Excimer Coronary Laser Atherectomy During Percutaneous Coronary Intervention of Complex Lesions: Balloon Failures, Chronic Total Occlusions and Under-Expanded Stents
Over the last several decades, the average life span of an adult in the western world has increased. More elderly patients with more complex coronary lesions are therefore being treated with percutaneous coronary intervention (PCI) by interventional cardiologists, particularly in high volume PCI centres. Typically such lesions are calcified and frequently may be either non-crossable or non-dilatable with standard angioplasty balloons and techniques.
The evidence for treatment of chronic total occlusions (CTO) and achieving full revascularization is more robust in the current era, leading more operators to take on these challenging cases. CTOs occur more commonly in older patients and in those patients who have been previously treated with coronary artery bypass graft (CABG) surgery and are usually associated with at least moderate calcification. Development of the CTO PCI algorithm has seen major advances in techniques to achieve higher overall success rates with utilization of anterograde-dissection re-entry and retrograde approaches.
This review examines the role of excimer laser coronary atherectomy (ELCA) as an adjunctive technique during PCI of balloon failure cases and CTOs. ELCA will be examined in the context of the alternative techniques available and the potential utilization will be demonstrated in a number of clinical cases. The expanding experience of ELCA in the treatment of under expanded stents will also be discussed.
KeywordsPercutaneous coronary intervention PCI Interventional cardiology Calcified lesions Angioplasty balloon Chronic total occlusions CTO Revascularization Coronary artery bypass graft surgery CABG CTO PCI algorithm Anterograde-dissection Retrograde approach Excimer laser coronary atherectomy ELCA
- 1.National population projections 2010-based statistical bulletin. London: Office for National Statistics. 2011. Available from: http://www.ons.gov.uk/ons/dcp171778_235886.pdf.
- 2.Rana O, Moran R, O’Kane P, Boyd S, Swallow R, Talwar S, et al. Percutaneous coronary intervention in the very elderly (≥85 years): trends and outcomes. Br J Cardiol. 2013;20:27–31.Google Scholar
- 3.Fernandez JP, Hobson AR, McKenzie D, Shah N, Sinha M, Wells TA, Levy T, Swallow R, Talwar S, O’Kane P. Beyond the balloon: excimer coronary laser atherectomy used alone or in combination with rotational atherectomy in the treatment of chronic total occlusions, non-crossable and non-expansible coronary lesions. EuroIntervention. 2013;9:243–50.Google Scholar
- 5.Patel VG, Brayton KM, Tamayo A, Mogabgab O, Michael TT, Lo N, et al. Angiographic success and procedural complications in patients undergoing percutaneous coronary chronic total occlusion interventions. J Am Coll Cardiol Intv. 2013;6:128–36.Google Scholar
- 6.Morino Y, Abe M, Morimoto T, Kimura T, Hayashi Y, Muramatsu Y, et al. Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes: the J-CTO (multicentre CTO registry in Japan) score as a difficulty grading and time assessment tool. J Am Coll Cardiol Intv. 2011;4:213–21.CrossRefGoogle Scholar
- 7.Whitlow P, Burke NM, Lombardi WL, Wyman MR, Moses JW, Brilakis ES, et al. Use of a novel crossing and re-entry system in coronary chronic total occlusions that have failed standard crossing techniques: results of the FAST-CTOs (facilitated antegrade steering technique in chronic total occlusions) trial. J Am Coll Cardiol Intv. 2012;5:393–401.CrossRefGoogle Scholar
- 11.Wei-Hsian Y. Rotational atherectomy: an update. J Geriatr Cardiol. 2013;10:211–2.Google Scholar
- 12.Barbato E, Colombo A, Heyndrickx GY. Rotational atherectomy. In: Eeckhout E, Serruys PW, Wijns W, Vahanian A, Sambeek MV, De Palma R, editors. Percutaenous interventional cardiovascular medicine. The PCR-EAPCI textbook, vol. II. 1st ed. 2012; Minneapolis: Cardiotext Publishing.Google Scholar
- 21.Fang HY, Fang CY, Hussein H, Hsueh SK, Yang CH, Chen CJ, et al. Can a penetration catheter (Tornus) substitute traditional rotational atherectomy for recanalizing chronic total occlusions? In Heart J. 2010;51:147–52.Google Scholar
- 24.Ahmed WH, Al-Anazi MM, Bittl JA. Excimer laser-facilitated angioplasty for undilatable coronary narrowings: study of 39 patients from the percutaneous excimer laser coronary angioplasty (PELCA) multicentre registry in the PTCA balloon failure to cross or dilate indication. Am J Cardiol. 1996;78:1045–7.CrossRefPubMedGoogle Scholar
- 25.Shen ZJ, García-García HM, Schultz C, van der Ent M, Serruys PW. Crossing of a calcified “balloon uncrossable” coronary chronic total occlusion facilitated by a laser catheter: a case report and review recent four years’ experience at the thoraxcenter. Int J Cardiol. 2010;145:251–4.CrossRefPubMedGoogle Scholar
- 27.O’Kane P, Redwood S. Laser. In: Redwood S, Curzen N, Thomas M, editors. Oxford textbook of interventional cardiology. 1st ed. 2010; Kettering, Northants: Oxford University Press.Google Scholar
- 28.Haude M, Papalexandris M, Degen H. Laser therapy. In: Eeckhout E, Serruys PW, Wijns W, Vahanian A, Sambeek MV, De Palma R, editors. Percutaenous interventional cardiovascular medicine. The PCR-EAPCI textbook, vol. II. 1st ed. 2012; Minneapolis: Cardiotext Publishing.Google Scholar
- 29.Topaz O. Laser for CTO recanalization. In: Waksman R, Saito S, editors. Chronic total occlusions. 2nd ed. 2013; Hoboken: Wiley-Blackwell Publishers.Google Scholar
- 34.Deckelbaum LI, Natarajan MK, Bittl JA, Rohlfs K, Scott J, Chisholm R, et al. Effect of intracoronary saline infusion on dissection during excimer laser coronary angioplasty: a randomized trial. The percutaneous excimer laser angioplasty (PELCA) investigators. J Am Coll Cardiol. 1995;26:1264–9.CrossRefPubMedGoogle Scholar
- 42.Dixon SR, Henriques JP, Mauri L, Sjauw K, Civitello A, Kar B, et al. A prospective feasibility trial investigating the use of the impella 2.5 system in patients undergoing high-risk percutaneous coronary intervention (the protect I trial): initial U.S. experience. J Am Coll Cardiol Intv. 2009;2:91–6.CrossRefGoogle Scholar