Contemporary management of critical lower limb ischemia in TASC D lesions with subintimal angioplasty in femoro-popliteal lesions, tibial angioplasty and sequential compression biomechanical device for infra-inguinal arterial occlusion. Experience and quality of life outcome learned over 25 years

AIM

Patients with end-stage critical limb ischemia (CLI) survive on borrowed time and amputation is inevitable if an aggressive management stratagem is not instigated. Our primary aim was to equate effectiveness of subintimal angioplasty (SIA) and tibial balloon angioplasty (TBA) in sustaining clinical improvement and amputation free survival (AFS) in patients with CLI TASD II D. Moreover, patients with severe CLI, who were not suitable for revascularization and who were offered therapy with a sequential compression biomechanical device (SCBD) were scrutinised as part of a comprehensive lower limb salvage program.

METHODS

From 2002-2012, 5876 patients were referred with peripheral vascular disease (PVD); 987 presented with CLI and 798 had intervention; 189 patients presenting with CLI were not candidates for revascularisation, out of which 171 were offered SCBD. We formed a prospective observational group study of 441 patient who had TASC D disease. All of these patients presented as emergencies and were allocated to the next available treatment list. Duplex ultrasound arterial mapping (DUAM) was the sole preoperative investigation tool in 92% of all cases. Of the 441 patients studied, 190 patients (206 procedures) has SIA for TASC D femero-popliteal occlusions, 80 patients (89 procedures) had TBA and cool eximer laser angioplasty (CELA) for tibial artery occlusions and 171 patients with severe CLI were not suitable for revascularization and joined the SCBD program. Mean age (SIA 73±13 years vs. TBA/CELA 74±8 years vs. SCBD 75±13 years), and comorbidity severity scores (P>0.05) were similar between groups.

RESULTS

Perioperative mortality within the SIA group was 1.6% vs. 0% within the TBA group and 0.6% in SCBD. Length of hospital stay within the TBA group was 3.8±2 days vs. SIA 14±16 days, P<0.0001. The 5-year freedom from major adverse events (MAE) for the SIA group was 68% that was comparable to the results obtained for both the TBA group; 59%, and SCBD group: 62.5% (P=0.1935). Five-year freedom from target lesion revascularization was 85.9% within the SIA group and 79% within the TBA group. A sustained clinical improvement was seen in 82.8% of primary SIA and 68% of TBA, which mimics the outcome of SCBD at 68% at one year. A total of 83% SCBD patients had no rest pain within one week of starting the program and gangrene remained dry and non-progressive. Ulceration healed in all but 12 patients. There were no device-related complications. Limb salvage was 94% at 5 years. All-cause survival was 69%. Quality time spent without symptoms of disease or toxicity of treatment (Q-TWiST) was 24.7 months for SIA and 8.5 months for TBA and was 38.13 for SCBD for a total of 708 months of usage. Cost per quality adjusted-life years (QALY) for SIA was € 5662.79, € 12,935.18 for TBA and € 2943.56 for SCBD.

CONCLUSION

All treatment pathways augmented patient-specific Q-TWiST with substantial cost reduction. SIA, TBA and SCBD expand AFS and symptom-free survival. All treatment modalities are minimally invasive and allow for a high patient turnover without compromising limb salvage, once they are performed by experienced vascular surgeons in high deliberate practice volume centers.

Role of laser atherectomy for the management of in-stent restenosis in the peripheral arteries

The prevalence of PAD is expected to increase as the population ages and the treatment for chronic disease becomes more sophisticated. The safety, efficacy, and lower cost of endovascular treatment for peripheral vascular disease of the lower extremities when compared with surgical revascularization are well known. Despite the clinical improvements and advances in endovascular techniques over the past decade, in-stent restenosis of peripheral arteries remains a challenge for the endovascular specialist. The use of excimer laser atherectomy has been shown to be safe and effective for the revascularization of complex, critical de novo peripheral lesions and offers promise in the treatment and prevention of in-stent restenosis.

Laser debulking and DEB for in-stent restenosis: technique and review of the literature

This paper will describe the technique of the treatment of in-stent restenosis of the infrainguinal arteries, using a combined technique of laser debulking followed by drug-eluting balloon angioplasty. The results of this technique from the literature will be discussed, and a comparison with other techniques that are currently used will be made.

Combined influence of proton-pump inhibitors, calcium-channel blockers and CYP2C19*2 on on-treatment platelet reactivity and on the occurrence of atherothrombotic events after percutaneous coronary intervention

BACKGROUND

The carriage of CYP2C19*2 and the use of proton-pump inhibitors (PPIs) and calcium-channel blockers (CCBs) has been associated with the diminished efficacy of clopidogrel. However, previous studies have only assessed the isolated impact of these risk factors for clopidogrel poor response.

OBJECTIVES

The aim of the present study was to investigate the impact of the combined presence of three risk factors for clopidogrel poor response, that is, the use of CCBs, PPIs and the carriage of CYP2C19*2, on on-treatment platelet reactivity and the occurrence of atherothrombotic events in 725 patients on dual antiplatelet therapy undergoing elective coronary stenting.

METHODS

In a prospective, follow-up study, on-treatment platelet reactivity was quantified using ADP-induced light transmittance aggregometry (LTA) and the VerifyNow P2Y12 assay. The clinical study endpoint was the composite of all-cause mortality, myocardial infarction, stent thrombosis and stroke at 1 year after stenting.

RESULTS

Patients with either one or more than one risk factor exhibited increased platelet reactivity (mean relative increase one risk factor: 11% and > 1 risk factor: 22%, respectively). Sixty-four events occurred during follow-up (8.8% of the study population). Patients with one risk factor for clopidogrel poor response did not have an increased risk of the composite endpoint. However, patients using both CCBs and PPIs and carriers of CYP2C19*2 who used CCBs had a statistically significant increased risk of the composite endpoint [hazard ratio(HR)(adj) 2.2 95% CI, 1.0-5.3, P = 0.044 and HR(adj) 3.3 95% CI, 1.1-9.8, P = 0.032, respectively].

CONCLUSIONS

The presence of more than one of the three investigated risk factors for clopidogrel poor response is associated with an increased risk of adverse cardiovascular events within 1 year after elective coronary stenting.

Mid-term results with laser atherectomy in the treatment of infrainguinal occlusive disease

BACKGROUND

Laser atherectomy offers a potential intervention for multivessel infrainguinal disease in patients with poor revascularization options. Despite promising early results reported in the literature, the proper patient population who might benefit from laser atherectomy has yet to be determined.

METHODS

From July 2004 to June 2006, patients undergoing laser atherectomy were retrospectively reviewed and assessed for comorbidities, operative and follow-up variables potentially associated with the end points of nondefinitive therapy, and limb salvage.

RESULTS

During the study period, 40 patients (21 women, 19 men) underwent laser atherectomy, and the average follow-up was 461 +/- 49 days (range, 17 to 1050 days). Their average age was 68 +/- 2 years (range, 43 to 93 years). The indication for laser atherectomy was critical limb ischemia in 26 (65%) and lower limb claudication in 11 (35%). A total of 47 lesions were treated in the following arterial segments: 34 femoropopliteal and 13 infrapopliteal. Femoropopliteal distribution by the Trans-Atlantic Society Classification (TASC) was A in 3, B in 17, C in 10, D in 4, and infrapopliteal lesions distribution was A in 1, B in 3, C in 4, and D in 5. Adjunctive angioplasty was used in 75% of cases. The overall technical success rate (<50% residual stenosis) was 88%. Laser atherectomy-based treatment was the definitive therapy for 23 patients (58%), and the overall 12-month primary patency was 44%. The limb salvage rate at 12 months in 26 patients with critical limb ischemia was 55%. Renal failure was a risk factor for amputation (P < .001) and failed primary patency (P < .05), type 2 diabetes mellitus was a risk factor for amputation (P < .05), and poor tibial runoff was associated with failed primary patency and amputation (P < .05). Outcome was associated with the number of patent infrapopliteal runoff vessels.

