1. Excimer Laser Atherectomy for the Treatment of Infra-inguinal Peripheral Arterial Disease Bryan P Yan MD, Thomas J Kiernan MD, Vishal Gupta MD, Jonathan Eisenberg, Robert Schainfeld DO, Michael Jaff DO, Joseph Garasic MD, Kenneth Rosenfield MD, Department of Vascular Medicine & Interventional Cardiology, Massachusetts General Hospital, Boston, MA
Background:
Excimer laser atherectomy offers a potential therapeutic intervention for infrainguinal arterial disease. Despite promising early results reported in the literature, optimal patient selection for laser atherectomy has yet to be determined.
Methods:
We analyzed baseline characteristics and outcomes of consecutive patients (Dec 04 - Nov 07) undergoing laser atherectomy. Changes in ankle brachial index (ABI), need for repeat intervention and limb salvage were assessed at follow-up.
Results:
Excimer laser atherectomy was performed in 21 patients (30 lesions) with mean age of 75±7 years. Of these, 71% were male and 34% had diabetes. The indication for intervention was critical limb ischemia in 33% and intermittent claudication in 66%. Of the 30 lesions treated, 19 (63%) were femoropopliteal and 11 (37%) were infrapopliteal. Femoropopliteal Trans-Atlantic Society Classification (TASC) was C in 79%, D in 21%; infrapopliteal TASC lesion distribution was A in 9%, C in 73% and D in 18%. Adjunctive angioplasty and stenting was used in 93% and 33% of cases, respectively. Procedural success (<30% residual stenosis) was 97%. Mean follow-up was 375 days (range 20 to 939 days). At follow-up, clinical improvement was observed in 16 patients (76%) with a mean increase in resting ABI of 0.39±0.21. There was one cardiac death, one patient (3.3%) required amputation and 5 lesions (17%) underwent repeat target lesion revascularization. The average time to re-intervention was 80 days. Limb salvage rate in patients with critical limb ischemia was 83% at mean follow-up of 390 days.
Table 1. Baseline Characteristics
Figure 1. Mechanism of Excimer Laser Photo-ablation
‘Photoablation’ is the use of ultraviolet laser light (308nm) to dissolve and remove matter
(1) Light pulse targets tissue for 125 billionths of a second (50 microns penetration depth) dissolve molecular bond
(2) Energy absorption creates molecular vibration through heating of intracellular water - water vaporizes, ruptures cells & produce a vapor bubble
(3) Expansion and collapse of vapor bubble breaks down tissue and clears byproducts away from tip
Variables
N = 21
Age (yrs)
Men
Smokers (current)
Diabetes Mellitus
Coronary Artery Disease
Hypertension
Hyperlipidemia
Renal Failure
Indication
Claudication
Critical Limb Ischemia
75±7
71%
13%
34%
53%
80%
87%
17%
57%
37%
Table 2. Procedural Characteristics
Variables
N = 30
Vessel Treated
Femoro-popliteal
Infra-popliteal
TASC, femoro-politeal / infra-popliteal A B C D
Adjunctive balloon angioplasty
Adjunctive stenting
Procedural success (<30% residual stenosis)
19 (63%)
11 (37%)
0% / 9%
0 / 0
79% / 73%
21% / 18%
93%
33%
97%
Table 3. Clinical Outcomes
CONCLUSIONS:
In an academic endovascular practice, adjunctive use of excimer laser atherectomy for infrainguinal atherosclerotic disease is associated with high initial technical success and high limb salvage rates
Procedural Distal Embolization
Mean 375 days Follow-up
Death
Clinical Improvement
Mean increase in Ankle-Brachial Index
Target Lesion Revascularization
Amputation
Limb Salvage for Critical Limb Ischemia
6.7%
3.3%
76%
0.39±0.21
17%
83%