1. Use of Laser When the Balloon Cannot Cross
Cases - Excimer Laser for Complex Coronary Artery Lesions
Itsik Ben-Dor, MD, Salem Bader, 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. Novel use of a high-energy excimer laser catheter for calcified and complex coronary artery lesions.
Prospective multicenter study that examined of 100 calcified and/or balloon-resistant lesions (in 95 patients) that were treated with 0.9mm X-80 excimer laser catheter
Luc Bilodeau, MD, et al. Catheter Cardiovasc Interv Jun;62(2):

15. Success:Laser 92%, Procedural 93%, Clinical 87%
Novel use of a high-energy excimer laser catheter for calcified and complex coronary artery lesions.
Lesions meeting inclusion criteria
Crossing success of balloon failed lesions
is 94%
n=100
n=5
Abandoned lesions
(31/33).
n=95
Fail n=29
Standard laser parameter therapy
Increased laser parameter therapy
Success
n=21
Fail
n=8
Success
n=66
Adjunctive therapy
Success:Laser 92%, Procedural 93%, Clinical 87%
Luc Bilodeau, MD, et al. Catheter Cardiovasc Interv Jun;62(2):

16. Novel use of a high-energy excimer laser catheter for calcified and complex coronary artery lesions.
Complications
n (%)
SLT (n = 66)
ILT (n = 29)
Laser complications
3 (5)
2 (7)
Dissection
Perforation
Spasm
No reflow/embolization
Thrombus formation
Acute closure
X-80 (n=95)* n %
Laser success 87
92%
Procedural success 89
93%
Clinical success 83
86%
In-hospital MACE 8 8%
* ILT, increased laser therapy; SLT, standard laser therapy.
X-80 laser catheter is ideal for treating: CTOs, calcified lesions, and balloon-resistant lesions (the laser crossed 92% of the time)
X-80 crossed 94% of lesions which previously failed balloon angioplasty
Data suggests that laser may also change the compliance of plaque, allowing for improved lesion management (i.e. 4 lesions which were previous balloon failures were adequately treated with balloons and stents after lasing with the X-80, despite the the fact that the laser catheter had not entirely crossed the target lesion)
Luc Bilodeau, MD, et al. Catheter Cardiovasc Interv Jun;62(2):

17. Cases

18. 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

19. CASE I- Balloon refractory lesion

20. CASE I- Balloon refractory lesion

21. 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) ?

22. 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

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

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

25. CASE II- 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

26. CASE II- Balloon refractory lesion
Guiding catheter 8F HS, SH
Guide wire BMW
Balloon 2.5/20 Sprinter did not cross
Balloon 1.5/15 Sprinter did not cross

27. CASE II- Balloon refractory lesion
Rotational Atherectomy 1.25mm did not cross

28. CASE II- Balloon refractory lesion
The 0.9 Excimer Laser
Start off with high energy and rates 60/40 and increase to 80/80
Than Rotational atherectomy 1.25mm and 1.5mm
2.5/20mm Sprinter
2.5/14mm Micro Driver

29. CASE II- Balloon refractory lesion

30. CASE III- Chronic total occlusion
58 years old male
Known CAD, s/p PCI RCA and LAD 1999
Admitted due to chest pain and positive thallium scan- ischemia in inferior wall
PMH:
Hyperlpidemia
HTN
Tobacco abuse
Clinical History

31. CASE III- Chronic total occlusion

32. CASE III- Chronic total occlusion
Venture catheter was used to direct the Miracle 6 guide wire

33. CASE III- Chronic total occlusion
1.5 OTW balloon did not cross
0.9 Excimer Laser did not cross, until fluency 80/80 was used

34. CASE III- Chronic total occlusion
IVUS of CX after laser+1.5 balloon

35. CASE III- Chronic total occlusion
CX after 2 drug eluting stents deployed at 24 atm

36. CASE IV- 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

37. CASE IV- Chronic total occlusion
Guiding catheter 7F 3DRight

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

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

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

41. 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

42. 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

43. CASE V- Under expanded stents with recurrent restenosis
Clinical History
64-year-old male
9 years ago PCI prox CX (3.0/24 BMS)
Seven months later, recurrent anginA-Diffuse ISR rotational atherectomy, POBA, and Irdium-192 radiation to 14 pGy, and a 3.0-mm BMS.
3 years ago, symptomatic ISR: PCI 3mm TAXUS
Now mild exertional angina reappeared and lateral ischemia

44. CASE V- Under expanded stents with recurrent restenosis
3 stents not expanded
2 mm Laser
3.69 mm2
Quantum 28 atm

45. CASE V- Under expanded stents with recurrent restenosis

46. CASE VI- Saphenous vein graft
Clinical History
71-year-old female
History of hypertension, hyperlipidemia, diabetes mellitus, and CABG in 2005
Admitted after developing hypotension and chest pain during nuclear stress testing. The scintigraphy revealed extensive ischemia involving the anterior, inferior and lateral walls.

47. CASE VI- Saphenous vein graft
0.9 mm Laser D
distal protection device (Spider FX 5.0-mm)

48. CASE VI- Saphenous vein graft

49. CASE VI- Saphenous vein graft

50. CASE VII- Acute myocardial infarction
Clinical History
80-year-old male
History of diabetes, hyperlipidemia, and prior CABG, and mechanical aortic valve replacement (1998).
1 year ago PCI SVG to the LAD Cypher 3.0/28-mm.
Presented 1with acute onset of chest pain and ST-segment elevation in the precordial leads

51. CASE VII- Acute myocardial infarction
1.4 mm Laser
repetition rate of 40 Hz and a fluence of 60 mJ/mm2

52. CASE VII- Acute myocardial infarction