1. The use of Laser for the treatment of coronary artery disease
Antonis Pratsos M.D
Director of Interventional Cardiology
Bryn Mawr Hospital
Bryn Mawr, PA
CRT 2010

2. DISCLOSURES
Antonis Pratsos, MD
Honoraria
Spectranetics Corporation

3. Overview Mechanism of action of laser
Indications and rationale for laser
Case reviews and clinical studies
Technical considerations
Conclusions
Questions

4. Ultraviolet vs. Infrared
The Wavelength Story
Ultraviolet vs. Infrared
193nm
2090nm
308nm
10600nm
Ultraviolet
Infrared
Surgical - Dental - Ophthalmic
Cardiovascular
To dissolve plaque
To cut tissue
To create holes in heart
Benefits of 308 nm:
Ablates only the tissue it touches - very precise action
interacts with the organic molecules in the cells
explodes cells from the inside out
low energy system - minimal side effects
Weaknesses of others:
Penetrates deeply into tissue - as much as a centimeter
Sometimes hard to control
Dehydrates and “cooks” tissue
Invites inflammatory response - very bad inside the vascular system
CO2
Excimer (CVX-300®)
Ho:YAG
Excimer (ophthalmology)

5. Laser mechanism of action

6. Why fire the laser ?!

7. 21st century PCI
Older, sicker, anatomically and clinically complex patients
DES
FAME
SYNTAX
Better strategies for DES delivery
Better strategies for PCI in AMI

8. Indications-ELCA Excimer Laser Coronary Atherectomy
Total occlusions
Failed balloon angioplasty
Moderately Calcified lesions
Ostial lesions
Long Lesions
Occluded Saphenous Vein Grafts
In-Stent Restenosis stainless steel stents prior to Brachytherapy

9. RCA occlusion, LAD collaterals via dual injections

10. Once wire across, unable to deliver 1. 5 balloon. Can we fix it
Once wire across, unable to deliver 1.5 balloon. Can we fix it? Yes we can!

11. Crossing Fielder XT- 1.5 balloon undeliverable, .9 laser

12. The Spectrum of Lumen Morphology in CTO - Clinical Challenges
Fibrotic plq:
Negative
remodelling
Small recanal.
channels
Large recanalization
channels
Proteoglycan-rich
Inflammation
Necrotic core
Calcification
Dr. Gregg Stone: Columbia Medical Center, Coronary Research Center 13

13. Final result after three long everolimus eluting stents

14. 0.9mm X-80 ELCA for Calcified and Complex Coronary Lesions
Luc Bilodeau, MD, et al. Novel Use of a High-Energy Excimer Laser Catheter for Calcified and Complex Coronary Artery Lesions. Catheterization and Cardiovascular Interventions (62: , 2004)
X-80 CROSSING RESULT FLOWCHART
Black: Study flowchart (n= # lesions)
Blue: # of balloon failures
Lesions meeting inclusion criteria
Notes:
Crossing success of balloon failed lesions
is 94%
n=100 (35)
n=5
Abandoned lesions (2)
(31/33).
n=95 (33)
Fail n=29
Standard laser parameter therapy (20)
Increased laser parameter therapy (13)
Success
n=21 (11)
Fail
n=8 (2)
Success
n=66 (20)
Adjunctive therapy
Success:Laser 92%, Procedural 93%, Clinical 87%

15. 45 year old male chronic stable angina for 1 year
45 year old male chronic stable angina for 1 year. Critical ostial LAD+ mid LAD CTO

16. Simultaneous Contralateral injections, successful wiring

17. Confirmation of wire position and angiogram after 0.9 laser

18. Final LAD angio post 3 DES

19. Saphenous Vein Grafts J. Bittl Data1: (1994)
495 Patients/545 SVG stenoses
Mean graft age yrs
92% Clinical Success
3% Embolization
2.4% QWMI/2.2%NQWMI
Death 1%
Ebersole data shows:
0% NQMI rate
0% angiographic embolization
2.3% CPK Rise >3x Normal
100% Success Rate
0% Death/Emergent CABG
6 Mo. TLR OF 6.9%
1D. Ebersole, Excimer Laser for Revascularization of Saphenous Vein Grafts; Lasers in Med. Sci :78-83
2D. Ebersole, Clinical App. For the Excimer Laser; CVR&R, June 1999
1J. Bittl et.al, Predictors of Outcome of percutaneous Excimer
Laser Coronary Angioplasty …..: AJC Vol 74, July 15, 1994

20. Sub-Totally Occluded SVG to LAD

21. X80 laser in Sub-Totally Occluded SVG to LAD- enabling DPD

22. Final SVG result

23. NSTEMI, Occluded SVG-OM1+2

24. LCx X-80@50-40. Retrograde wire and laser into SVG

25. Final result native LCx and SVG

26. Calcified LAD- incomplete balloon expansion

27. 1.4mm laser maximum settings

28. Full balloon expansion and DES

29. 93y lady-Critical distal LM/LAD/LCx bifurcation

30. Wiring of LAD and OM of Lcx and 0.9 laser into LAD and prox Lcx

31. 0.9/1.4/1.7 into LM/LAD and 0.9/1.4 into LCx-LM/LAD stent

32. Final LM result

33. GREECE: Global Revascularization & Evaluation of Excimer Laser In the Coronaries
Retrospective cohort of 101consecutive patients between January 2007 and December 2008 who underwent PCI utilizing laser ablation as a component of the procedure.
Endpoints: Laser Success, Procedural success, avoidance of MACE