CONCLUSION

These data demonstrate that laser atherectomy can be used with high initial technical success rate. Chronic renal failure and diabetes are risk factors for a negative outcome. Poor results in patients with diabetes and renal failure necessitate careful case selection in this subgroup, in which laser atherectomy is less likely to provide a definitive revascularization result or limb salvage.

Initial Experience with Directed Laser Atherectomy Using the Clirpath Photoablation Atherectomy System and Bias Sheath in Superficial Femoral Artery Lesions

PURPOSE

To report a safety and efficacy study of directed excimer laser atherectomy with the Bias Sheath guiding catheter to create larger lumens in the superficial femoral artery (SFA).

METHODS

Fourteen patients (9 men; mean age 66+/-9 years, range 46-76) with chronic lower limb ischemia (Rutherford class 2 to 5) referable to SFA stenoses were treated with the 8-F-compatible Bias Sheath and a 1.7- or 2.0-mm laser catheter. Eight (57%) lesions were de novo and 6 (43%) were in-stent restenoses (ISR). Mean diameter stenosis was 96%+/-8% (range 80%-100%; 10 total occlusions), and mean lesion length was 126+/-78 mm (range 30-290). The primary study endpoint was laser success, defined as <50% angiographic residual stenosis post-laser, without major perforations.

RESULTS

The primary endpoint was achieved in 8 (57%) lesions; all patients underwent additional balloon angioplasty, which achieved an angiographic residual stenosis <30% in all. Three lesions could not be completely traversed with the study device. Two dissections were detected after Bias Sheath application; 1 required stenting. There were 2 embolic events (specific to the antegrade device design); both were treated with aspiration therapy. Intravascular ultrasound (IVUS)-based minimal lumen diameters were 0.23+/-0.2 mm (range 0-1.0) at baseline and 3.2+/-0.8 mm after Bias Sheath application. Rutherford category improved at 1 month in 10 (71%) patients. One patient remained unchanged, another worsened (category 2 to 3), 1 died, and the fourth was not examined. The ankle-brachial index improved from 0.41+/-0.18 at baseline to 0.79+/-0.19 at discharge and to 0.80+/-0.19 at 1 month. Primary 1-month patency (<50% restenosis by duplex) was 85% (11/13 lesions).

CONCLUSION

SFA lesions, including ISR, can be treated in the majority of cases with directed laser atherectomy, significantly reducing plaque burden as measured by IVUS. Embolization was attributed to device-specific features of the prototype antegrade sheath design, which was discontinued. Larger studies are mandatory to document the long-term technical and clinical impact of this new device.

Percutaneous Laser-Facilitated Thrombectomy: An Innovative, Easily Applied, and Effective Therapeutic Option for Recanalization of Acute and Subacute Thrombotic Hemodialysis Shunt Occlusions

PURPOSE

To report our experience with excimer laser-facilitated recanalization of acute and subacute thrombotic occlusions of hemodialysis shunts.

METHODS

Twenty-one patients (16 women; mean age 54+/-19 years, range 31-76) presented with acute and subacute thrombotic occlusions of their hemodialysis shunts (4 Cimino, 17 prosthetic; 18 forearm, 3 upper arm); mean occlusion time was 4.1+/-3 days (range 1-14), and the thrombotic occlusion measured a mean 17.4+/-9 cm (range 5-27). Fresh thrombus was observed in addition to the total shunt occlusion in all cases. All patients were treated initially with a pulsed ultraviolet (308-nm) excimer laser. Eighteen (85.7%) patients received adjunctive local thrombolysis for treatment of residual thrombus. Nineteen (90.5%) patients underwent angioplasty of the underlying anastomotic stenosis.

RESULTS

The angiographic occlusion was reduced from 100% to 63%+/-28% after laser treatment and to 36%+/-18% after 1 hour of thrombolytic therapy (20 mg tissue plasminogen activator). TIMI flow increased significantly from grade 0 to 2.7+/-0.5 following laser ablation (p<0.001) and to 3.0+/-0.2 upon completion of the angioplasty procedure (p>0.001 versus baseline). The immediate procedural success was 95.2% (20/21). Detectable thrombotic embolization and laser-related complications were not observed in any case. Primary patency was 85%; 3 patients had abnormal Doppler flow within 6 weeks and underwent reintervention (secondary patency 100%). All successfully treated shunts were usable for further dialysis at the 6-week follow-up.

CONCLUSION

Percutaneous excimer laser-facilitated thrombus vaporization is safe and effective for recanalization of acute and subacute thrombotic occlusions of hemodialysis shunts.

Limb Salvage Following Laser-Assisted Angioplasty for Critical Limb Ischemia:Results of the LACI Multicenter Trial

PURPOSE

To evaluate the effectiveness of laser-assisted angioplasty for patients with critical limb ischemia (CLI) who were poor candidates for surgical revascularization.

METHODS

A prospective registry at 14 sites in the US and Germany enrolled 145 patients with 155 critically ischemic limbs; the patients were poor candidates for bypass surgery owing to inadequate target vessel or saphenous vein, prohibitive cardiac disease, or significant comorbidities (ASA class 4). Additional comorbid risk factors included diabetes in 66%, hypertension in 83%, previous stroke in 21%, and myocardial infarction in 23%. Endovascular treatment included guidewire traversal and excimer laser angioplasty followed by balloon angioplasty with optional stenting.

RESULTS

Occlusions were present in 92% of limbs. A mean of 2.7+/-1.4 lesions were treated per limb; the total median treatment length was 11 cm (mean 16.2, range 0.2-123). Stents were implanted in 45% of limbs. Procedural success, defined as <50% residual stenosis in all treated lesions, was seen in 86% of limbs. At 6-month follow-up, limb salvage was achieved in 110 (92%) of 119 surviving patients or 118 (93%) 127 limbs.

CONCLUSION

Excimer laser-assisted angioplasty for CLI offers high technical success and limb salvage rates in patients unfit for traditional surgical revascularization.

[Causes and outcomes of coronary arteries perforations]

Coronary artery perforation is a rare but serious complication of percutaneous coronary interventions. Aim of this study--to assess inhospital and long term outcomes in patients in whom perforation occurred during coronary intervention and elucidation of predictors of coronary artery perforation. Between May 1997 and October 2002 perforations were formed in the course of percutaneous interventions in 127 patients what amounted 1.08% of 11,793 patients, subjected to coronary interventions, and 0.77% of 16,494 treated coronary segments. Causes of perforations were complex stenoses, chronic occlusions, calcified lesions, small predicted and minimal vessel lumen, high percent stenosis, use of excimer laser or thromboextrator. Rates of arterial perforations and subsequent adverse events including cardiac tamponade and urgent coronary artery bypass surgery as well as mortality had been declining throughout observation period.

