laser may lessen vascular damage and reduce restenosis. This study examined the acute and chronic effects of midinfrared laser angioplasty with and without balloon angioplasty in atherosclerotic femoral arteries in rabbits. STUDY DESIGN/MATERIALS AND METHODS Atherosclerosis was induced in arteries by air desiccation and cholesterol feeding. Arteries were assigned to one of four groups: (1) laser angioplasty with a Thullium/Holmium/Chromium:YAG infrared laser (Eclipse), (2) balloon angioplasty, (3) laser followed by balloon angioplasty, and (4) no intervention. Arteries were examined angiographically and histologically at 2 hours and 28 days. RESULTS Intervention groups had significant initial gain, but this gain was less with laser alone than after balloon or after laser plus balloon. At 2 hours, laser alone caused greater arterial damage and thrombosis compared to controls. At 28 days, arteries treated with laser plus balloon had greater narrowing compared with arteries treated with balloon angioplasty. By multivariate regression analysis, the severity of the pre-intervention stenosis (P = 0.001) and intervention with laser plus balloon (P = 0.01) correlated independently with the severity of luminal narrowing at 28 days. CONCLUSION Midinfrared Ho:YAG laser angioplasty resulted in substantial acute damage with increased frequency of thrombus formation in this rabbit model. arteries treated with laser alone had suboptimal initial gain and more obstruction by plaque at 28 days compared to nonintervened arteries. The adjunctive use of balloon angioplasty improved initial gain, but correlated with smaller luminal diameters and more severe narrowing by plaque at 28 days.
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Affiliation(s)
- M Ragosta
- Department of Medicine, University of Virginia School Medicine, Charlottesville 22908, USA
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21
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Abstract
This review gives a short overview of the results of 15 years of experimental and clinical work on laser angioplasty. Experimentally, photothermal and photomechanical ablation of plaque could be demonstrated. However, laser angioplasty did not cause reduction of platelet adhesion and intimal hyperplasia. Clinically, the technique of laser angioplasty was continuously improved until the initial recanalization rates and long-term patency rates in femoropopliteal artery occlusions were the same as the success rates of percutaneous transluminal angioplasty (PTA). This was proven by various randomized studies. Currently, laser angioplasty cannot be proposed as a routine procedure because it is an expensive technology. However, laser recanalization and debulking of total occlusions should be further developed, especially in combination with endoluminal graft placement.
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Affiliation(s)
- J Lammer
- Department of Angiography and Interventional Radiology, University Vienna, Austria
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22
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Corr L. New methods of making blocked coronary arteries patent again. BMJ (CLINICAL RESEARCH ED.) 1994; 309:579-83. [PMID: 8086947 PMCID: PMC2541391 DOI: 10.1136/bmj.309.6954.579] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The use of percutaneous transluminal coronary angioplasty is limited by procedural complications and the serious drawback of restenosis, but some new techniques have been developed in an attempt to lower the complication rate for difficult lesions and reduce the rate of restenosis. These include devices to physically remove atheromatous plaque, such as the Simpson Coronary AtheroCath and the transluminal extraction catheter, as well as devices to ablate the plaque in situ, including the Rotablator and the excimer laser catheter. Although each device may have advantages in certain types of lesion, few data on their use have been reported in properly controlled randomised trials. The data available so far do not suggest that these devices will be safer than balloon angioplasty or that they will reduce restenosis. However, using metallic stents to support coronary arteries after balloon angioplasty seems to reduce acute complications and to lower the rate of restenosis, and the use of stents is likely to increase.
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Affiliation(s)
- L Corr
- Regional Cardiac Unit, Brook General Hospital, London
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23
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Honye J, Mahon DJ, Nakamura S, Wallis J, al-Zarka A, Saito S, Berns M, Tobis JM. Intravascular ultrasound imaging after excimer laser angioplasty. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1994; 32:213-22. [PMID: 7954768 DOI: 10.1002/ccd.1810320304] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
To help elucidate the mechanism of excimer laser coronary angioplasty (ELCA), intravascular ultrasound (IVUS) imaging was performed in 19 of 29 patients who were treated with ELCA. The results were compared with a non-randomized control group of 18 patients who had IVUS studies both before and after PTCA alone. After ELCA alone, lumen diameter (1.9 x 1.7 mm) and lumen cross-sectional area (CSA) (2.9 mm2) by IVUS were not significantly different from baseline values in the patients before PTCA alone (2.1 x 1.8 mm, 3.2 mm2). After balloon dilatation in the laser treated group, lumen diameter (2.5 x 2.1 mm) and lumen CSA (4.9 mm2) were significantly greater than those post ELCA alone. However, there was no difference in lumen CSA or atheroma CSA in the group treated with excimer laser plus balloon dilatation vs. these measurements in the group treated with PTCA alone. ELCA does not ablate a large amount of atheroma (9% reduction) but creates a pathway to permit easier passage of a PTCA balloon. These quantitative and morphologic results may help explain why the restenosis rate with ELCA is similar to PTCA alone.
