Excimer laser coronary angioplasty (ELCA) for diffuse in-stent restenosis: beneficial long-term results after sufficient debulking with a lesion-specific approach using various laser catheters.
Although brachytherapy became frequently used technique for treating in-stent restenosis (ISR) in 2000 (stenosis recurrence: 14-25%), removing the tissue (i.e., debulking) is still under evaluation. Regarding XeCl Excimer laser no randomised trials have been completed so far. The entirely attainable and published data originate from five one-centre and one multicentre registries which showed a high procedural success-(98%) and a very low complication rate (<2%), but heterogeneous results based on (I) manifold laser- and lasing technology due to evolving catheter and lasing technology during the studies and (II) inhomogeneous patient-populations, which had been documented only occasionally, although we now know that ISR-recurrence rates are significantly higher in patients with (1) high grade stenosis (>70%), (2) long lesions (>15mm in length), (3) recurrent ISR. (4) ISR in saphenous vein grafts, (5) early-ISR (<3 months after stent implantation), (6) multi-vessel disease and (7) low ejection fraction. Because all athero-ablative procedures are typically finalised by adjunctive balloon PCI, diameter stenosis before adjunctive PTCA was between 23% and 64%, reflecting the different lasing (and therefor debulking) intensity between the studies. The mean lesion-length, vessel diameter, stent-type and coronary differed significantly between the studies (i.e. mean lesion length between 14 and 32 mm) and although of major influence, the speed of lasing (=ablation) was not recorded in the various studies. Concerning eccentric ELCA the invention of the area-ablation technique provide a significant greater ablation effect and the new OS-technology provide 60% more ablating area. In summary, the feasibility, effectiveness, procedural success and presumably long-term outcome of the Excimer laser for treating ISR depend on multiple outcome-influencing aspects. The lack of recording variables make analysis of various laser-for-ISR trials difficult or even impossible. ELCA seems to have advantageous procedural and long term results in lesions, where aggressive debulking effect using eccentric ELCA catheters can be achieved. The OS-catheter can provide a maximum debulking in distal lesions and tortuous vessels, where the debulking abilities of the eccentric catheter are limited. If laser debulking is inadequate (DS 30%), the incidence of recurrent restenosis appear to be higher and brachytherapy is probably more suitable. Sufficient laser debulking can only be achieved through use of precise technique respecting the laser-specific abilities of plaque dissolution, appropriate energy levels and quantities, and possibly recovery time.
Dahm
J B
JB
Department of Cardiology, Ernst-Moritz-Arndt University Greifswald, Germany. dahm@mail.uni-greifswald.de
D016342:Angioplasty, Laser / Q000379:methods*; D002404:Catheterization; D003327:Coronary Disease / Q000601:surgery*; D006801:Humans; D012008:Recurrence; D015607:Stents