Laser,"closure", stents and other new technology in the treatment of venous disease

New technology is transforming our approach to venous disease. Once considered taboo for fear of causing deep venous thrombosis, surgical or endovenous intervention in the deep venous system is now known to be safe. Newer techniques allow minimally invasive procedures, many carried out on an outpatient basis. Traditional conservative regimens to treat acute ilio-femoral DVT are yielding to more aggressive interventional approaches to minimize the high incidence of postthrombotic syndrome with the former. Stent technology can safely and effectively relieve many of the disabling symptoms of chronic venous obstruction. Stent patency is high and morbidity low. Knowledge of venous pathophysiology has also advanced, though much remains to be learned. The beneficiaries are the large patient population with DVT and chronic venous insufficiency, which is estimated to be at least three times as large as patients with arterial disease. Unlike arterial disease, venous pathology afflicts the younger working age population in large numbers at enormous direct and social costs. In the older patient, deep venous disease is common, but seldom suspected. The symptoms are often ascribed to systemic causes. A thorough venous investigation is the key to proper diagnosis and treatment. Often, a minimally invasive procedure such as EVLT or stent insertion can offer surprising symptom relief with significant improvement in the quality of life during the twilight years.

Radiation exposure to patients undergoing percutaneous coronary interventions: are current reference values too high?

PURPOSE

To determine predictors of patient radiation exposure due to percutaneous coronary interventions (PCI) and to compare our results with the "preliminary reference levels", recently proposed by the European DIMOND research cardiology group: i. e., 75 Gy.cm(2) for dose area kerma product (DAP), 17 min for fluoroscopy time (T(F)), and 1,300 for cinegraphic frames (F).

MATERIAL AND METHODS

For 642 PCI-exclusive of the fraction for diagnostic catheterization to avoid statistical confounder effects-we measured total DAP, cinegraphic (DAP(C)) and fluoroscopic (DAP(F)) fractions, the number of cinegraphic frames and runs, and T(F). DAP(C)/F and DAP(F)/s were calculated to indicate the quality of focusing to the region of interest.

RESULTS

The mean total patient DAP for elective one-, two-, and three-vessel PCI amounted to 6.7, 11.6, and 19.4 Gy.cm(2), for PCI of focal in-stent restenoses to 4.2 Gy.cm(2), and for excimer laser angioplasty of diffuse in-stent restenoses to 19.4 Gy.cm(2), respectively. Recanalization of chronic occlusions and PCI in acute myocardial infarction occasioned mean levels of 16.0 and 17.3 Gy.cm(2). Implantation of one and > or = two stents during one-vessel PCI significantly increased total mean DAP from a baseline level of 5.7 up to 7.1 and to 13.8 Gy.cm(2). DAP significantly varied according to the various PCI target regions and amounted to 4.0, 4.5, and 5.5 Gy.cm(2) for intermedius, diagonal, and left anterior descending arteries, to 4.9, 5.0, and 7.0 Gy.cm(2) for obtuse marginal, left posterolateral, and circumflex arteries, to 8.3, 9.1, and 9.5 Gy.cm(2) for proximal/mid right coronary segments, posterior descending, and right posterolateral arteries, and to 11.6 Gy.cm(2) for saphenous vein grafts, respectively.

CONCLUSION

This study, carried through by consistent use of radiation-reducing techniques, enables a reliable scoring of patient radiation exposure according to complexity and target vessel of the intended PCI. Our 95th percentiles for elective PCI, for recanalizations of chronic occlusions, and for emergency PCI advise reference levels of 22, 32, and 42 Gy.cm(2) for DAP, of 16, 25, and 24 min for T(F), and of 400, 600, and 700 cinegraphic frames, respectively.

Wireless laser-assisted angioplasty of the superficial femoral artery in patients with critical limb ischemia who have failed conventional percutaneous revascularization

Percutaneous revascularization has become an effective treatment for patients suffering from chronic critical limb ischemia (CLI) due to chronic atherosclerotic obstructions, including total occlusions. Unlike other vascular beds, total chronic occlusions of the femoropopliteal arteries are frequently found in patients with severe claudication or CLI. As a consequence, patients with long chronic total occlusions of the femoropopliteal arteries are generally not considered optimal candidates for percutaneous revascularization and are frequently referred for surgical revascularization. In the present study, we sought to evaluate the feasibility, safety, and outcome of a modified wireless laser ablation technique to recanalize total occlusions in patients with CLI who had failed conventional percutaneous techniques for limb salvage. Procedural success, complications, actuarial freedom of limb loss, and surgical revascularization were evaluated in 25 patients after a mean follow-up of 13 +/- 8 months. Procedural success was achieved in 21 patients (84%). Actuarial freedom from surgical revascularization or limb loss was 72%. There was one vascular perforation. No deaths or distal embolization occurred. Three patients (12%) required limb amputation during follow-up, whereas four patients (16%) had surgical revascularization in the presence of feasible vascular targets. Limb salvage was achieved in 88% of patients when laser recanalization was combined with surgical revascularization. These results suggest that the use of laser ablation is safe and facilitates angioplasty and stenting in patients with CLI that failed conventional endovascular revascularization. This technique might prevent limb loss in patients with CLI due to femoropopliteal total occlusions, particularly in patients with unsuitable anatomy for surgical revascularization.

Prevention of distal embolization and no-reflow in patients with acute myocardial infarction and total occlusion in the infarct-related vessel: A subgroup analysis of the cohort of acute revascularization in myocardial infarction with excimer laser?CARMEL multicenter study

To overcome the adverse complications of percutaneous coronary interventions in thrombus laden lesions (i.e., distal embolization, platelet activation, no-reflow phenomenon), mechanical removal of the thrombus or distal embolization protection devices are frequently required. Pulsed-wave ultraviolet excimer laser light at 308 nm can vaporize thrombus, suppress platelet aggregation, and, unlike other thrombectomy devices, ablate the underlying plaque. The following multicenter registry was instituted to evaluate the safety and efficacy of laser ablation in patients presenting with acute myocardial infarction (AMI) complicated by persistent thrombotic occlusions. Patients with AMI and complete thrombotic occlusion of the infarct-related vessel were included in eight participating centers. Patients with further compromising conditions (i.e., cardiogenic shock, thrombolysis failures) were also included. Primary endpoint was procedural respective laser success; secondary combined endpoints were TIMI flow and % stenosis by quantitative coronary analysis and visual assessment at 1-month follow-up. Eighty-four percent of all patients enrolled (n = 56) had a very large thrombus burden (TIMI thrombus scale > or = 3), and 49% were compromised by complex clinical presentation, i.e., cardiogenic shock (21%), degenerated saphenous vein grafts (26%), or thrombolysis failures (5%). Laser success was achieved in 89%, angiographic success in 93%, and the overall procedural success rate was 86%. The angiographic prelaser total occlusion was reduced angiographically to 58% +/- 25% after laser treatment and to 4% +/- 13% final residual stenosis after adjunctive balloon angioplasty and/or stent placement. TIMI flow increased significantly from grade 0 to 2.7 +/- 0.5 following laser ablation (P < 0.001) and 3.0 +/- 0.2 upon completion of the angioplasty procedure (P > 0.001 vs. baseline). Distal embolizations occurred in 4%, no-reflow was observed in 2%, and perforations in 0.6% of cases. Laser-associated major dissections occurred in 4% of cases, and total MACE was 13%. The safety and efficacy of excimer laser for thrombus dissolution in a cohort of high-risk patients presenting with AMI and total thrombotic occlusion in the infarct-related vessel are encouraging and should lead to further investigation.

Successful management of osteal perforation of left anterior descending artery with coated stent

Coronary perforation is a rare complication of percutaneous coronary intervention. We report a case of left anterior descending artery osteal perforation that led to acute cardiac tamponade during excimer laser angioplasty. Perforation was successfully covered with a PTFE-coated stent with preserved distal coronary flow.

