1. 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

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

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

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

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

6. 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

7. 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

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

9. Balloon refractory lesion
Case 1
Balloon refractory lesion

10. 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

11. Diagnostic coronary angiography

12. Diagnostic coronary angiography

13. Diagnostic coronary angiography

14. 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

15. Intervention
Rotational Atherectomy 1.25mm did not cross

16. 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

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

18. Intervention

19. Chronic total occlusion cx
Case 2
Chronic total occlusion cx

20. 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

21. Diagnostic Catheterization

22. Chronic total occlusion CX

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

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

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

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

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

28. Chronic total occlusion RCA
Case 3
Chronic total occlusion RCA

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

30. PCI CTO RCA
Guiding catheter 7F 3DRight

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

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

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

34. PCI CTO RCA
Balloon 1.5/15mm
Post balloon

35. PCI CTO RCA
Drug Eluting Stent 2.5mm 30mm Cypher

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

37. 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