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Affiliation(s)
- J Honye
- Division of Cardiology, University of California, Irvine, Orange 92668-3298
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24
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Nakamura F, Kvasnicka J, Decoster HL, Geschwind HJ. Percutaneous angioscopy in patients with restenosis after excimer laser coronary angioplasty. J Interv Cardiol 1994; 7:261-6. [PMID: 10151056 DOI: 10.1111/j.1540-8183.1994.tb00454.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Coronary angioscopy was performed in two patients with restenosis after excimer laser coronary angioplasty to improve our knowledge of restenosis after excimer laser angioplasty. The characteristics of the angioscopic findings in restenosis after excimer laser angioplasty consisted of smooth white plaques, which were distinctly different from the yellow plaques commonly observed in primary lesions. These findings indicate that restenosis in these patients after excimer laser angioplasty may be associated with smooth muscle cell proliferation and fibrosis.
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Affiliation(s)
- F Nakamura
- Hemodynamic and Interventional Cardiology Unit, University Hospital Henri Mondor, University of Paris XII, Creteil, France
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25
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NAKAMURA FUMITAKA, KVASNICKA JAN, GESCHWIND HERBERTJ. Comparison of Early Recoil after Coronary Excimer Laser Angioplasty with and without Adjunctive Balloon Dilatation. J Interv Cardiol 1994. [DOI: 10.1111/j.1540-8183.1994.tb00449.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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26
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Larrazet FS, Dupouy PJ, Rande JL, Hirosaka A, Kvasnicka J, Geschwind HJ. Angioscopy after laser and balloon coronary angioplasty. J Am Coll Cardiol 1994; 23:1321-6. [PMID: 8176089 DOI: 10.1016/0735-1097(94)90373-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Percutaneous intracoronary angioscopy was used to study the morphologic changes occurring in coronary arteries after balloon or laser angioplasty. BACKGROUND Angioscopy is thought to provide details of the coronary vessel lumen and the inner wall. METHODS Coronary lesions were studied in 44 patients with a 4.5F Imagecath angioscope before and after each interventional procedure. Balloon and laser angioplasty were performed in 21 (group I) and 23 patients (group II), respectively. There was no difference in age, gender or angiographic lesion appearance before the procedure between the two groups. RESULTS Circumferential visualization of the target lesion was successfully completed in 17 group I and 19 group II patients. A larger lumen than that observed at baseline was seen in all 17 group I and in 13 of the 19 group II patients. Tissue remnants were observed in all group I and II patients. Laser irradiation resulted in characteristic sharp-edged craters. Dissection was identified in 2 of 19 patients before versus 9 of 19 patients after balloon angioplasty (p < 0.05) and in 0 of 23 patients before versus 4 of 23 patients after laser angioplasty (p = NS). Subintimal hemorrhage was observed in 3 of 19 patients before versus 11 of 19 patients after balloon angioplasty (p < 0.05) and in 2 of 23 patients before versus 4 of 23 patients after laser angioplasty (p = NS). The frequency of hemorrhage was higher in group I than in group II (11 of 19 vs. 4 of 23, respectively, p < 0.02). CONCLUSIONS Angioscopy provides valuable information on lesion morphology after coronary interventions. Balloon dilation results in a high rate of dissection and subintimal hemorrhage. Laser angioplasty is able to ablate obstructing tissue and results in a lower rate of subintimal hemorrhage than balloon dilation.
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MESH Headings
- Aged
- Angioplasty, Balloon, Coronary/instrumentation
- Angioplasty, Balloon, Coronary/methods
- Angioplasty, Balloon, Coronary/statistics & numerical data
- Angioplasty, Balloon, Laser-Assisted/instrumentation
- Angioplasty, Balloon, Laser-Assisted/methods
- Angioplasty, Balloon, Laser-Assisted/statistics & numerical data
- Angioscopes
- Angioscopy/methods
- Angioscopy/statistics & numerical data
- Chi-Square Distribution
- Coronary Disease/complications
- Coronary Disease/epidemiology
- Coronary Disease/surgery
- Coronary Vessels/pathology
- Female
- Humans
- Male
- Middle Aged
- Postoperative Complications/diagnosis
- Postoperative Complications/epidemiology
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Affiliation(s)
- F S Larrazet
- University Hospital Henri-Mondor, University of Paris XII, Créteil, France
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27
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Baumbach A, Bittl JA, Fleck E, Geschwind HJ, Sanborn TA, Tcheng JE, Karsch KR. Acute complications of excimer laser coronary angioplasty: a detailed analysis of multicenter results. Coinvestigators of the U.S. and European Percutaneous Excimer Laser Coronary Angioplasty (PELCA) Registries. J Am Coll Cardiol 1994; 23:1305-13. [PMID: 8176087 DOI: 10.1016/0735-1097(94)90371-9] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES The aim of this study was to document and analyze the incidence and consequences of complications of excimer laser coronary angioplasty. BACKGROUND Excimer laser coronary angioplasty has been reported to be a safe and feasible alternative or adjunct to conventional balloon angioplasty, but serious and unique complications have been observed. METHODS Data on 1,595 interventions of excimer laser coronary angioplasty in 1,521 patients were analyzed, using a merged data base from the U.S. and European Percutaneous Excimer Laser Coronary Angioplasty (PELCA) registries. RESULTS Procedural success was achieved in 89.3% of interventions. Stand-alone laser angioplasty was performed in 17.8% of interventions. Complications included dissection (22.0%), vasospasm (6.1%), filling defects (4.8%), abrupt reclosure (6.1%), embolization (2.3%), perforation (2.4%), arrhythmia (0.7%) and aneurysm formation (0.3%). Major complications were non-Q wave myocardial infarction (2.3%), Q wave myocardial infarction (1.0%), coronary artery bypass grafting (3.1%) and death (0.7%). Logistic regression analysis revealed correlation between dissections and the use of larger catheter size (p = 0.0005), high energy per pulse levels (p = 0.0001 for native vessels), lesion length > 10 mm (p = 0.001) and presence of a side branch (p = 0.01). The incidence of perforations was higher in women (p = 0.004), in treatment of total occlusions (p = 0.02) and in the presence of a side branch (p = 0.03). Fatal complications were correlated with patients with multivessel disease (p < 0.0001), patients with acute myocardial infarction (p = 0.0009) and older patients (> 70 years old, p = 0.004). The incidence of major complications decreased after performance of 50 laser angioplasty procedures at one institution (p = 0.02). CONCLUSIONS This analysis defines both the learning curve and the profile of complications for excimer laser angioplasty and provides insight into the selection of appropriate patients and proper performance of the procedure.
