Excimer Laser Coronary Angioplasty: Clinical Applications and Procedural Outcome, in a Large-Volume Tertiary Centre.

Excimer-laser coronary angioplasty can be used to modify undilatable and uncrossable lesions in native arteries and in-stent restenosis which are increasingly encountered with the ageing population undergoing coronary intervention. We present our laser experience over a 10-year period in a large cardiac tertiary centre. METHOD: Retrospective analysis of prospectively collected data on all procedures where laser was used from August 2008 to December 2019. Clinical presentation, demographics, and procedural details were all recorded. Successful procedures were defined as <30% stenosis at the end. Periprocedural and in-hospital complications were recorded and verified. Results are presented as numbers and percentages. RESULTS: A total of 331 patients were identified with 473 lesions treated with laser and an overall total of 637 lesions. Of the 473 lesions treated, 46 (9.9%) were in-stent restenosis, 146 (30.9%) were chronic total occlusions, and the rest were uncrossable or undilatable lesions. The vast majority of procedures (97.0%) were performed with the 0.9-mm laser catheter. The overall success rate was 81.6% (58-87%) from low- to high-volume user. Complications included dissection 3 (0.6%), no-reflow 3 (0.6%), coronary perforation 13 (2.7%), and tamponade in 1 (0.2%). Only 3 (0.6%) of the perforations were seen after the laser catheter passage, the rest were seen later following balloon preparation or stent insertion. CONCLUSION: Laser is a valuable tool for treating complex and resistant coronary lesions. Its efficacy and safety are well established and when applied appropriately, it helps to achieve optimal outcomes for our patients.

Endovenous Thermal Ablation of Prominent Central Forehead Veins (Supratrochlear Veins).

BACKGROUND: Many patients complain of prominent vertical veins in the center of their forehead, worse when smiling, wrinkling the forehead in bright light, leaning forward, and when vasodilated in heat, when exercising, or with alcohol. Previous attempts to treat these with external laser, sclerotherapy, and phlebectomy have not been successful. OBJECTIVE: To describe a new method of treating prominent vertical forehead veins and to report the early results. MATERIALS AND METHODS: We used endovenous laser ablation with a 1470 nm diode laser in 15 patients (F:M 12:3; mean age 38.4 years range 24-69). A bare fiber was used once and a 400-µm single ring radial fiber (Biolitec, Vienna, Austria) in all other cases. Tumescence was placed around the vein and a power of 2 to 3 W with a pullback of 7 to 10 seconds per centimeter. RESULTS: Twelve of the 15 patients (80%) ended up with a good cosmetic result and were satisfied, although 2 needed redo treatment. One patient had minor skin tethering, and 2 (13%) suffered burns-one was the only bare fiber case and the other, the only one where 4 W was used. CONCLUSION: We present a novel technique to treat prominent vertical forehead veins, with apparently good early results.

Laser Uses in Noncoronary Arterial Disease.

BACKGROUND: In the past decade, excimer laser angioplasty (ELA) has emerged in the field of peripheral artery disease (PAD). Laser indications now extend to off-label uses, such as in situ fenestration of aortic endograft. The aim of this study was to review the different therapeutics applications of lasers in arterial disease treatment. METHODS: We reviewed the English-language literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We selected 106 relevant papers. We excluded unrelated papers (n = 67), letters and commentaries (n = 6), and review articles (n = 7), leaving 26 articles to form the basis of this review. RESULTS: A total of 18 articles were included in the analysis of ELA applications in PAD. Nine articles were related to atherosclerotic plaques. With a mean follow-up of 15 ± 7 months, primary patency was 65% ± 20%. The mean distal embolism rate during the procedure was 5%. Eight more articles focused on in-stent restenosis. The mean technical success was 98%, and the rate of distal embolism during the procedure was 9%. With a mean follow-up of 10 ± 4 months, primary patency was 68% ± 18%. Eight articles described "off-label" excimer laser indications in endovascular therapy, including 5 papers regarding in situ fenestrations for complex aortic aneurysms. CONCLUSION: Laser atherectomy and laser-assisted techniques are an important part of a vascular surgeon and interventionalist's armamentarium.

Five-year follow-up of a randomized clinical trial comparing open surgery, foam sclerotherapy and endovenous laser ablation for great saphenous varicose veins.

BACKGROUND: New treatment methods have challenged open surgery as a treatment for great saphenous vein (GSV) insufficiency, the most common being ultrasound-guided foam sclerotherapy (UGFS) and endovenous laser ablation (EVLA). This study evaluated the long-term results of surgery, EVLA and UGFS in the treatment of GSV reflux. METHODS: Patients with symptomatic GSV reflux were randomized to undergo either open surgery, EVLA or UGFS. The main outcome measure was the occlusion rate of the GSV at 5 years after operation. RESULTS: The study included 196 patients treated during 2008-2010; of these, 166 (84·7 per cent) participated in the 5-year follow-up. At 5 years, the GSV occlusion rate was 96 (95 per cent c.i. 91 to 100) per cent in the open surgery group, 89 (82 to 98) per cent after EVLA and 51 (38 to 64) per cent after UGFS (P < 0·001). For patients who had received no additional treatment during follow-up, the occlusion rates were 96 per cent (46 of 48), 89 per cent (51 of 57) and 41 per cent (16 of 39) respectively. UGFS without further GSV treatment was successful in only 16 of 59 patients (27 per cent) at 5 years. CONCLUSION: UGFS has significantly inferior occlusion rates compared with open surgery or EVLA, and results in additional treatments.

