More than any other recent approach to revascularization, laser-assisted angioplasty has aroused great interest [l], hope [2], and hype [3]. Already falling short of expectations too high [4] and involved in a controversy on its exact clinical role ("has laser finally found its niche?" [5]), this expensive technology is linked to a relatively high rate of complications [ 6 ] . Critics maintain that the real issue is whether laser-facilitated angioplasty offers anything over conventional balloon angioplasty other than greatly increased expense and increased complications [7]. Others insist that a prospective randomized trial with convincing results would be necessary in order for laser angioplasty to gain credibility. Additional negative aspects by which this procedure is judged are the financial interests and conflict of interest among leading laser investigators [8]. This leads to doubts concerning accuracy of data on laser as presented in national scientific meetings. The audience often encounters laser session chairmen and presenters who are investors as well as investigators. Despite several large-scale studies [9-111 reporting high clinical success rates in complextype lesions, a sense of skepticism concerning laser angioplasty is commonly found among interventional cardiologists."Is there anything balloons can't do?" asks/postulates one authority [ 121. Indeed, considering the impressive performance of balloon angioplasty and debulking devices less expensive than laser such as directional atherectomy [ 131 and rotational atherectomy [ 141, a question arises as to whether coronary laser angioplasty still has a role in the interventional armamentarium. The answer is in the affirmative and for three main reasons: (1) conceivably, plaque mass removal is preferred over plaque displacement; (2) clinically, where balloon fails, laser can excel [11,15,16], e.g., calcified stenoses, thrombotic lesions, and chronic total occlusions; and (3) a new niche application emerges for laser: thrombolysis in patients who fail to respond to thrombolytic agents or in whom these medications are contraindicated. Removal of thrombus by laser without significantly damaging the arterial wall may well be preferable over other mechanical modalities [17][18][19]. With a belief in the potential of laser, yet bearing in mind its limitations, the aim of this communication is to discuss issues pertaining to laser success as well as its failure and to provide suggestions to improve the first and reduce the latter.
LASERSUCCESSVERSUS LASERFAILURETo date, more than 5,000 patients worldwide have been treated by the Food and Drug Administration (FDA)-approved excimer laser systems (pulsed-wave, gas medium, ultraviolet optical range; 308 nm), and almost 2,000 patients by the investigational ho1mium:YAG laser (pulsed-wave, solid-state, midinfrared optical range; 2,100 nm). Investigators in both excimer [9] and holmium [ 1 11 registries use the nonstringent criterion of "complete crossing of the lesion and reduction in diameter stenosis by at lea...