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Affiliation(s)
- A Baumbach
- Department of Medicine, University of Tübingen, Germany
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28
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Faxon, Mehra. Current status of percutaneous transluminal coronary angioplasty. Curr Probl Cardiol 1994. [DOI: 10.1016/0146-2806(94)90021-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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29
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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]
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30
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Litvack F, Eigler N, Margolis J, Rothbaum D, Bresnahan JF, Holmes D, Untereker W, Leon M, Kent K, Pichard A. Percutaneous excimer laser coronary angioplasty: results in the first consecutive 3,000 patients. The ELCA Investigators. J Am Coll Cardiol 1994; 23:323-9. [PMID: 8294681 DOI: 10.1016/0735-1097(94)90414-6] [Citation(s) in RCA: 122] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES We report the comprehensive results of the first consecutive 3,000 patients treated in an excimer laser coronary angioplasty registry. BACKGROUND Excimer laser coronary angioplasty involves the use of a pulsed, 308-nm ultraviolet laser transmitted by optical fibers to reduce coronary stenoses. Preliminary reports have described safety and efficacy profiles in small numbers of patients. METHODS Patients were enrolled in a prospective, nonrandomized manner. The catheters used were 1.3, 1.6, 2.0, 2.2 and 2.4 mm in diameter, at energy densities up to 70 mJ/mm2. Procedures were performed by standard angioplasty technique with conventional guide catheters. RESULTS Seventy-five percent of patients were male, 68% were in Canadian Cardiovascular Society functional class III or IV and the cohort included 3,592 lesions. Procedural success (final stenosis < or = 50% without in-hospital Q wave myocardial infarction, coronary artery bypass surgery or death) was 90% and did not differ between the first 2,000 and the last 1,000 patients treated. There was no significant difference in success or complication rates with respect to lesion length, nor were there differences between selected complex and simple lesions. Complications included in-hospital bypass surgery (3.8%), Q wave myocardial infarction (2.1%) and death (0.5%). Coronary artery perforation occurred in 1.2% of patients (1% of lesions) but significantly decreased to 0.4% in the last 1,000 patients (0.3% of lesions). Angiographic dissection occurred in 13% of lesions, transient occlusion in 3.4% and sustained occlusion in 3.1%. Comprehensive lesion morphologic data collected in the latter portion of the study showed the procedure predominantly limited to American College of Cardiology-American Heart Association type B2 and C lesions, with no significant difference in short-term outcome between groups. CONCLUSIONS Excimer laser angioplasty can be safely and effectively applied, even in a variety of complex lesions not well suited for percutaneous transluminal coronary angioplasty. These types may include aorto-ostial, long lesions, total occlusions crossable with a wire, diffuse disease and vein grafts. Most recent data show a trend for the selection of predominantly complex lesions and a reduction in the incidence of perforation. This procedure may broaden the therapeutic window for the interventional treatment of selected complex coronary artery disease.
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Affiliation(s)
- F Litvack
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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31
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de Marchena EJ, Mallon SM, Knopf WD, Parr K, Moses JW, Murphy-Chutorian D, Myerburg RJ. Effectiveness of holmium laser-assisted coronary angioplasty. The Holmium Laser Coronary Registry. Am J Cardiol 1994; 73:117-21. [PMID: 8296731 DOI: 10.1016/0002-9149(94)90200-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The efficacy of holmium laser-assisted angioplasty was studied in 365 narrowings in 331 consecutive patients with coronary artery disease. Clinical indications for study were unstable angina pectoris in 140 patients (42%), stable angina in 136 patients (41%), postmyocardial infarction angina in 35 patients (10.5%), silent myocardial ischemia in 11 patients (3%), acute myocardial infarction in 1 patient (0.3%) and undefined in 8 patients (2%). Coronary morphology characteristics by Multivessel Angioplasty Prognosis Study group criteria were type A in 12.6%, type B1 in 34.2%, type B2 in 27.4% and type C in 25.4%. The laser successfully crossed the total length of the narrowing in 85.2%. Procedural success was 94.2%. Laser alone reduced mean percent luminal narrowing from 88 +/- 11% to 57 +/- 22%. Subsequent balloon angioplasty further reduced the mean luminal narrowing to 23 +/- 18%. Major complication rate was 2.7% (death 0.3%, Q-wave myocardial infarction 0.5%, and emergent bypass surgery 2.7%). Six-month angiographic restenosis (> 50% stenosis) rate was 44%.