Treatment of in-stent restenosis with excimer laser coronary angioplasty

Diffuse in-stent restenosis remains an important problem in percutaneous transluminal coronary angioplasty (PTCA). In this trial, we studied the early and mid-term outcomes of excimer laser coronary angioplasty (ELCA) on diffuse in-stent restenosis. ELCA was performed in 23 patients (19 males). The mean length of the lesions was 14.3 +/- 3 mm and the mean age was 58 +/- 7 years. The minimal lumen diameter (MLD) was measured by on-line quantitative coronary angiography. Before the procedure, MLD was 0.9 +/- 0.4. The Q/non-Q-wave myocardial infarction (MI), coronary artery bypass graft (CABG), PTCA, and mortality were recorded during the procedure and at 6 months follow up. The fluence of laser emission was 45 mj/m2 and the repetition rate was 25 pulses per second. Adjunctive balloon angioplasty was performed in all of the cases at a mean 7 +/- 2 atm pressure. The procedure was successfully performed in all of the cases. Type-B dissection developed, after ELCA in 1 patient (4%). Perforation, death, cerebrovascular accidents, emergency CABG, PTCA or Q/non-Q wave myocardial infarction were not observed. MLD was 0.9 +/- 0.4 mm before ELCA, 1.8 +/- 0.9 mm (P<0.05) after ELCA, and 3.1 +/- 0.7 mm after PTCA. At 6 months follow up, there were 2 (8.7%) Q-wave myocardial infarctions and 2 (8.7%) recurrent anginal pain cases. Control angiography was obtained in 20 cases (87%). Control angiography was not accepted by 3 patients. Their maximal exercise test was negative. Angiographic restenosis was observed in 6 cases (30%). The rate of target lesion revascularization (TLR) was 5 of 23 (22%) in the patients treated with ELCA. It is concluded, ELCA is a safe and efficient debulking technology for treating diffuse in-stent restenosis.

Excimer laser-assisted high-flow extracranial/intracranial bypass in patients with symptomatic carotid artery occlusion at high risk of recurrent cerebral ischemia: safety and long-term outcome

BACKGROUND AND PURPOSE

The goal of this study was to determine safety and long-term outcome of the excimer laser-assisted high-flow extracranial/intracranial (EC/IC) bypass in patients with symptomatic carotid artery occlusion (CAO) at high risk of recurrent stroke.

METHODS

In a prospectively collected cohort of 103 patients with symptomatic CAO, 15 patients were selected for excimer laser-assisted EC/IC bypass surgery on the basis of predefined selection criteria: (1) transient or moderately disabling symptoms of focal cerebral ischemia, not symptoms of the retina only; (2) continuing symptoms after documentation of the CAO; (3) evidence of a possible hemodynamic origin of symptoms; and (4) informed consent of the patient.

RESULTS

Eleven patients underwent the operation without complications One patient had a severely disabling stroke (Rankin grade 4) 11 days after the operation; the bypass was found occluded on reoperation. Two other patients had a moderately disabling stroke (Rankin grade 3) immediately after the operation. One patient died of myocardial infarction 1 day after surgery. Median follow-up time was 27 months. Of the 11 patients who underwent the operation without complications, 1 died 17 months after the operation of a brainstem stroke, and another patient had a new stroke ipsilateral to his CAO 10 months after the operation but without a change in Rankin grade.

CONCLUSIONS

The excimer laser-assisted high-flow EC/IC bypass operation is a potentially promising procedure in patients with symptomatic CAO and a presumably high risk of recurrent stroke, but the procedure carries a definite risk. This risk is probably related not only to the procedure itself but also to the selection of patients.

Short (1-10 cm) superficial femoral artery occlusions: results of treatment with excimer laser angioplasty

PURPOSE

To evaluate the safety and long-term results after laser angioplasty of short occlusions of the superficial femoral artery (SFA).

METHODS

In a prospective trial in 312 patients with short occlusions of the SFA excimer laser angioplasty for recanalization was applied. The average occlusion length of the SFA was 7.5 cm (range 1-10 cm). The recanalization attempt was done using either a cross-over technique from the contralateral femoral artery (278 patients), antegrade technique (16 patients) or transpopliteal technique (18 patients).

RESULTS

Percutaneous transluminal laser angioplasty (PTLA) produced successful recanalization of the SFA in 286 of 312 patients (91.7%). In 26 patients (8.3%) recanalization was not possible. The reason for the unsuccessful PTLAs was obstructing calcified materialn = 8) which was resistant to laser application. In nine cases obstructing calcifications resulted in positioning of the laser catheter in subintimal tissue or perforation of the SFA. In another four patients there was an aberrant anatomy of the SFA which resulted in a direct vessel injury after advancing the laser catheter. In five patients subintimal recanalization failed. After a follow-up period of 36 months there was a primary, primary assisted and secondary patency rate of 49.2%, 76.5% and 86.3%.

CONCLUSION

Excimer laser angioplasty of short occlusions of the SFA is a feasible procedure with a low failure rate. Long-term results are promising but additional interventions are required in most patients to achieve a patency rate of 86.3% after 3 years. Further studies are needed to compare the clinical outcome of PTLA and PTA in short occlusions of the SFA.

Do transmyocardial and percutaneous laser revascularization induce silent ischemia? An assessment by exercise testing

BACKGROUND

Transmyocardial and percutaneous laser revascularization (TMR, PTMR) may reduce angina and increase exercise tolerance in otherwise untreatable angina patients, although the mechanism is unknown and the placebo effect may be significant. One other proposed mechanism is cardiac denervation leading to silent ischemia.

METHODS

Electrocardiograms obtained during symptom-limited exercise (ETT, modified Bruce protocol) at baseline and 12 months were analyzed (blinded core laboratory) from 182 patients randomized to TMR (n = 92) or medical therapy alone (MED(TMR), n = 90) and 219 patients randomized to PTMR (n = 109) or medical therapy alone (MED(PTMR), n = 110).

RESULTS

Exercise duration increased 1 year after TMR or PTMR relative to medically treated patients (6.8 +/- 3.4 min vs 8.6 +/- 3.5 min for TMR; 7.3 +/- 3.1 min vs 9.1 +/- 3.6 min for PTMR, P <.05). At baseline, 20% of TMR and MED(TMR) subjects had ST depression >1.0 mm, >80% had angina during exercise, but only 3% had ST changes without chest pain (silent ischemia). This did not change after TMR. In the PTMR group, more subjects exercised to >1.0 mm ST depression (from 17% to 34%, P <.05), with no change in MED(PTMR), but the proportion with silent ischemia did not change in either group.

CONCLUSION

Exercise tolerance improved after TMR and after PTMR. Relative to PTMR, TMR more effectively suppressed pain during exercise and ischemic ST depression. However, neither TMR nor PTMR induced significant silent ischemia. These results suggest that denervation may not be a significant factor contributing to angina relief after these procedures. The contribution of the placebo effect was not determined by these results.

