Laser Angioplasty for Chronic total occlusion and balloon

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

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

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

Catheter Overview 0. 9 mm Rapid Exchange (RX) Proximal Coupler Distal Tip

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

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 308 nm) Photochemical Photothermal Photomechanical Dissolving molecular bonds Produces photothermal energy Creating kinetic energy

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

Excimer Laser Coronary Atherectomy (ELCA) • Spectranetics CVX -300, Spectranetics, Colorado Springs, CO) Ø Wavelength 308 nm Ø Pulse duration 125 -200 n. S Ø Fluence 30 -80 m. J/mm 2 Ø Repetition Rate 25 -80* Hz Ø Catheter-diameter 0. 9 - 2. 5 mm Ø 6 FR- compatible Laser as the 5. Total occlusions crossable by guidewire last option • Approved by FDA for coronary 1992 for: 1. Dubulking of SVG 2. Ostial lesion 6. Moderately calcified lesion 3. Eccentric lesions 7. Balloon refractory lesions 4. Long lesions 20 mm 8. In stent restenosis 9. Acute myocardial infarction

Case 1 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

Diagnostic coronary angiography

Diagnostic coronary angiography

Diagnostic coronary angiography

Intervention The decision was to proceed with PCI of RCA Guiding catheter 8 F HS, SH Guide wire BMW Balloon 2. 5/20 Sprinter did not cross Balloon 1. 5/15 Sprinter did not cross

Intervention Rotational Atherectomy 1. 25 mm did not cross

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 61 micron fibers Beam Profile 0. 9 mm Vitesse COS Than Rotational atherectomy 1. 25 mm and 1. 5 mm

Intervention 2. 5/14 mm Micro Driver 2. 5/20 mm Sprinter

Intervention

Case 2 Chronic total occlusion cx

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

Diagnostic Catheterization

Chronic total occlusion CX

Chronic total occlusion CX LV IVUS LAD and Left main • • • LMCA: near normal LAD stent: no intimal hyperplasia Mid and distal LAD: 2 -2. 5 mm with diffuse non significant disease.

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

Chronic total occlusion CX 1. 5 OTW balloon did not cross 0. 9 Excimer Laser did not cross, until fluence 80/80 was used

Chronic total occlusion CX IVUS of CX after laser+1. 5 balloon

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

Case 3 Chronic total occlusion RCA

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

PCI CTO RCA Guiding catheter 7 F 3 DRight

PCI CTO RCA Guide wire. 014 in Miracle. Bros 6 CTO 2. 1 f 135 cm Tornus

PCI CTO RCA Guide wire. 014 in Confianza Balloon 1. 5 mm 15 mm Apex did not cross

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

PCI CTO RCA Balloon 1. 5/15 mm Post balloon

PCI CTO RCA Drug Eluting Stent 2. 5 mm 30 mm Cypher

PCI CTO RCA IVUS post balloon and laser IVUS post stenting

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