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Affiliation(s)
- E J de Marchena
- Department of Medicine, University of Miami/Jackson Memorial Medical Center, Florida
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32
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Umans VA, Robert A, Foley D, Wijns W, Haine E, de Feyter PJ, Serruys PW. Clinical, histologic and quantitative angiographic predictors of restenosis after directional coronary atherectomy: a multivariate analysis of the renarrowing process and late outcome. J Am Coll Cardiol 1994; 23:49-58. [PMID: 8277095 DOI: 10.1016/0735-1097(94)90501-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To characterize predictors of restenosis after successful directional atherectomy, we reviewed the clinical, angiographic and procedural data obtained during 132 consecutive procedures. METHODS Clinical and angiographic follow-up data were obtained in a prospectively collected and consecutive series of 125 patients who underwent 132 atherectomy procedures for de novo (89%) or restenotic (11%) lesions in native coronary arteries. Restenosis was assessed clinically and by quantitative coronary angiography. A dual approach to data analysis was taken to gain insight into factors affecting the clinical outcome and vessel wall healing response. Therefore, multivariate analysis was performed to 1) determine the correlates of residual lumen diameter at follow-up (angiographic outcome), and 2) characterize the determinants of the late lumen loss (renarrowing process). RESULTS Clinical and angiographic follow-up data after successful atherectomy were obtained in 100% and 95%, respectively. Atherectomy achieved an acute lumen gain of 1.28 +/- 0.48 mm (mean +/- SD), resulting in a minimal lumen diameter of 2.44 +/- 0.47 mm. At follow-up, the minimal lumen diameter decreased to 1.78 +/- 0.64 mm. The angiographic restenosis rate was 28% if the traditional 50% stenosis cutoff criterion was applied. Larger vessel size and postatherectomy minimal lumen diameter and right coronary or left circumflex artery lesions were independent predictors of a larger minimal lumen diameter (angiographic outcome). Lumen loss during follow-up (renarrowing process) was independently predicted by relative lumen gain and preprocedural minimal lumen diameter. CONCLUSIONS In analyzing the long-term results of new interventional techniques such as directional atherectomy, the late lumen loss during follow-up (renarrowing process), which is characterized by the vessel wall healing response after an intervention, should be considered together with the residual lumen diameter at follow-up (clinical outcome). It is clear that whereas improved clinical outcome is associated with larger vessel size and postprocedural lumen diameter and non-left anterior descending artery location, greater relative gain at intervention is predictive of more extensive lumen renarrowing.
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Affiliation(s)
- V A Umans
- Catheterization Laboratory, Thoraxcenter, University Hospital Dijkzigt, Erasmus University Rotterdam, The Netherlands
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Baumbach A, Haase KK, Rose C, Oberhoff M, Hanke H, Karsch KR. Formation of pressure waves during in vitro excimer laser irradiation in whole blood and the effect of dilution with contrast media and saline. Lasers Surg Med 1994; 14:3-6. [PMID: 8127204 DOI: 10.1002/lsm.1900140104] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Pressure waves during excimer laser ablation of vascular tissue may be responsible for complications of coronary excimer laser angioplasty. In this experimental study, pressure waves were measured during excimer laser irradiation in blood and contrast media using a polyvinilidenefluoride hydrophone. At a distance of 4 mm lateral to the tip of a 1.7 mm multifiber laser catheter, excimer laser irradiation in blood resulted in a linear increase of peak pressures from 1,365 +/- 165 kPa at 30 mJ/mm2 to 2,866 +/- 404 kPa at 60 mJ/mm2. In contrast media, peak pressure increased from 3,172 +/- 573 kPa (30 mJ/mm2) to 5,763 +/- 467 kPa (60 mJ/mm2). Contrast media and saline were added to blood. At a concentration of 60% contrast in blood, a 3.4 fold increase of peak pressures was documented as compared to pure blood. Further increase of the concentration did not result in higher pressure waves. Concentrations of saline in blood of 90% and 96% reduced the peak pressures by 16% and > 50%, respectively, as compared to pure blood.
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Affiliation(s)
- A Baumbach
- Department of Medicine, University Hospital, Tübingen, Germany
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34
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Preisack MB, Athanasiadis A, Liewald C, Baumbach A, Karsch KR. Acute vessel closure following excimer laser coronary angioplasty: can we predict it? THE CLINICAL INVESTIGATOR 1993; 71:978-84. [PMID: 8124055 DOI: 10.1007/bf00180027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Of 124 consecutive patients undergoing elective excimer laser coronary angioplasty, 33 (26%) had periprocedural occlusion following excimer laser irradiation. Successful management (reopened vessel, no death, no myocardial infarction, no emergency bypass surgery) including repeat lasing, subsequent percutaneous transluminal coronary angioplasty, use of intracoronary nitroglycerin or streptokinase was achieved in 32 of the patients with acute occlusion following excimer laser coronary angioplasty. In one patient a nonfatal anterior myocardial infarction occurred. A late event occurred in two patients despite patency at the control angiography 24 h later. Multiple logistic regression modeling was used to examine the relationship between various characteristics and the risk of acute vessel closure. The preprocedural and procedural variables analyzed included progressive spasm prior to occlusion and lesion morphology after intervention (angiographic complications after percutaneous transluminal coronary angioplasty were prospectively divided into class 0, no complication, and classes 1-3, according to purely descriptive morphological characteristics). These showed a multivariate correlation with acute occlusion during excimer laser coronary angioplasty. These results suggest that acute vessel closure during stand-alone excimer laser coronary angioplasty is a benign but unpredictable event.
