1. 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

2. 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.

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

4. 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

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

6. 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

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

8. Guiding support
Confirm distal bed
Saline flush
60/ / /80

9. Washington Hospital Center(2000-2005)

10. Washington Hospital Center(2005-2011)

11. 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%

12. 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%)

13. 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%)

14. 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

15. CASE I- Balloon refractory lesion

16. CASE I- Balloon refractory lesion

17. 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) ?

18. 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

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

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

21. 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

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

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

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

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

26. 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

27. 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
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