In vivo effect of coronary laser angioplasty on atherosclerotic plaques: histopathologic analysis

Information from histopathologic examination of coronary arterial atherosclerotic plaques treated with in vivo laser energy is sparse. Directional atherectomy provides biopsies for study of tissue changes (injury) due to coronary arterial debulking devices, including laser. Sixteen patients who presented with acute ischemic coronary syndromes underwent debulking of a total of 17 obstructive intracoronary lesions with pulsed-wave holmium:YAG laser (2.1 microm wavelength). Laser was performed with the "pulse and retreat" technique which incorporates slow catheter advancement (0.5-1 mm/s) with controlled emission of energy. Immediately postlasing, directional atherectomy was utilized to obtain irradiated plaque tissue for pathologic examination. Extent of laser-induced tissue injury to plaques was graded as 0 (no tissue damage), 1 (small foci or charring and vacuoles), 2 (large amount of charring, edge disruption and vacuoles) and 3 (extensive tissue damage). Angiographically and clinically, all 17 lesions were successfully debulked with the laser energy (mean 47+/-25 pulses), with a reduction of target lesion percent diameter stenosis from 92+/-6% to 47+/-25%. Adjunct balloon dilations further reduced the target lesions to a final of 10+/-10% stenosis. The histopathologic examination of the lased specimens demonstrated that 13 lesions (76%) had no evidence of laser-induced injury (Grade 0). Four lesions had low-level injury (Grade 1), and none had evidence of Grade 2 or 3 laser-induced trauma. Therefore, a laser debulking technique, which incorporates slow catheter advancement with controlled emission of pulses, does not cause significant injurious effects to the irradiated plaque.

Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention

We have analyzed the incidence, management, and outcome of 84 cases of coronary artery perforation in patients who underwent percutaneous coronary intervention at our institution. This complication was more frequent in female patients and in patients who underwent lesion modification with atheroablative devices. A total of 8 patients (9.5%) died after the procedure. They were usually older and had a higher incidence of cardiac tamponade; a larger percentage of these patients underwent emergency surgery than those who survived.

Restenosis: a challenge for pharmacology

The quest for an anti-restenotic drug continues to be a major challenge in the field of cardiovascular pharmacology because most therapies with proven efficacy in experimental neointima models have failed to limit restenosis. Some drug classes, including glycoprotein IIb/IIIa antagonists, nitric oxide donors and the antioxidant probucol, have recently demonstrated potential benefits in clinical trials. Progress in the development of local delivery systems for administration of drugs, antisense oligonucleotides or genes, in combination with an improved understanding of the pathogenesis of restenosis holds promise for ultimate pharmacotherapy of this condition.

Cell damage induced by Angiovist-370 and 308nm excimer laser radiation

BACKGROUND AND OBJECTIVE

Radiographic contrast media containing iodine-labeled organic compounds can be present in the irradiated field during laser angioplasty using 308 nm excimer laser radiation. These compounds absorb light at 308 nm and may undergo photochemical reactions that produce products that damage cells.

STUDY DESIGN/MATERIALS AND METHODS

This study was undertaken to determine whether photoproducts that damage human lymphocytes in vitro are formed when Angiovist 370 (AV), a contrast medium containing triiodinated aromatic compounds, is exposed to 308 nm radiation.

RESULTS

The absorption spectrum of AV developed a new peak at 360 nm that extended to wavelengths greater than 500 nm when dilute AV solutions were exposed to 308 nm radiation indicating that photoproducts were formed. Irradiating dilute AV solutions above a layer of human lymphocytes caused a dose-dependent decrease in thymidine incorporation using fluence rates between 5.2 x 10(6) and 1.0 x 10(8) W/cm2. Decreased DNA synthesis was independent of the pulse length (10 ns vs. 230 ns) but was lower, at a given dose, when the highest fluence rate was used. Incubation of lymphocytes with preirradiated AV solutions also decreased incorporation of thymidine in a radiation dose-dependent manner. The cell damaging photoproducts in preirradiated AV solutions were unstable; within 15 min, the effectiveness had decreased by approximately 85%.

CONCLUSIONS

These results indicate that exposure of AV to 308 nm excimer laser radiation produces photochemical products that damage human cells in vitro.

Treatment of in-stent coronary restenosis with excimer laser angioplasty

OBJECTIVE

To evaluate the efficacy and safety of excimer laser coronary angioplasty (ELCA) with adjunctive balloon angioplasty in patient with in-stent restenosis.

METHODS

ELCA was performed in 20 patients of instent restenosis. All patients were symptomatic and had class III-IV angina. ELCA was performed with the Spectranetics CVX-300 System. The laser catheter of Vittesse C (concentric) and E (eccentric) with diameter of 1.4-2.0 mm was used.

RESULTS

Laser catheter crossed all stenotic stents without difficulty. The lesion length was 4.6-51.2 mm, mean 20.7 +/- 13.7 mm, including 14 lesions > 10 mm. Laser treatment alone increased minimal lumen diameter (MLD) from 0.3 +/- 0.3 mm to 1.4 +/- 0.3 mm (P < 0.0001) and improved the diameter stenosis from 88.8% +/- 10.0% to 46.0% +/- 8.0% (P < 0.0001). Adjunctive balloon angioplasty further increased minimal lumen diameter to 2.3 +/- 0.7 mm and reduced diameter stenosis to 14.2% +/- 8.2% (P < 0.0001). At follow-up (1-17 months, mean 8.9 +/- 5.7 months), 17 (85%) patients had remained asymptomatic, 3 (15%) patients had mild to moderate exertional angina, 1 (5%) patient received CABG.

CONCLUSION

ELCA with adjunctive percutaneous transluminal coronary angioplasty (PTCA) is an efficient and safe technique to debulk tissue in the patient with in-stent restenosis. The incidence of procedural related complication was low and ELCA may be used as a good method for in-stent restenosis treatment.

Clinical, angiographic, and procedural correlates of abrupt vascular closure during coronary intervention: a 10-year experience at Mayo Clinic

A large matched-cohort study was carried out to determine correlates of in-hospital abrupt vascular closure (AC). Univariate analysis identified current cigarette smoking (P = 0.021), myocardial infarction within 24 hr prior to procedure (P = 0.0035), emergency procedure (P = 0.02), lesion thrombus (P = 0.0001), and lesion angulation (P = 0.021) as significant clinical and angiographic variables. Relative to balloon angioplasty (PTCA), use of atherectomy (P = 0.015) and laser devices (P = 0.018) but not elective stent placement (P = 0.97) were associated with increased risk of AC. In the multivariate model, current cigarette smoking (P = 0.0474), lesion thrombus (P = 0.0001), lesion angulation (P = 0.0124), use of atherectomy devices (P = 0.001), and laser devices (P = 0.0037) remained as significant correlates of increased AC events. In conclusion, the risk of AC appears associated primarily with lesion characteristics and use of nonballoon devices other than stents. Elective stent placement did not appear to reduce AC risk over conventional PTCA; the small number of patients studied may have prevented any benefit from being observed.

Early deterioration after excimer laser-assisted coronary angioplasty

Coronary lumen changes after excimer laser coronary angioplasty, after adjunct percutaneous transluminal coronary angioplasty, and at 24 hours after intervention were assessed using quantitative coronary angiography. Lesions treated with this combined technique showed significant early deterioration within 24 hours.