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35
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Abstract
In vitro studies during cold pulsed-wave laser angioplasty have demonstrated production of gas bubbles within the target tissue, creation of shock wave and formation of multi-layer dissections accompanied by an increase in the plaque and vessel wall temperature. These processes account for certain complications of coronary lasing, including acute vessel closure, dissections, spasm, and even perforation. The traditional lasing technique in which a large number of pulses is continually emitted across the lesion, may in fact contribute to the development and acceleration of the above mentioned processes. To overcome the shortcomings we have developed a new, safe lasing technique that consists of multiple trains of a small number of pulses each. Between laser sessions the laser catheter is retracted into the guiding catheter and nitroglycerin is injected intracoronary, thus providing time for dispersion of produced gas bubbles, cooling of the target artery, and adequate coronary vasodilatation. This new technique results in a significant reduction of laser associated complications.
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Affiliation(s)
- O Topaz
- Laser Interventional Cardiovascular Laboratory, McGuire VA Medical Center, Medical College of Virginia, Richmond 23298
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36
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White CJ, Ramee SR, Collins TJ, Mesa JE, Murgo JP. Holmium: YAG laser-assisted coronary angioplasty with multifiber delivery catheters. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1993; 30:205-10. [PMID: 8269490 DOI: 10.1002/ccd.1810300305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Mid-infrared lasers are attractive for coronary angioplasty based upon their excellent fiberoptic transmission and enhanced tissue absorption. Using a solid-state, mid-infrared holmium:YAG laser with prototype multifiber laser delivery catheters, we performed coronary laser angioplasty with or without adjunctive balloon angioplasty or directional atherectomy in 14 patients with 17 stenoses. Procedural laser success was obtained in 13/14 (93%) patients and 16/17 (94%) lesions; however clinical success was achieved in 9/14 (64%) patients and 12/17 (71%) stenoses. Angiographic restenosis at 4.6 +/- 1.6 months was found in 5/8 (63%) patients. We achieved an excellent procedural laser success rate in patients with generally unfavorable angioplasty anatomy. However, our clinical success rate was not different from that expected with conventional angioplasty alone. The holmium laser remains an attractive energy source for laser angioplasty; but as is the case for all coronary laser systems, its utility as a stand-alone therapy is limited by catheters which create small channels. In this small group, we could demonstrate no clinical benefit for laser-assisted angioplasty in complex coronary lesions. Our results suggest that a randomized trial comparing laser-assisted angioplasty and conventional angioplasty be performed to determine the clinical benefits of this more expensive therapy.
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Affiliation(s)
- C J White
- Department of Medicine, Ochsner Clinic, New Orleans, Louisiana 70121
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37
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Serruys PW, Foley DP, Kirkeeide RL, King SB. Restenosis revisited: insights provided by quantitative coronary angiography. Am Heart J 1993; 126:1243-67. [PMID: 8237780 DOI: 10.1016/0002-8703(93)90689-7] [Citation(s) in RCA: 87] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In this editorial, the problem of restenosis after coronary balloon angioplasty and other transluminal interventions is reviewed from the perspective of quantitative coronary angiography. The review is largely based on the experience of the Thoraxcentre in the application of quantitative angiography to the study of restenosis over the past decade, with incorporation and discussion of relevant and significant contributions from other groups. Current discrepancies in the angiographic definition of restenosis are highlighted and the use of percent diameter stenosis or MLD as the measurement parameter of choice is objectively addressed. Perspectives on the pathologic paradigm of restenosis are briefly reviewed as a basis from which to evaluate quantitative angiographic information provided by various studies. Particular attention is then paid, in chronologic fashion, to discussion and elaboration of insights to the restenosis process provided by quantitative angiographic studies, which have led to the introduction of some new methodological approaches to the comparison of short- and long-term angiographic luminal changes after various interventions. A word of caution on the potential pitfalls of quantitative angiographic studies is provided and counterbalanced with a discussion of clinical correlations of quantitative angiographic measurements. Finally, a proposal is made for the application of quantitative angiographic measurements to randomized clinical trials for the purpose of comparing new interventional devices.
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38
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Timmis GC. Interventional Cardiology: A Comprehensive Bibliography. J Interv Cardiol 1993. [DOI: 10.1111/j.1540-8183.1993.tb00864.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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de Feyter PJ, MacLeod DC, Foley D, de Jaegere PP, Serruys PW. Interventional techniques for the management of coronary artery lesions: an update. Clin Cardiol 1993; 16:586-93. [PMID: 8370189 DOI: 10.1002/clc.4960160806] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Coronary balloon angioplasty has become standard treatment for ischemic coronary artery disease. Major limitations of angioplasty are the inferior results obtained with unfavorable lesions, the occurrence of abrupt occlusion responsible for in-hospital mortality and morbidity, and the high restenosis rate at 6 months. New techniques for stents, laser, and atherectomy have been developed to overcome these limitations. Until now, although the initial results are encouraging, these new techniques have not as yet shown to be clearly superior to balloon angioplasty. However, due to the limitations of balloon angioplasty, further development of new techniques should be stimulated so that nonsurgical treatment of coronary artery disease will become safer, more effective, and applicable to a wider spectrum of coronary artery disease.
