Laser Atherectomy for Balloon Failure in Chronic Total Occlusion

Abstract

SummaryExcimer laser coronary atherectomy (ELCA) is based on ultraviolet energy and is capable of disintegrating atheroma, without burning or grossly fragmenting it. ELCA has proven effective in the percutaneous treatment of a variety of complex lesions, including chronic total occlusions (CTO) and severely calcified lesions, in case of balloon failure-tocross or failure-to-expand. Here we present a case of a successful CTO recanalization with ELCA after balloon failure, review the literature on this topic, and present an algorithm outlining the management of this challenging clinical scenario. (Int Heart J 2014; 55: 546-549) Key words: Laser-assisted angioplasty, Coronary occlusion, Percutaneous coronary intervention E xcimer laser coronary atherectomy (ELCA) has been proven to be effective for the percutaneous treatment of a variety of complex lesions, including chronic total occlusions (CTO) and severely calcified lesions when conventional ballooning techniques have failed, stent restenosis, saphenous vein graft debulking, and thrombus vaporization in acute coronary syndromes. 1)ELCA has been shown to be both safe and effective for plaque modification in severely calcified plaques and CTO, in which balloons have failed to cross or expand the lesion. 2,3)However, when tested against balloon angioplasty, stenting and rotational atherectomy (RA), ELCA failed to show superiority for efficacy and safety. 4,5) Subsequently, especially after the introduction of drug-eluting stents (DES), use of ELCA has become quite limited. Nevertheless, in well-defined clinical settings ELCA still represents a valid -and sometimes the only -alternative. Here, we present the case of a successful CTO recanalization with ELCA, after failure to cross with multiple coronary devices. Case ReportA 34-year-old man presented to a referring hospital's emergency room with multiple episodes of prolonged chest pain at rest. His prior medical history included heterozygosis for Factor V Leiden mutation with documented pulmonary embolism 4 years earlier. He also had an important family history of premature coronary artery disease (CAD). After screening tests ruled out pulmonary embolism and despite a lack of dynamic EKG changes, a diagnosis of non-ST elevation myocardial infarction motivated the decision to refer the patient for cardiac catheterization. Prior to transfer to our institution, aspirin and clopidogrel were preloaded. Coronary angiography showed left dominance and two-vessel disease ( Figure 1): a thrombotic, 85%, type B2, bifurcation lesion in the proximal circumflex (Medina 1, 0, 1), followed by a 60%, diffuse, type C lesion in the mid circumflex; and a CTO of the mid left anterior descending (LAD) artery, which received Werner collateral connections grade 2 from the right coronary artery (RCA) and circumflex artery, through septal and epicardial vessels. Thrombectomy in the circumflex was performed. Balloon dilatation was followed by the implantation of two Integrity TM (Medtronic Inc., Minneapolis, MN) bare-metal stents (a 3.0 ...

Calcium Modification Techniques in Complex Percutaneous Coronary Intervention

“…While there are no large scale trial data for its use, increasing case series data suggest that ELCA can be employed safely and effectively in a number of scenarios with fibro-calcific disease including chronic total occlusion recanalization, debulking native, and vein graft disease and in the presence of peri-stent calcium in the setting of in-stent restenosis. [62][63][64][65][66][67] While the routine use of ELCA is undertaken with a saline infusion, aiming to remove both blood, and contrast media from the vessel. Both blood and iodinated contrast media contain nonaqueous cellular macromolecules, such as proteins which absorb the majority of delivered laser energy creating microbubbles which form at the site of energy delivery, increasing the likelihood of intimal dissection.…”

Excimer laser coronary atherectomy for uncrossable coronary lesions. A multicenter registry

“…12 ELCA appears particularly appealing to deal with uncrossable lesions in the context of CTOs, 13 as indicated by the high prevalence of such lesion subset in our series (46%) and supported by prior literature. 14,15 The prevalence of balloonuncrossable lesion is as high as 9% in CTOs, 16 and in such setting losing distal wire access to the vessel is not an option, thus inducing the operator to favor ELCA over rotational or orbital atherectomy. In line with previous studies not exclusively targeted uncrossable lesions (Table 5), the success rate in our series was high taking into account the complexity of the lesions and the beforehand high probability of failure with the conventional technology.…”

Prevalence, indications and management of balloon uncrossable chronic total occlusions: Insights from a contemporary multicenter US registry

“…This is not surprising given that the subintimal space provides less resistance as compared with intimal planes, and highlights a potential advantage of dissection/re-entry strategies in those lesions. Indeed dissection and re-entry has been used as an advanced technique for treating balloon uncrossable lesions when other attempts failed [17][18][19]. An increased frequency of balloon uncrossable lesions may be a potential downside of the higher antegrade wiring escalation crossing success that can be achieved with the recently introduced highly torquable composite core guidewires [20].…”