Excimer laser angioplasty versus balloon angioplasty in functional and total coronary occlusions

Registries of excimer laser coronary angioplasty have reported good results in the treatment of complex coronary artery disease, including total or subtotal coronary occlusions. One hundred three patients (103 lesions) with a functional or total coronary occlusion were included in a randomized trial (Amsterdam-Rotterdam [AMRO] trial, total of 308 patients), 49 patients were allocated to laser angioplasty and 54 patients to balloon angioplasty. The primary clinical end points were death, myocardial infarction, coronary bypass surgery, or repeated coronary angioplasty of the randomized segment during a 6-month follow-up period. The primary angiographic end point was the minimal lumen diameter at follow-up in relation to the baseline value (net gain), as determined by an automated contour-detection algorithm. Laser angioplasty was followed by balloon angioplasty in all procedures. The angiographic success rate was 65% in patients treated with excimer laser-assisted balloon angioplasty compared with 61% in patients treated with balloon angioplasty alone. No deaths occurred. There were no significant differences between the laser angioplasty group and the balloon angioplasty group in the incidence of myocardial infarctions (1 patient vs 3, respectively, p = 0.36), coronary bypass surgery (4 patients vs 2, respectively, p = 0.34), repeat angioplasty (10 patients vs 8, respectively, p = 0.46) or primary clinical end point (15 patients vs 12, respectively, p = 0.34). The net gain in minimal lumen diameter and restenosis rate (>50% diameter stenosis at follow-up) were 0.81 +/- 0.74 mm and 66.7%, respectively, in patients treated with laser angioplasty compared with 1.04 +/- 0.68 mm and 48.5%, respectively, in patients treated with balloon angioplasty (p = 0.59 and p = 0.15, respectively). Excimer laser-assisted balloon angioplasty demonstrated no benefit over balloon angioplasty with respect to initial and long-term clinical and angiographic outcome in the treatment of patients with functional or total coronary occlusions of >10 mm in length.

Myocardial infarction as a complication of new interventional devices

Percutaneous transluminal coronary balloon angioplasty has been associated with acute myocardial infarction (MI) as a complication of the procedure. Abrupt closure, distal coronary embolization, intimal dissection, coronary spasm, and acute thrombosis are the principal etiologies. New interventional devices (stent, laser, and atherectomy catheters) have been introduced as alternatives or adjuncts to balloon angioplasty. With use of the New Approaches to Coronary Intervention Registry, the incidence, predictors, and outcome of MI as a complication of using these devices as the primary mode of intervention were studied. There were 3,265 patients from 39 participating centers in the cohort treated with new devices. MI was reported as an in-hospital complication of using new devices in 154 patients (4.7%), including Q-wave MI in 36 patients (1.1%), and non-Q-wave MI in 119 patients (3.6%). MI rates were not significantly different among all patients with devices in the cohort treated with atherectomy (directional, extractional, rotational), laser (AIS, Spectranetics) or the Palmaz-Schatz stent. Multivariate logistic regression showed that post-procedure MI was associated with multivessel disease, high surgical risk, postinfarction angina, and presence of a thrombus prior to the procedure. Prior percutaneous transluminal coronary angioplasty was inversely related to the incidence of MI. When a specific cause of MI could be detected, the main etiologies were: coronary embolus 16.9%, and abrupt closure 27.3%. Other major in-hospital complications were higher in the MI group than the non-MI group: death 7.8% versus 0.8% (p <0.001), and bypass surgery 13.6% versus 1.7% (p <0.001). At 1 year, mortality rates remain higher at 12.9% in the MI group versus 4.9% in the non-MI group (p <0.01). Despite different indications for the use of new devices, they were not predictors for MI with the exception of the rotablator. The incidence of MI (1.1% Q-wave, 3.6% non-Q-wave) was comparable to previously reported rates for balloon angioplasty. The occurrence of MI is associated with an increase in other in-hospital complications and a doubling of 1-year mortality.

Clinical results with excimer laser coronary angioplasty

This comprehensive review of randomized trials and registry reports makes several assertions about the clinical usefulness of excimer laser angioplasty. First, refinements in patient selection and excimer laser technique have resulted in improved procedural outcome. Second, the overall rates of clinical success for excimer laser angioplasty are approximately 90%, major and minor complications 6%, and vessel perforation 1%. Third, superior success rates are achieved for saphenous vein graft lesions, ostial stenoses and total occlusions, but decreased success rates are obtained for bifurcation, calcified and thrombus-containing lesions. The routine use of saline infusion during excimer laser angioplasty and careful evaluation of this therapy for new indications such as in-stent restenosis will increase the usefulness of excimer laser angioplasty in interventional cardiovascular medicine.

Homogeneous light distribution to reduce vessel trauma during excimer laser angioplasty

Excimer laser coronary angioplasty (ELCA) is associated with vascular damage, caused by rapidly expanding water vapour bubbles and accumulation of insoluble gas. The size of the rapidly expanding bubbles and the volume of gas can be reduced by decreasing the laser pulse energy density. However, using current multifibre catheters, penetration through porcine aortic tissue was found to be impossible at energy densities < or = 45 mJ/mm2. By contrast, by employing a 660 microns bare fibre it was observed that efficient tissue crossing was possible at 12 mJ/mm2, with considerable reduction of the rapidly expanding bubble volume and insoluble gas production. We attribute this efficient tissue penetration at low energy densities to the absence of 'dead space' in the homogeneous light distribution (HLD) at the fibre tip. Accordingly we hypothesize the ELCA performed at lower energy densities may result in less mechanical trauma to the vessel wall when compared with ELCA using current multifibre catheters.

Comparison of tissue disruption caused by excimer and midinfrared lasers in clinical simulation

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.

[Excimer laser assisted angioplasty. Immediate results in the treatment of complex coronary lesions]

Transluminal coronary angioplasty (TCA) with pulsed excimer laser (CVX 300 Spectranetics) was performed in 89 patients (age 63.7 years); CCS I: 6; CCS II: 12; CCS III: 40; CCS IV: 31; instable: 58%. There was a previous history of myocardial infarction (MI) in 27 cases, TCA (9 restenoses) in 24 cases, 19 bypass graft procedures, 13 failures of TCA. The lesions (n = 90) affected the left main coronary artery: 1 case; the left anterior descending artery: 37 cases; the left circumflex: 8 cases; the right coronary: 28 cases and there were saphenous vein grafts in 16 cases. The lesions were classified B2 (ACC/AHA) in 56 cases and type C in 34 cases. There were 24 lesions > 10 mm, 15 > 20 mm; calcification in 49 cases; excentric in 65 cases; ostial in 9 cases; affecting bifurcations in 13 cases; affecting collateral vessels in 16 cases; chronic occlusions in 12 cases and restenoses of stents in 4 cases. Multifiber catheters: 1.4 mm (50), 1.7 mm (41) and 2 mm (3), were used to deliver energies of 43.3 mj/m2 (+/- 8.1 mj) with an average of 5.2 +/- 1.2 applications persite, and 2.7 +/- 1.1 passages. A balloon dilatation was performed after laser angioplasty in 96% of cases. The following results were observed: success of laser angioplasty (20% reduction of stenosis) in 95.5%, a successful procedure (residual stenosis less than 50% without major complications) in 95.5%, and a clinical success (no pathological Q wave or non-Q wave infarction, bypass graft, or repeat TCA): 92.1%. The following complications were observed: death = 0, non-Q wave infarction 2.2%, emergency bypass surgery in 1 case with Q wave infarction: 1.1%. The use of laser angioplasty may be proposed in the following indications: long, moderately calcified lesion, ostial lesions, complete occlusions, bypass graft disease, failure of angioplasty. In addition to these indications, we propose the treatment of restenosis on stents. The main disadvantage of the Excimer Laser is the poor cost/benefit ratio, given the relatively small number of indications.