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Affiliation(s)
- P J de Feyter
- Catheterization Laboratory, Erasmus University Rotterdam, The Netherlands
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40
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Tenaglia AN, Zidar JP, Jackman JD, Fortin DF, Krucoff MW, Tcheng JE, Phillips HR, Stack RS. Treatment of long coronary artery narrowings with long angioplasty balloon catheters. Am J Cardiol 1993; 71:1274-7. [PMID: 8498366 DOI: 10.1016/0002-9149(93)90539-o] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Balloon angioplasty of long coronary artery narrowings has been associated with a lower rate of acute success, and a higher rate of acute complications and restenosis than that observed for short narrowings. Angioplasty catheters with longer length balloons (30 and 40 mm) are now available, and the objective of this study was to determine the acute and long-term success for patients with long coronary artery narrowings treated with these longer balloons. All patients with long narrowings (> or = 10 mm) treated with long balloons at 1 institution over a 1-year period were identified (93 narrowings in 89 patients), and acute and long-term outcomes were carefully documented. Procedural success (residual stenosis < or = 50%) was 97%. Abrupt closure occurred in 6% and major dissection in 11% of narrowings. Clinical success (procedural success without in-hospital death, bypass surgery or myocardial infarction) was achieved in 90% of patients. Repeat catheterization was performed in 61 patients (76% of those eligible), and restenosis was found in 50 to 55%, depending on the definition used. The treatment of long coronary artery narrowings using angioplasty catheters with longer balloons leads to high rates of acute success. However, there is a high rate of restenosis. New interventional devices for long lesions should be compared with long balloons in a randomized controlled trial.
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Affiliation(s)
- A N Tenaglia
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
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41
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Estella P, Ryan TJ, Landzberg JS, Bittl JA. Excimer laser-assisted coronary angioplasty for lesions containing thrombus. J Am Coll Cardiol 1993; 21:1550-6. [PMID: 8496518 DOI: 10.1016/0735-1097(93)90367-a] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The purpose of this study was to analyze the success rates for excimer laser-assisted coronary angioplasty performed in patients undergoing angioplasty for lesions containing thrombus. BACKGROUND The presence of intracoronary thrombus increases the risk of a poor clinical outcome after balloon angioplasty. The effect of intracoronary thrombus on the safety and efficacy of excimer laser-assisted coronary angioplasty is unknown. METHODS Percutaneous excimer laser-assisted coronary angioplasty was attempted in 142 patients, of whom 12 had angiographic evidence of intracoronary thrombus in 14 lesions, defined as a filling defect surrounded by contrast medium or an area of contrast staining. RESULTS Clinical success (< 50% residual stenosis without myocardial infarction, death or bypass surgery at any time during hospitalization) was achieved in 7 (58%) of the 12 patients with intracoronary thrombus, compared with 123 (95%) of the 130 patients without thrombus (p = 0.00001). Angiographic and clinical complications were more common in patients with thrombus: embolization (25% vs. 1%, p < 0.001), myocardial infarction (33% vs. 2%, p < 0.001), abrupt closure (17% vs. 4%, p = 0.049). Angiographic restenosis at 6 months was seen at 7 (70%) of 10 treated sites with intracoronary thrombus and at 59 (51%) of 116 sites without thrombus (p = 0.245). Presence of intracoronary thrombus was identified as the most important predictor of clinical success (p = 0.013) by multivariable logistic regression analysis, which controlled for other co-variables, such as lesion complexity or lesion location in a saphenous vein graft. CONCLUSIONS This analysis shows that the success of excimer laser-assisted coronary angioplasty is compromised when thrombus is detected angiographically. Further investigation of other strategies is needed to improve the outcome of angioplasty for this challenging problem.
