Herz

, Volume 22, Issue 6, pp 299–307

Laserangioplastie und -rekanalisation

  • M. Haude
  • D. Welge
  • L. Koch
  • T. Roth
  • J. Ge
  • D. Baumgart
  • R. Erbel
Interventionelle Kardiologie 1997—Perspektiven für die Zukunft

Zusammenfassung

Die perkutane transluminale Koronarangioplastie ist auch 20 Jahre nach ihrer Einführung durch Andreas Grüntzig die Standardintervention zur Behandlung der koronaren Herzerkrankung. Der Hauptwirkmechanismus liegt in einer plastischen Verformung der obstruierenden Plaque. Hiermit assoziiert sind Akutkomplikationen wie symptomatische Dissektionen und Koronarverschlüsse sowie die Ausbildung von Rezidivstenosen. Um diese Limitationen zu überwinden, sind Alternativtechniken entwickelt worden, die primär die obstruierende Plaque abtragen sollen. Eine solche Alternativtechnik ist neben der Hoch- und Niedrigfrequenzrotationsangioplastie, der direktionalen Atherektomie, dem transluminalen Extraktionskatheter und der Ultraschallangiopastie auch die Laser-(Light Amplification by Stimulated Emission of Radiation-) Angioplastie. Die Excimer-Laserangioplastie unter Verwendung von 308 nm XeCl hat sich heute in der klinischen Anwendung durchgesetzt. Dieser gepulste Kontaktlaser führt innerhalb von <200 μs zur Entstehung von Dampfblasen, die eine explosionsartige Veränderung der Plaque bewirken. Die Indikation für die 308-nm-XeCl-Excimer-Laserangioplastie wurde in diffusen und langstreckigen Koronarstenosen bzw.-verschlüssen gesehen. Trotz vielversprechender Anwendungen konnte die 308-nm-XeCl-Excimer-Laserangioplastie im Vergleich zur koronaren Ballonangioplastie keine besseren Akut- und Langzeitergebnisse in der Behandlung dieser Koronarläsionen aufzeigen («Amsterdam-Rotterdam-[AMRO-]» und «Excimer-Rotational-Balloon-Angioplasty-Comparison-[ERBAC-]»Studien), so daß diese Technik hierbei nicht mehr sehr häufig verwendet wird. Erst im Rahmen der Behandlung von Instentrestenosen, die eine exzessive Neointimabildung darstellen, wurde das Konzept der Plaqueabtragung mittels 308-nm-XeCl-Excimer-Laserangioplastie erneut aufgegriffen. Die «Laser-Angioplasty-of-Restenosed-Stents-(LARS-)»Studie hat die Anwendbarkeit dieses Konzeptes verdeutlichen können. Mit der Verfügbarkeit von Laserdrähten ist eine neue Option zur Behandlung von chronischen Gefäßverschlüssen hinzugekommen. In der «Total-Occlusion-Trial-with-Angioplasty-assisted-by-Laser-guidewire-(TOTAL-)»Studie konnte hiermit eine erfolgreiche Passage durch chronisch verschlossene Gefäße in bis zu 66% der Fälle erzielt werden. Die Langzeitergebnisse stehen noch aus, um einen endgültigen Stellenwert dieser aufwendigen und auch teuren Interventionstechnik zu definieren. Technische Weiterentwicklungen und Verbesserungen in der Vorgehensweise, wie zum Beispiel Kochsalzspülung während der Laseranwendung, das Konzept der Lichthomogenisierung am Katheterende und die sogenannte «sanfte» Laserangioplastie sollen helfen, diese Technik sicherer und effektiver zu machen.

Schlüsselwörter

Laserangioplastie Excimer PTCA Komplikationen Instentrestenose Chronischer Koronarverschluß 

Laser angioplasty and laser recanalization

Summary

Percutaneous transluminal coronary balloon angioplasty (PTCA)still is the most frequently applied interventional technique for treatment of coronary artery disease. Plastic deformation of the obstructive plaque with creation of splits, intimal tears and dissections is the main mechanism of PTCA for lumen widening. As a result, acute complications due to flow limiting dissections and acute vessel closure can unpredictably occur resulting in myocardial infarction, urgent bypass surgery and death. Furthermore, long-term success of PTCA is limited by restenosis. In order to overcome these limitations of PTCA, alternative interventional techniques were developed, which instead of deforming the obstructive plaque ablate this tissue. These techniques include high and low speed rotational angioplasty, directional atherectomy, the transluminal extraction catheter, ultrasound angioplasty and laser (Light Amplification by Stimulated Emission of Radiation) angioplasty. 308 nm XeCl excimer laser angioplasty today is the laser technique of choice for clinical application. This pulsed laser requires direct contact to the obstructive plaque. It creates fast (<200 μs) expanding gas bubbles which induce plaque ablation. Main indications for 308 nm XeCl excimer laser angioplasty are diffuse and long coronary lesions and total coronary occlusions. Despite promising initial results this technique showed no better acute and long-term results in comparison to PTCA for the treatment of these types of lesions („Amsterdam-Rotterdam” Study, „Excimer Rotational Balloon Angioplasty Comparison” Study). As a result, this interventional technique was rarely applied for patient treatment. More recently, the concept of plaque ablation by 308 nm XeCl excimer laser angioplasty was renewed for the treatment of in-stent restenosis. This indication is being investigated in the „Laser Angioplasty of Restenosed Stents” trial. First results document the practicability and safety of this approach. Long-term results are awaited. With ongoing miniaturization, laser guidewires were developed for the recanalization of chronic total occlusions. The randomized multicenter „Total Occlusion Trial with Angioplasty assisted by Laser guidewire” Study documented a success rate of laser wire recanalization in up to 66% in contrast to 47.5% for mechanical wires only. Long-term results are still awaited. Technical and procedural progress including saline flush during laser application, homogenous light distribution and the concept of smooth laser ablation is pushed foreward to make excimer laser angioplasty safer, more predictable and more effective.

Key words

Laser angioplasty Excimer PTCA Complications In-stent restenosis Chronic coronary occlusion 

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Copyright information

© Urban & Vogel 1997

Authors and Affiliations

  • M. Haude
    • 1
  • D. Welge
    • 1
  • L. Koch
    • 1
  • T. Roth
    • 1
  • J. Ge
    • 1
  • D. Baumgart
    • 1
  • R. Erbel
    • 1
  1. 1.Abteilung für Kardiologie, Zentrum für Innere MedizinUniversität-GHS EssenEssen

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