Laser Angioplasty for Chronic total occlusion and balloon refractory lesions Ben-Dor Itsik, MD Lowell Satler, MD Ron Waksman,MD Augusto Pichard, MD Washington Hospital Center

Itsik Ben-Dor, MD DISCLOSURES I have no real or apparent conflicts of interest to report.

What it is Excimer Laser Coronary Atherectomy (ELCA)? Light Amplification Stimulated Emission Radiation

Catheter Overview 0.9mm Rapid Exchange (RX) Proximal Coupler Distal Tip

Excimer Laser Is a form of ultraviolet light. A cold laser which does not burn or cut. Vaporizes tissue by breaking bonds between molecules.

Excimer Laser Coronary Atherectomy (ELCA) An excimer (originally short for excited dimer) excimers are often diatomic and are formed between two atoms or molecules that would not bond if both were in the ground state. The lifetime of an excimer is very short. An excimer laser typically uses a combination of an inert gas xenon and a reactive gas chlorine. Under the appropriate conditions of electrical stimulation((induced by an electrical discharge or high-energy electron beams), a pseudo-molecule called an excimer is created and very quickly disassociates back into two unbound atoms -give rise to laser light in the ultraviolet range (wavelength 308nm)  Photochemical  Photothermal  Photomechanical Dissolving molecular bonds Produces photo-thermal energy Creating kinetic energy

Excimer Laser Coronary Atherectomy (ELCA) Ultraviolet energy photoablates arterial blockages into particles most of which are smaller than a red blood cell and are absorbed into the blood stream without embolizing distal capillaries The energy pulses create a forward acting vapor bubble that can weaken the very fibrotic proximal cap, vaporization of thrombi, ablation of underlying atherosclerotic plaque. The layer removed by each pulse I about 10 µm thick The Size of the Vapor Bubble is dependent upon the fluency delivered 40 hz 80 hz

Laser as the last option Excimer Laser Coronary Atherectomy (ELCA) Spectranetics CVX -300, Spectranetics, Colorado Springs, CO) Wavelength 308 nm Pulse duration 125-200 nS Fluence 30-80 mJ/mm2 Repetition Rate 25-80* Hz Catheter-diameter 0.9 - 2.5 mm 6 FR- compatible Approved by FDA for coronary 1992 for: 1. Dubulking of SVG 5. Total occlusions crossable by guidewire 2. Ostial lesion 6. Moderately calcified lesion 3. Eccentric lesions 7. Balloon refractory lesions 4. Long lesions 20mm 8. In stent restenosis 9. Acute myocardial infarction Laser as the last option

Balloon refractory lesion Case 1 Balloon refractory lesion

CLINICAL HISTORY 82 years female who admitted with dizziness and syncope post viral gastroenteritis. On ECG she had rapid atrial fibrillation with prolong post conversion sinus pauses. She had positive cardiac enzyme PMH: Hypertension Hyperlipidemia

Diagnostic coronary angiography

Diagnostic coronary angiography

Diagnostic coronary angiography

Intervention The decision was to proceed with PCI of RCA Guiding catheter 8F HS, SH Guide wire BMW Balloon 2.5/20 Sprinter did not cross Balloon 1.5/15 Sprinter did not cross

Intervention Rotational Atherectomy 1.25mm did not cross

Intervention The 0.9 Excimer Laser Start off with high energy and rates 60/40 and increase to 80/80 Vitesse COS 0.014” compatible 61micron fibers Vitesse COS Beam Profile 0.9 mm Vitesse COS Than Rotational atherectomy 1.25mm and 1.5mm

Intervention 2.5/20mm Sprinter 2.5/14mm Micro Driver

Intervention

Chronic total occlusion cx Case 2 Chronic total occlusion cx

CLINICAL HISTORY 58 years old male Known CAD, s/p PCI RCA and LAD 1999 Admitted to diagnostic Cath due to positive thallium scan- ischemia in inferior wall and chest pain PMH: Hyperlpidemia HTN Tobacco abuse

Diagnostic Catheterization

Chronic total occlusion CX

Chronic total occlusion CX IVUS LAD and Left main LV LMCA: near normal LAD stent: no intimal hyperplasia Mid and distal LAD: 2-2.5 mm with diffuse non significant disease.

Chronic total occlusion CX Venture catheter was used to direct the Miracle 6 guide wire

Chronic total occlusion CX 1.5 OTW balloon did not cross 0.9 Excimer Laser did not cross, until fluence 80/80 was used

Chronic total occlusion CX IVUS of CX after laser+1.5 balloon

CX after 2 drug eluting stents deployed at 24 atm Final Results CX after 2 drug eluting stents deployed at 24 atm

Chronic total occlusion RCA Case 3 Chronic total occlusion RCA

CLINICAL HISTORY 57 years old male Presented with chest pain He underwent a stress test that was positive –inferior wall PMH: Hyperlpidemia Hypertension

PCI CTO RCA Guiding catheter 7F 3DRight

Guide wire.014in MiracleBros 6 PCI CTO RCA CTO 2.1f 135cm Tornus Guide wire.014in MiracleBros 6

Guide wire.014in Confianza PCI CTO RCA Balloon 1.5mm 15mm Apex did not cross Guide wire.014in Confianza

An anchoring balloon and Excimer Laser .9mm PCI CTO RCA An Excimer Laser .9mm Did mot cross An anchoring balloon and Excimer Laser .9mm

PCI CTO RCA Balloon 1.5/15mm Post balloon

PCI CTO RCA Drug Eluting Stent 2.5mm 30mm Cypher

IVUS post balloon and laser PCI CTO RCA IVUS post balloon and laser IVUS post stenting

Summary: Laser is a very useful tool in complex coronary intervention Laser is safe and effective for balloon refractory lesions Laser is safe and effective for total occlusions crossable by guide wire