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Affiliation(s)
- P Estella
- Department of Medicine, Brigham and women's Hospital, Harvard Medical School, Boston, Massachusetts 02115
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42
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de Marchena E, Mallon S, Posada JD, Garvey-Patsias K, Joshi B, Correa L, Sequeira R, Murphy-Chutorian D, Myerburg RJ. Direct holmium laser-assisted balloon angioplasty in acute myocardial infarction. Am J Cardiol 1993; 71:1223-5. [PMID: 8480651 DOI: 10.1016/0002-9149(93)90651-r] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- E de Marchena
- Department of Medicine, University of Miami School of Medicine/Jackson Memorial Medical Center, Florida 33101
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43
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Hoffman JIE. Uses and Limitations of Echocardiography in Neonatal Intensive Care Units. J Intensive Care Med 1993. [DOI: 10.1177/088506669300800301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Julien I. E. Hoffman
- Professor of Pediatrics University of California, San Francisco Box 0545, HSE 1403 San Francisco, CA 94143
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44
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Umans VA, Hermans W, Foley DP, Strikwerda S, van den Brand M, de Jaegere P, de Feyter PJ, Serruys PW. Restenosis after directional coronary atherectomy and balloon angioplasty: comparative analysis based on matched lesions. J Am Coll Cardiol 1993; 21:1382-90. [PMID: 8473645 DOI: 10.1016/0735-1097(93)90313-p] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Late lumen narrowing after directional coronary atherectomy was assessed by quantitative coronary angiography and compared with that after balloon angioplasty. BACKGROUND Directional coronary atherectomy has been introduced as an alternative technique for balloon angioplasty and may reduce the incidence of restenosis. METHODS A prospectively collected consecutive series of 87 native coronary artery lesions successfully treated with atherectomy were matched with 87 coronary artery lesions selected from a consecutive series of lesions that had been successfully dilated by balloon angioplasty. Late angiographic analysis was performed in 158 lesions. The net gain index represents the ultimate gain in minimal lumen diameter at follow-up study, normalized for the vessel size. This index is the result of the relative gain attained during the procedure (the ratio of the change in minimal lumen diameter and reference diameter) and the relative loss observed during the follow-up period (the ratio of the change in minimal lumen diameter during the follow-up period and the reference diameter). RESULTS Matching for clinical and angiographic variables resulted in two comparable groups with similar baseline stenosis characteristics. Atherectomy resulted in a more pronounced increase in minimal lumen diameter than did balloon angioplasty (mean +/- SD 1.17 +/- 0.29 to 2.44 +/- 0.42 mm vs. 1.21 +/- 0.38 to 2.00 +/- 0.36 mm, p < 0.001). However, this favorable immediate result was subsequently lost during late angiographic follow-up, so that the minimal lumen diameter at follow-up and the net gain index did not differ significantly between the two groups (1.76 +/- 0.62 vs. 1.77 +/- 0.59 mm, p = 0.93, and 0.18 +/- 0.19 vs. 0.17 +/- 0.17, p = 0.70). Consequently, the relative gain and relative loss were higher in the atherectomy group. For both techniques, the relative gain was linearly related to the relative loss but the slope of the regression line was steeper for atherectomy, suggesting that the relative loss in the atherectomy group is proportionally even larger for a given relative gain compared with that in the angioplasty group. CONCLUSIONS In matched groups of patients, atherectomy induces a greater initial gain in minimal lumen diameter than does balloon angioplasty. However, the vascular wall injury induced by the device is of a different nature (debulking vs. dilating) that leads to more relative loss over the follow-up period in the atherectomy group.
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Affiliation(s)
- V A Umans
- Catheterization Laboratory, University Hospital Dijkzigt, Erasmus University, Rotterdam, The Netherlands
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45
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van Leeuwen TG, Meertens JH, Velema E, Post MJ, Borst C. Intraluminal vapor bubble induced by excimer laser pulse causes microsecond arterial dilation and invagination leading to extensive wall damage in the rabbit. Circulation 1993; 87:1258-63. [PMID: 8462152 DOI: 10.1161/01.cir.87.4.1258] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Previous in vitro studies demonstrated that during excimer laser ablation of aortic tissue in saline, a fast-expanding and imploding vapor bubble is formed. The present in vivo study was designed to demonstrate the formation of a fast-expanding intraluminal bubble in flowing blood and to assess any damage to the adjacent arterial wall. METHODS AND RESULTS Excimer laser pulses (one to 10, at 55 mJ/mm2 per pulse) were delivered coaxially in the femoral and iliac arteries of nine normal rabbits. Time-resolved flash photography of dissected arteries in situ demonstrated a 50% diameter increase within 75 microseconds after the laser pulse and a subsequent invagination (150-500 microseconds) that corresponded with the temporal course of the bubble expansion (up to 3.2 mm in diameter) and implosion observed in a hemoglobin solution. One day after laser light delivery, light microscopy (47 arterial segments) showed abrasion of the internal elastic lamina, medial necrosis, and extensive dissection planes filled with red blood cells. The degree (up to 100% medial necrosis) and extent of damage (up to 1.9 mm in length) increased with the number of delivered laser pulses. CONCLUSIONS In blood, each excimer laser pulse generated a fast-expanding and imploding vapor bubble. In vivo, the intraluminal vapor bubble produced microsecond dilation and invagination of the adjacent arterial segment, which induced dissections and extensive wall damage far beyond the penetration depth of 308-nm laser light (< 100 microns). This unique pattern of extensive wall damage observed in the rabbit might explain the mechanism of dissection observed in humans and might have an impact on the acute and chronic outcome after excimer laser coronary angioplasty.
