Excimer laser technology in percutaneous coronary interventions: Cardiovascular laser society's position paper
Introduction
From the mid-1990s until the year 2014, when the ELLEMENT [1] Registry was published, lasers were used in coronary and peripheral areas predominantly at a low to medium energy level and only in combination with saline solution, regardless of the lesion to be treated. This led to very disappointing results, especially in the case of complex lesions due to calcifications. The gradual introduction of higher energy strategies and more advanced methodologies (contrast medium, type of probe, anterograde and/or retrograde passages, number of laser passages) significantly changed the effectiveness of the results of both coronary and peripheral interventions (Table 1). However, the way lasers were used in coronary and peripheral areas did not have well-defined rules and very often depended on the operator. For this reason, there was a need to standardize the use of lasers in interventional procedures to ensure better efficacy and consistent results for patients. The Cardiovascular Laser Society (CLS - www.cardiovascularlasersociety.com) is a multidisciplinary, non-profit association founded for this purpose in 2017. Alongside doctors with expertise in interventional cardiology, interventional radiology, and endovascular surgery, the CLS also has users specializing in excimer lasers applied to atherectomy and other coronary and peripheral interventional procedures. Four years after its foundation, the CLS felt the need to establish in more detail how and when exactly this particular technique should be used in the treatment of coronary artery disease; with this in mind, the CLS working group decided to publish a consensus document.
Section snippets
Laser equipment
The system consists of an excimer laser generator, the CVX-300 unit (Philps), and a series of pulsed xenon‑chlorine laser catheters capable of delivering excimer energy via optical fibers; the power unit emits laser energy through an output catheter at a wavelength of 308 nm, a pulse length of 185 ns, energy between 30 and 80 mJ/mm2 at a pulse repetition frequency between 25 and 80 Hz. The large size of the power unit (length 125 cm/49 in, width 61.3 cm/21 in, height 89 cm/35 in), its weight
General principles
The excimer laser is a pulsed xenon‑chlorine (XeCl) laser based on the medium ultraviolet wavelength (308 nm) which relies on absorption into the non-aqueous components of the atherosclerotic plaque, such as proteins and nucleic acids, for debulking. The penetration depth of the laser is directly related to its wavelength: with a shorter wavelength UV laser, there is less penetration, less heat generation, and less damage to unwanted tissue. The typical absorption depth of the Excimer Laser is
How to perform a successful laser procedure
In contrast to the interesting “five S's” algorithm proposed by Egred & Brilkis [21], we felt instead that, in line with the latest scientific evidence and in our experience, three steps are really essential to perform a successful ELCA procedure: 1) patient selection; 2) correct setup; 3) slow laser advancement. Although there is a choice of four sizes of catheters, we strongly recommend the use of the smaller 0.9 mm X-80 catheter (Philips), which is useful in the vast majority of cases, as it
Possible complications
Complications are quite low and may include: coronary dissection (3–5% of cases), which does not represent a dramatic event as the rupture of the calcium sleeves may allow better dilatation and implantation of the stent; distal coronary embolization (1–2% of cases); and worse, but rarely, coronary perforation (0.5% of cases) [22], [23].
Acute coronary syndromes
The gold standard treatment for ST Elevated Myocardial Infarction (STEMI) is primary PCI [24]. Ultraviolet and pulsed-wave excimer laser light can vaporize the thrombus, suppress platelet aggregation and, unlike other thrombectomy devices, ablate the underlying atherosclerotic plaque [25]. The potential benefit of ELCA is effective in removing large intracoronary thrombi, promoting fibrinolysis [26], platelet stunning [27], and concomitant plaque debulking [28] (Fig. 5a, b, c). Several studies
Future directions
After a less satisfying start, the ELCA technique has undergone major refinements over time in catheter technology and in the introduction of safe and improved laser techniques, leading it to a renewed place in the treatment of complex and resistant coronary lesions. The gradual introduction of higher energy strategies combined with the contrast infusion technique, not only for under-expanded stents, has significantly changed the effectiveness of outcomes in a wide range of complex coronary
Conclusions
The ELCA technique has begun to be considered an established therapy that can be applied to treat a wide range of coronary lesions during PCI, due to the high standard of materials and the advancement of its technique. Used by experienced operators, it can be instrumental in completing difficult and complicated cases, such as uncrossable and non-expandable coronary atherosclerotic lesions, stent under-expansion, as well as very difficult CTO cases. The prevalence of ballon-uncrossable lesion is
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