Intravascular ultrasound findings after excimer laser coronary angioplasty

Intravascular ultrasound (IVUS) was used to study 104 lesions in 98 patients after excimer laser coronary angioplasty (ELCA). Lesion site external elastic membrane (EEM) and lumen cross-sectional areas (CSA) were measured; plaque+media (P+M = EEM - lumen) CSA and percentage of cross-sectional narrowing (CSN = P+M CSA/EEM CSA) were calculated; and the results were compared to a reference site. The lumen CSA (2.6 +/- 1.0 mm2) averaged 24% larger than the cross-sectional area of the largest laser catheter used, and 64 lesions (62%) fit the definition of arterial expansion (lesion EEM CSA > reference site EEM CSA). The residual percentage of cross-sectional narrowing averaged 83.8 +/- 8.8%. Dissections were present in 44% of lesions, and were more common in lesions with superficial calcium (59%) than in lesions with only deep calcium (31%) or no calcium (20%, P = 0.0102). Dissections of superficial calcified plaque had an unusual "shattered" or "fragmented" appearance. These findings suggest that excimer laser angioplasty causes forced vessel expansion with dissection, but limited atheroablation.

Laser-assisted coronary angioplasty in patients with severely depressed left ventricular function: quantitative coronary angiography and clinical results

Laser-assisted coronary angioplasty can be successfully applied to lesions not ideal for balloon angioplasty. Patients with severely impaired left ventricular (LV) function and complex coronary artery stenoses who call for percutaneous revascularization are considered a high risk group for balloon angioplasty. In order to determine the feasibility, safety, and acute clinical outcome of a solid state, pulsed wave, mid-infrared (2.1 micron) laser facilitated angioplasty in these patients, data from 112 patients with 129 lesions were analyzed. Patients were identified according to angiographic LV function; group I included 22 patients with left ventricular ejection fraction (LVEF) < or = 40% (mean = 25% +/- 10%) and group II included 90 patients with LVEF > or = 40% (mean = 58% +/- 8%). No difference in age, gender, diabetes, hypertension, tobacco use, history of previous coronary artery bypass surgery (CABGS) or percutaneous transluminal coronary angioplasty was registered between the two groups. Multivessel disease, previous myocardial infarction (MI), and severe angina were more prevalent among group I patients (P = 0.03). No difference was found in lesion location, complexity, length, or calcification between the two groups; although group I had more eccentric lesions. Both groups were treated with the same laser energy level followed by adjunctive balloon angioplasty. One hundred percent procedural success was obtained in group I versus 93% in group II (P = NS). By Q.C.A. (independent core lab), minimal luminol diameter increased in group I from 0.9 +/- 0.5 mm preprocedure to 2.0 +/- 0.5, as compared to 0.8 +/- 0.5 mm to 1.9 +/- 0.5 mm (P = NS) in group II. Stenosis severity improved from 69% +/- 16% preprocedure to 37% +/- 13% postprocedure in group I, as compared to improvement from 78% +/- 16% to 37% +/- 12.7% in group II (P = NS). Overall complication rate was remarkably low, with no death or perforation in either group; emergency CABGS 0% in group I and 1.1% in group II; dissections 4.5% in group I and 8.8% in group II. There was no significant difference in complication rate between the two groups. The results of this study suggest that holmium:YAG laser facilitated coronary angioplasty can be safely performed in patients with severe LV dysfunction, achieving a remarkably high procedural success and low complication rate.

The changing profile of patient selection, procedural techniques, and outcomes in excimer laser coronary angioplasty. Participating Investigators of the Percutaneous Excimer Laser Coronary Angioplasty Registry

During the course of development of excimer laser angioplasty, several changes in patient selection and technique have occurred. It is uncertain, however, whether these changes have been associated with improved procedural outcome. In this study, multivariable regression methods were used to identify the factors responsible for clinical success, major complications, and vessel perforation in 2,041 consecutive patients treated with excimer laser coronary angioplasty. The overall rates of clinical success were 89%, major complications 7.5%, and vessel perforation 2.1%. Clinical success was 86% in patients treated with prototype catheters, 89% with flexible catheters, 92% with extremely flexible catheters, and 95% in patients treated with directional eccentric catheters (P < 0.001). By multivariable analysis, clinical success increased with each subsequent catheter design (odds ratio [OR] = 1.4 per iteration [95% confidence interval 1.2, 1.6]), and with improved lesion selection. Major complications were reduced when operators had performed more than 25 cases (rate = 6.5%, OR = 0.7 [0.5, 0.9]), and the incidence of vessel perforation was decreased when the size of the target vessel was > 1.0 mm larger than the diameter of the laser catheter (rate = 1.1%, OR = 0.3 [0.2, 0.5]). In conclusion, during the course of clinical investigation with excimer laser angioplasty, procedural outcome has improved. These results emphasize the importance of careful patient selection and procedural technique to enhance the success of excimer laser angioplasty.

Coronary laser angioplasty

Balloon angioplasty was introduced among the armament of therapy for coronary heart disease in 1977 by Gruentzig in Zurich. Since the first case was successful, this method of treatment spread out rapidly so that at the present time, more than 400,000 procedures are being performed per year in the U.S. The reasons for such on explosive success includes the relative safety of the procedure, the reduction in cost as compared to surgical bypass procedures, the short in-hospital stay, and short recovery time.

Six month outcome and determinants of adverse clinical events after successful excimer laser coronary angioplasty. ELCA A.I.S. Multicenter Registry

OBJECTIVE

To describe the six month outcome and predictors of adverse clinical events following successful excimer laser coronary angioplasty (ELCA).

DESIGN

Retrospective analysis of comprehensive data collected at time of initial procedure and during planned follow-up intervals.

SETTING

There were 35 participating institutions throughout the United States.

PATIENTS

The study population was comprised of 3,069 patients who had successful ELCA and completed follow-up at 6 months, representing 91% of eligible cases. Forty percent had prior balloon angioplasty and 34% had prior bypass surgery.

MEASUREMENTS

Patient symptomatology was assessed by Canadian Cardiovascular Society functional (CCSF) class. Interim adverse clinical events [death, Q wave myocardial infarction (QMI), repeat intervention, bypass surgery, and a composite end-point] were tracked. Twenty-six pre-ELCA clinical, angiographic and procedural variables were evaluated to assess their ability to predict outcome.

RESULTS

At 6 months, there was 2.8% mortality, 2.5% incidence of QMI, and 28.7% required either repeat intervention or bypass surgery. Overall, 69.2% of patients had no adverse event. In this cohort, the pre-ELCA CCSF class grade was 2.7 +/- 1.2, but at 6 months, it was 0.7 +/- 1.1 (p < 0.001). The multivariate predictors of the composite end point were gender, stenosis location, and rest and unstable angina.

CONCLUSIONS

There is an excellent 6 month outcome after successful ELCA in this selected population with complex coronary artery disease. The majority of patients without interim events enjoy significant alleviation of symptoms. The predictors of adverse events are clinical rather than angiographic.

[Laser-assisted balloon angioplasty of occlusions in the femoropopliteal segment]

During 1990 through 1992, 32 patients with arterial occlusive disease of the femoropopliteal segment underwent laser-assisted balloon angioplasty at the vascular service of Rigshospitalet, Copenhagen. A pulsed ultraviolet excimer laser was employed. Initial angiographic and clinical success was achieved in 20 of 32 femoropopliteal occlusions (63%). Life-table analysis revealed a cumulated patency rate of 40%, 33% and 25% after one month, one and three years, respectively. There was no correlation between initial success rate and length of occlusion, status of run-off, calcification or number of collateral vessels. In this series, laser angioplasty carried a high risk of perforation. The initial and long-term results were no better than could be expected of percutaneous transluminal angioplasty, suggesting that laser-assisted balloon angioplasty has no place in the vascular surgical armamentarium.

Femoropopliteal artery recanalization: factors affecting clinical outcome of conventional and laser-assisted balloon angioplasty

PURPOSE

The clinical efficacy of 44 successful conventional and laser-assisted recanalizations of the femoropopliteal artery was assessed in a noncomparative study by the life-table method.