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Affiliation(s)
- T G van Leeuwen
- Department of Cardiology, University Hospital Utrecht, The Netherlands
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Bittl JA, Ryan TJ, Keaney JF, Tcheng JE, Ellis SG, Isner JM, Sanborn TA. Coronary artery perforation during excimer laser coronary angioplasty. The percutaneous Excimer Laser Coronary Angioplasty Registry. J Am Coll Cardiol 1993; 21:1158-65. [PMID: 8459071 DOI: 10.1016/0735-1097(93)90240-2] [Citation(s) in RCA: 116] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES The aim of this study was to analyze the risk of vessel perforation during excimer laser angioplasty. BACKGROUND Vessel perforation is a serious complication of angioplasty. METHODS A total of 764 patients had 858 stenoses treated with excimer laser angioplasty. Laser catheters had a diameter of 1.4, 1.7 or 2 mm. Laser energy was delivered in pulses of 135 ns, at a frequency of 25 s-1 and at a fluence of 30 to 60 mJ/mm2. Follow-up angiography was requested for all patients who did not require emergency bypass surgery. RESULTS In the 764 consecutive patients treated with excimer laser coronary angioplasty, vessel perforation occurred in 23 patients (3%). Nine patients had a major complication resulting directly from vessel perforation (cardiac tamponade, myocardial infarction or need for bypass surgery) and 14 had no clinical complications after successful sealing of the puncture site. No patient with a perforation died. Multivariate analysis showed that bifurcation lesions (odds ratio [OR] = 3.5; p = 0.049), diabetes mellitus (OR = 3.15; p = 0.029) and female gender (OR = 2.86; p = 0.013) were associated with an increased risk of vessel perforation. Lesions > 10 mm in length (OR = 0.45; p = 0.206), calcified stenoses (OR = 0.26; p = 0.088) and saphenous vein graft lesions (OR = 0.50; p = 0.295) were not at increased risk. Vessel perforation was seen in 10 (8.3%) of 120 lesions in which the laser catheter was equivalent in diameter to the target vessel (< or = 0.5 mm smaller in size) but in only 8 (1.5%) of 525 lesions in which the laser catheter was > 1 mm smaller than the target vessel (p = 0.001). CONCLUSIONS Most lesions thought to be suitable for excimer laser treatment are not at increased risk of perforation. The complication may be avoided by improved patient and laser catheter size selection.
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Affiliation(s)
- J A Bittl
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115
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47
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Nilsson J, Herzfeld I, Grip L, Aberg B, Ryden L. Immunohistochemical analysis of a human coronary artery exposed to excimer laser angioplasty in vivo: evidence for release of fibroblast growth factor at the site of injury. Am Heart J 1993; 125:908-12. [PMID: 8438730 DOI: 10.1016/0002-8703(93)90196-g] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- J Nilsson
- Department of Medicine, Karolinska Sjukhuset, Karolinska Institutet, Stockholm, Sweden
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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).
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Affiliation(s)
- S Strikwerda
- Department of Cardiology, University Hospital Dijkzigt, Erasmus University, Rotterdam, The Netherlands
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Duda SH, Huppert PE, Kreis A, Karsch KR, Claussen CD. Ultrasound-monitored laser angioplasty: preliminary clinical results. Cardiovasc Intervent Radiol 1993; 16:89-92. [PMID: 8485750 DOI: 10.1007/bf02602985] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A novel coaxial catheter system for ultrasound (US)-guided, pulsed laser angioplasty was tested clinically in 4 patients with stenoses of the femoral and external iliac artery. The mean lesion length was 1.3 +/- 0.4 cm. The 9F multifiber laser catheter incorporated a 4.8F commercial intravascular US catheter and can be guided over a 0.014 inch wire. Laser angioplasty alone reduced the mean degree of stenoses from 84 +/- 8% to 47 +/- 10%. Though laser-induced artifacts compromised detailed US monitoring during laser firing itself, the system proved to be clinically useful as assessment of laser effects and measurement of the severity of residual stenoses was possible immediately after laser irradiation.
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Affiliation(s)
- S H Duda
- Department of Diagnostic Radiology, University of Tübingen, Federal Republic of Germany
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Popma JJ, De Cesare NB, Pinkerton CA, Kereiakes DJ, Whitlow P, King SB, Topol EJ, Holmes DR, Leon MB, Ellis SG. Quantitative analysis of factors influencing late lumen loss and restenosis after directional coronary atherectomy. Am J Cardiol 1993; 71:552-7. [PMID: 8438740 DOI: 10.1016/0002-9149(93)90510-j] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Although encouraging initial results have been demonstrated after directional atherectomy, the mechanisms and predictors of late lumen loss and restenosis after this procedure have not been evaluated. To examine these issues, clinical and angiographic follow-up were obtained in 262 (96%) and 212 (77%) of 274 patients undergoing successful directional coronary atherectomy. Symptom recurrence developed in 87 (33%) patients and angiographic restenosis was found in 93 (44%). Restenosis was highest in re-stenotic lesions in saphenous vein grafts (78% [95% confidence interval (CI): 56 to 100%]) and lowest in new-onset lesions in the left anterior descending (27% [95% CI: 15 to 39%]) and circumflex (14% [95% CI: 0 to 43%]) coronary arteries. Residual lumen diameter immediately after atherectomy was smaller in re-stenotic lesions (p = 0.002) and in lesions > or = 10 mm in length (p = 0.02). Late lumen loss was associated with the minimal lumen diameter immediately after atherectomy (p < 0.001), saphenous vein graft lesion location (p = 0.008), and male gender (p = 0.02). Re-stenotic lesions (p < 0.001), lesions > or = 10 mm in length (p = 0.018), saphenous vein graft lesion location (p = 0.025) and male gender (p = 0.045) were independent predictors for restenosis. It is concluded that restenosis after directional atherectomy is related both to factors resulting in a suboptimal initial result and to factors contributing to excessive late lumen loss. These results may have implications for lesion selection in patients undergoing directional coronary atherectomy.
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Affiliation(s)
- J J Popma
- Department of Internal Medicine (Cardiology Division), Washington Hospital Center, Washington, D.C. 20010
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