Acute closure during coronary excimer laser angioplasty and conventional balloon dilatation: a comparison of management outcome and prediction

Abstract

Of 523 consecutive patients undergoing elective percutaneous transluminal coronary angioplasty (PTCA) and 83 patients treated with coronary excimer laser angioplasty (ELCA), 17 (3.3%) had in-laboratory occlusion following PTCA and 25 (30%) following ELCA; they were enrolled into a prospective study. Successful management (reopened vessel, patency at repeat angiography within 24 h, no death, no myocardial infarction (MI), no emergency bypass surgery) including repeat lasing, subsequent PTCA, use of intracoronary nitroglycerin or streptokinase was achieved in 24 (96%) of the 25 patients with acute occlusion during ELCA. An anterior MI occurred in one patient of the laser group. Repeat balloon dilatation was successfully performed in seven of the 17 patients (41%) with acute closure during PTCA. Among the 10 patients with persistent occlusion after PTCA, five developed a limited myocardial infarction (35%). One patient required emergency CABG, and died peri-operatively. Severe spasm prior to occlusion defined by a new coronary flow depression without evidence of dissection or thrombus showed a significant positive association with acute occlusion during ELCA (P = 0.0008). Thus, in contrast to occlusion during PTCA, subsequent balloon dilatation was successfully performed in the majority of patients with acute occlusion during ELCA, implying that different underlying mechanisms are responsible for this complication. In this limited patient group, occlusion after excimer laser angioplasty was much more frequent than closure during PTCA, but was infrequently associated with major events such as myocardial infarction or death.

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

“…Use of atherectomy and laser devices do not appear to increase safety by reducing abrupt closure rates. Rather, these devices were associated with an increased risk of abrupt closure that is consistent with findings in other studies [6,21,22]. In our investigation, these associations persisted after adjustment for other potential cofounding variables.…”

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

“…Rather, these devices were associated with an increased risk of abrupt closure that is consistent with findings in other studies [6,21,22]. In our investigation, these associations persisted after adjustment for other potential cofounding variables.…”

Mechanical thrombectomy options in complex percutaneous coronary interventions

“…Also of note were the rates of perforation (0.6%), dissection (5% with 3% being attributable to the laser), acute closure (0.6%), distal embolization (2.0%), and bleeding (3%), with laser therapy [29]. Studies in smaller laser volume centers have reported variable outcomes and adverse events, which may undermine the reliability of this technology [31–34]. Furthermore, one randomized trial using laser in addition to balloon angioplasty in unstable angina patients reported no difference in procedural success or outcome with laser use but a significant increase in procedural complications (18% vs. 3%; P = 0.0004), MI (4% vs. 0%; P = 0.04), and total in‐hospital MACE (10% vs. 4%; P = 0.08) with laser angioplasty [34].…”