METHODS

Laser-assisted angioplasty using continuous laser and a sapphire probe was performed to achieve primary recanalization in femoral artery occlusions when conventional guidewire recanalization had already failed. Nineteen of the patients underwent a conventional recanalization (PTA; mean length of occlusion 4.4 +/- 4.1 cm), and 25 underwent percutaneous laser-assisted angioplasty (PLA; mean length of occlusion 10.1 +/- 6.7 cm).

RESULTS

There was no statistical relation between the preprocedure Fontaine classification and the success rate in the PTA cases (p = 0.25), whereas there was a statistical relation in the PLA cases: The success rate in patients preprocedurally classified as Fontaine II was better than in those classified as Fontaine III/IV (p = 0.05). After a 3-year follow-up the patency rate in the patients with the PTA recanalizations was 37% and that in those with the PLA procedure was 53%. This difference was not statistically significant (p = 0.47).

CONCLUSION

It is concluded that the laser should remain an investigational device.

[Excimer laser in the treatment of obstructive coronary disease. Initial experience]

The aim of this study is to evaluate a group of four male patients aged between 47 and 77 years (mean 52 +/- 4.5) with coronary artery disease who underwent excimer laser with classical indication for this method. The vessels considered were the left anterior descending artery in three patients and the right coronary artery in one. Conventional percutaneous transluminal coronary angioplasty (PTCA) was applied in all patients after the laser procedure. Reduction to 50% or less of the internal diameter was considered a satisfactory result. Early success (laser plus PTCA) was obtained in 100%. There were a decreasing in number of obstruction from 75-100% (mean of 80 +/- 8.5%) to 0-50% (mean of 20 +/- 6%) after the procedure (laser plus PTCA). During hospitalization no complication have been found. In conclusion, we certified that excimer laser has been applied in special situation (complex lesions) with high rate of success than conventional angioplasty but these results will require further studies.

Comparative long-term results of laser-assisted balloon angioplasty and atherectomy in the treatment of peripheral vascular disease

BACKGROUND

Early results of laser-assisted balloon angioplasty (LABA) and peripheral directional atherectomy (PDA) are encouraging. The true value of these procedures has remained in doubt, however, because of the absence of data on long-term objective patency rates.

PATIENTS AND METHODS

From August 1988 through October 1993, LABA and PDA were performed on 151 limbs of 124 patients. Presenting symptoms were mild-to-severe claudication in 128 limbs (63 LABA, 65 PDA) and rest pain or necrosis in 23 (7 LABA, 16 PDA). Seventy-seven percent of the atherosclerotic lesions were localized in the iliofemoral tract (77% LABA, 76% PDA). Seventy limbs were treated with LABA and 81 with PDA.

RESULTS

Initial hemodynamic and arteriographic success was achieved in 46 LABA limbs (66%) and 75 PDA limbs (93%) (P < 0.002). Mean follow-up was 16 +/- 2 months after LABA and 18 +/- 1 months after PDA. During this time, 32 failures were recorded in limbs treated with LABA, and 29 in limbs treated with PDA. The patency rate at 40 months was 23% in the LABA group and 45% in the PDA group (P < 0.005). Patency rates were not affected by the length or site of the arterial lesion or the runoff score.

CONCLUSIONS

PDA had a better long-term patency rate than LABA, but long-term results were dismal with both techniques. PDA appears to have a limited role and LABA no role in the treatment of lower extremity occlusive disease.

Excimer laser coronary angioplasty

Excimer laser angioplasty has evolved from a difficult experimental procedure to a more refined intervention with flexible catheters, well-defined indications, and consistent results for certain lesion types such as aortoostial stenosis, total occlusions, and certain saphenous vein graft lesions. This article reviews the current clinical results with excimer laser angioplasty, discusses the procedural technique and indications, and emphasizes the need for rigorous comparison of excimer laser angioplasty with alternative approaches for patients with coronary artery disease.

[Laser-assisted angioplasty in chronic obliterative arteriopathies of the lower limbs. The authors' personal experience]

The laser represents one of the most interesting new methods of vascular surgery. As for laser-assisted angioplasty, the major clinical experience has come with Nd: Yag and Argon lasers. The authors comment on the 1989-1992 series of cases consisting of 51 arteries recanalized with a Nd:Yag laser--the patients were 42 men and 9 women, their mean age being 56.6 years. Four iliac obliterations, 36 femoropopliteal and 11 popliteotibial obliterations were treated surgically, according to the single anatomical radiologic circumstances. The immediate results showed 41 recanalizations (80.4%) 3 perforations (5.9%), 6 dissections (11.8%) and 2 distal emboli (3.9%). The long-term results, with a follow-up period ranging 6 months to 4 years (average: 1.8 years), were investigated with seriated c.w. Doppler, Doppler US and digital venous angiography and showed, in 34 examined patients, 22 patencies (64.7%), 8 stenoses > 50% (23.5%) and 3 occlusions (11.8%). These findings prove the value of laser-assisted--both percutaneous and surgical--angioplasty in the treatment of arterial occlusions both alone and combined with surgery. The results, whose positivity comes also from an eclectic interaction with surgery, and mostly from a systematic enhancement of the laser channel with balloon angioplasty, could be markedly improved upon by means of more selective and effective equipment.

Predictors of outcome of percutaneous excimer laser coronary angioplasty of saphenous vein bypass graft lesions. The Percutaneous Excimer Laser Coronary Angioplasty Registry

A total of 495 patients underwent treatment with excimer laser angioplasty for 545 saphenous vein graft stenoses. Clinical success was achieved in 455 of 495 patients (92%), as indicated by < or = 50% residual stenosis at every target lesion and no complication during hospitalization. At least 1 in-hospital complication occurred in 30 of 495 patients (6.1%): death (1.0%), bypass surgery (0.6%), and Q-wave (2.4%) or non-Q-wave (2.2%) myocardial infarction. Relative risk analysis showed that ostial lesions (n = 65) tended to have higher clinical success (success rate = 95%, adjusted odds ratio [OR] = 2.1 [95% confidence interval (CI) 0.62, 6.88]; p = 0.24) and lower complications (complication rate = 0%, OR = 0.10 [CI 0.01, 0.79]; p = 0.03) than lesions in the body of the vein graft. Lesions > 10 mm (n = 131) had lower success (success rate = 84%, OR = 0.30 [CI 0.16, 0.56]; p = 0.001) and higher complications (complication rate = 12%, OR = 3.3 [CI 1.6, 6.6]; p = 0.004) than discrete lesions. Lesions in small vein grafts < 3.0 mm (n = 76) tended to have increased success (success rate = 94%, OR = 1.55 [CI 0.70, 3.44]; p = 0.39) and lower complications (complication rate = 2.2%, OR = 0.31 [CI 0.10, 0.94]; p = 0.03). Thus, excimer laser-facilitated angioplasty has the most favorable outcome for discrete lesions located at the ostium of all grafts and in the body of smaller saphenous vein grafts.(ABSTRACT TRUNCATED AT 250 WORDS)

Pseudoaneurysm following successful excimer laser coronary angioplasty of a restenotic left internal mammary artery graft ostial lesion

Although significant left internal mammary artery graft ostial stenosis is extremely rare, the clinical importance can be profound. In this report we describe a case in which a restenotic left internal mammary artery graft ostial lesion was successfully opened with excimer laser coronary angioplasty. A resulting pseudoaneurysm spontaneously closed after conservative therapy.