34. Lesion Subsets as Indicators for ELCA
101 Patients with 107 Lesions of Multiple Type/Location
Long Lesion >20mm
39.3% (n=42)
Calcified Lesion
36.4% (n=39)
CTO Crossable by a Guidewire
22.4% (n=24)
Ostial Lesion
19.6% (n=21)
In Stent Restenosis
Bifurcation Lesion
14.0% (n=15)
Occluded/Degenerated SVG
4.7% (n=5)
Balloon Refractory Lesion
0.9% (n=1)
Other
9.3% (n=10)
NSTEMI
28.7% (n=29)
STEMI
13.9% (n=14)
Low EF (< 30%)
4.0% (n=4)

35. Results Pre Treatment mean %DS (n=107) 89.6% (±9.39)
Post ELCA mean %DS (n=104)
69.6% (±17.99)
PTA used Post ELCA (n=106)
81.1% (n=86)
Stenting used Post ELCA (n=107)
88.7% (n=95)
Stent Success (n=95)
99.0% (n=94)
Final %DS (mean)
3.9% (n=107)

36. Study Results 98.1% Laser Technical Success (n=105 lesions)
100% Success in CTOs crossable by a guidewire (n=24 lesions)
100% Procedural Success
Zero In-Hospital MACE
5% Overall Procedural SAE rate (n=5)
2% Laser related Procedural SAE (n=2)
3% PTA/Stent related Procedural SAE (n=3)

37. Laser in AMI Device options for AMI in 2009
Rationale for thrombo-ablation in AMI
Registries supportive of ELCA in AMI

38. Contemporary device choices for PCI in AMI
PTCA/Stent
Embolic protection devices
Distal EMERALD
Proximal PREPARE
Thrombectomy
Rheolytic AiMI
Passive X AMINE, EXPIRA , REMEDIA, PIHRATE TAPAS
Local drug delivery CRYSTAL AMI, COCTAIL
Laser CARMEL, EXTENDED FAMILI, Ambrosini et.al

39. TIMI 10B trial:Thrombolytics and relationship to mortality
based on TMPG
theblush.com
Get some videos from dr gibson No
blush

40. Abnormal Myocardial Perfusion after PCI is Associated with Mortality at 8 Years3
Majority of patients have TIMI Grade 3 flow in epicardial artery after primary PCI
However
2 of 3 patients have a closed muscle
n=148 2
n=393
Survival
0/1
n=236 90
360
900
1440
2250
2790
Time (days)
van’t Hof AWJ et al. Circulation 1998; 97:2302-6

41. Potential Advantages of ELCA in thrombus
Thrombus dissolution
Local anti-platelet effect
Less distal embolization
Potential for less stent malaposition
Potential for less SAT
?? Reduced restenosis

42. Studies of ELCA in STEMI
CARMEL
Topaz Am JC 04
EXTENDED FAMILI Dave
Ambrossini Int Card J 2007
Number of pts
151 87 66
Inclusion
Shock, SVG, failed lytics
Within 12 hrs Excl. sick pts
Included rescue PCI
Catheters
Vitesse C
Included X80
1.4, 1.7, 2.0
Angiog Success
97%
N/A
Final blush
3-78%, 2-14%
TIMI CFC
ST res>70%
STR >70 % 35%, ST res >50%, 64%
48%

43. Acute inferior MI –X80-2 wires

44. After laser and final result

45. Practical considerations ELCA vs. Aspiration vs PTCA
Laser
Aspiration
Balloon/Stent
Thrombus
++++ +
Fibro-Calc. plaque ++
Tortuosity
Deliverability
If baseline TIMI 3 flow
+/-
+++

46. Proposed AMI Protocol ER Plavix 600mg or prasugrel 60mg load
Wire
ER Plavix 600mg or prasugrel 60mg load
Heparin following sheath insertion
TIMI 0-2
If thrombus 0.9(larger if SVG)
Clearway intra-coronary 2b3a
TIMI 3
Aspiration if still significant thrombus
Otherwise Direct stent if possible

47. Laser complications

48. General Procedural Best Practices
Supportive guide, no side holes
Saline flush
Slow advancement of catheter
Sizing of catheter (0.9mm workhorse)
Settings fluency/repetition rate

49. Conclusions ELCA – for complex coronary PCI
AMI- Current Rx leaves a lot to be desired
Open artery, TIMI flow grade, TMPG
Aspiration promising but some limitations
Pharmacotherapy- IV <IC < intra-lesion
ELCA safe, effective in AMI. RCTs needed

50. Questions?