Use of Laser When the Balloon Cannot Cross Cases and chronic total occlusion Itsik Ben-Dor, MD, Lowell Satler, MD, Augusto Pichard ,MD, Ron Waksman, MD Washington Hospital Center

I have no real or apparent conflicts of interest to report. Itsik Ben-Dor, MD 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 RX and OTW (Concentric) 1.4mm RX (Concentric) 1.7mm RX (Eccentric & concentric) 2mm RX (Eccentric & concentric) Proximal Coupler Distal Tip

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

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 Size of the Vapor Bubble is dependent upon the fluency delivered  Photochemical  Photothermal  Photomechanical Dissolving molecular bonds Produces photo-thermal energy Creating kinetic energy

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 guide wire 2. Ostial lesion 6. Moderately calcified lesion 3. Eccentric lesions 7. Balloon refractory lesions 4. Long lesions 20mm 8. In stent restenosis * Acute myocardial infarction

Guiding support Confirm distal bed Saline flush 60/40----60/80----80/80

Washington Hospital Center(2000-2005)

Washington Hospital Center(2005-2011)

Calcified lesion and chronic total occlusion Baseline characteristics Calcified lesion N=25 Chronic total occlusion N=32 Age 71.2±13.2 62.1±11.5 Male 14(56%) 23(71.9%) Hypertension 22(88%) 29(90.6%) Diabetes 9(36%) 15(46.9%) Hyperlipidemia 23(92%) 31(96.9%) Peripheral vascular disease 2(8%) 9(28.1%) Renal failure 15(60%) 18(56.3%) Prior PCI 10(40%) 9(31.0%) Prior CABG 7(28%) 5(15.6%) Ejection fraction 54±11% 45±17%

Chronic total occlusion Procedural data Calcified lesion N=25 Chronic total occlusion N=32 Procedure length (min) 94.4±29.4 106.1±36.4 Contrast (ml) 226.9±115.4 206.9±78.5 Left main LAD CX RCA 1(4%) 5(20%) 4(16%) 15(60%) 5(15.6%) 6(18.7%) 21(65.6%) Stent DES Diameter Length 21(84%) 12(48%) 2.9±0.3 19.1±4.6 26(81.2%) 23(71.8%) 2.8±0.3 24.8±6.9 Laser 0.9mm 1.4mm 1.7mm 2.0mm 23(92%) 27(84.3%) 3(9.3) 1(3.1%) Laser success 20(80%) 30(93.7%) Angiographic success 29(90.1%) Balloon non crossable lesions 14(56%) Concomitant Rota ablation Before After 2(6.2%) IABP 4(16.6%)

Calcified lesion and chronic total occlusion In hospital complication Calcified lesion N=25 Chronic total occlusion N=32 Dissection 3(9.3%) Perforation 1(4%) 1(3.1%) No reflow 2 (8%) Thrombus formation Death Q wave MI Max CKMB (ng/ml) 12.2±22.3 9.8±18.2 Troponin (ng/ml) 11.8±41.0 4.7±11.3 TLR/TVR CABG Stent thrombosis Renal failure 1(4.2%) In hospital dialysis TIA/CVA Vascular complication Major bleeding 2(6.2%)

CASE I- Balloon refractory lesion Clinical history 73 female, diabetes Insulin treatment She has developed progressive S.O.B and chest pain Nuclear stress test –Inferior ischemia

CASE I- Balloon refractory lesion

CASE I- Balloon refractory lesion

CASE I- Balloon refractory lesion Guide – 7F HS Guide wire – Fielder XT Balloon 1.5/8mm APEX did not cross FineCross did not cross (exchange for ROTA wire) ?

CASE I- Balloon refractory lesion 0.9mm OTW Repetition rate of 40Hz and a fluence of 60 mJ/mm2 and then increased to a repetition rate of 80Hz with a fluence of 80 mJ/mm2

CASE I- Balloon refractory lesion Rotablator wire was passed through the OTW laser catheter 1.5mm Rota burr

CASE I- Balloon refractory lesion Balloon 3/12mm Voyager Stent- Xience 3/15mm

CASE II- Chronic total occlusion Clinical History 57 years old male Presented with chest pain He underwent a stress test that was positive –inferior wall PMH: Hyperlpidemia Hypertension

CASE II- Chronic total occlusion Guiding catheter 7F 3DRight

CASE II- Chronic total occlusion CTO 2.1f 135cm Tornus Guide wire.014in MiracleBros 6

CASE II- Chronic total occlusion Guide wire.014in Confianza Balloon 1.5mm 15mm Apex did not cross An Excimer Laser .9mm Did mot cross

CASE II- Chronic total occlusion An anchoring balloon and Excimer Laser .9mm Drug Eluting Stent 2.5mm 30mm Cypher

Summary Laser is a very useful tool in complex coronary intervention including calcified, CTO, SVG, AMI and unexpanded stent Laser is safe and effective for balloon refractory lesions Laser is safe and effective for total occlusions crossable by guide wire

Summary Laser can also be used as an adjunct to facilitate rotational atherectomy calcified lesion – rotational atherectomy better but: -Rotational atherectomy hard to manipulate the guide wire -Can not protect side branch -Can not in AMI -In stent there is risk distal embolization of microparticles