[A MIDDLE-TERM RESULTS OF ENDOVENOUS LASER ABLATION FOR VARICOSE DISEASE OF THE LOWER EXTREMITIES].

Abstract The results of endovascular laser ablation (EVLA) under ultrasonographic control in treatment of the lower extremities varicose disease (LEVD) in 189 patients (214 extremities) were analyzed. There was established, that for the trustworthy information obtaining the ultrasonographic duplex angioscanning conduction is necessary. The fibrous involution of a big subcutaneous vein trunk was achieved in (97.7 ± 1.0)% observations, in (1.9 ± 0.9)%--while the clinical signs absence--there were revealed the echo-signs of a reflux recurrence--the "ultrasonographic recurrence", and in one observation--a clinical recurrence of LEVD. In (5.1 ± 1.5)% observations in fibrous involution of the segments treated the signs of venous insufficiency in earlier competent parts were revealed--the disease progress registered. The recurrence rate and the pain syndrome severity did not depend on the treated veins diameter. High security of EVLA was established while the complications analyzing.

[EFFICACY OF SURGICAL TREATMENT OF VARICOSE DISEASE, DEPENDING ON ADSORPTION-RHEOLOGIC PROPERTIES OF BLOOD].

Physico-chemical adsorption-rheological properties of venous blood in patients, suffering varicose disease of the lower extremities, and their impact on efficacy of various methods of surgical treatment were studied. Conduction of endovasal laser coagulation in combination with crossectomy have promoted enhancement of operative treatment efficacy in patients in initial terms of observation (in 1 week), in 1 month a complete occlusion of the vein was noted more rarely. Efficacy of a small--power laser ablation with irradiation power of 10 W and less in 4 weeks postoperatively is higher, than of surgical treatment with a laser irradiation power 15 W. In a varicose disease of the lower extremities there were observed the raising of the blood volume toughness, superficial relaxation and superficial stress on background of reduction of the toughness--elasticity module, superficial toughness and superficial elasticity. Crossectomy conduction did not influence the integral dynamics of adsorption--rheological properties of venous blood, but in 1 month after endovasal laser coagulation a normalization of physicchemical parameters of blood was noted. Application of laser irradiation of the 10 W power and less promotes inhibition of the relaxation properties of venous blood; a prognostic meaning owes initial value of the blood volume toughness.

High-risk lead removal by planned sequential transvenous laser extraction and minimally invasive right thoracotomy.

INTRODUCTION: Transvenous pacemaker or implantable cardioverter defibrillator (ICD) lead extraction via mechanical or excimer laser sheath is typically safe and effective. Longer duration from implant, presence of large vegetations or thrombi, fractured leads, and prior failed extraction are risk factors predicting higher complication rates or incomplete or failed lead removal. Techniques developed for minimally invasive valve surgery were used in conjunction with laser extraction to refine a "hybrid" technique for lead extraction. We assessed the outcomes of high-risk lead extraction using this hybrid lead extraction technique. METHODS AND RESULTS: Retrospective assessment of clinical parameters and procedural outcomes in patients undergoing planned hybrid lead extraction from February 2008 to September 2012 was performed. We report 8 cases of hybrid lead extraction performed at our institution. We extracted 21 leads with average lead age of 13.8 years since implant. All leads were removed with complete clinical and radiographic success. There were no intraprocedure complications. One patient died of continued sepsis and 1 other had symptoms consistent with pulmonary embolism. CONCLUSIONS: Hybrid lead extraction using this technique is a safe and effective approach for removal of high-risk chronic pacemaker or ICD leads. This method extends the range of approachable leads resulting in complete removal without median sternotomy. Hybrid lead extraction can be scheduled electively facilitating complete lead removal with a low complication rate and short postoperative recovery time, mitigating the risks inherent in midline sternotomy or emergent cardiac surgical rescue.

[Use of laser technologies in treatment of chronic venous insufficiency in patients with a wide ostial segment of the main trunks of subcutaneous veins].

Presented herein is the authors' experience in endovascular laser obliteration of the major trunks of the grate saphenous vein (GSV) with a wide ostial segment (measuring from 15 to 34 mm) in patients presenting with chronic venous insufficiency. Group One patients (n=32) underwent crossectomy followed by endovasal laser obliteration (EVLO) of the GSV's trunk on the femur. Group Two patients (n=46) were not subjected to crossectomy, whereas obliteration of the GSV's trunk was carried out immediately from the ostium. In Group One we managed to achieve obliteration of the GSV's trunk in 32 patients (100%) with no additional interventions, and in Group Two this was achieved in 42 (91.3%) patients. Four patients (8.7%) required performing a secondary procedure of EVLO after which obliteration of the trunk was achieved in all patients of Group Two. There was no evidence of deep-vein thrombosis.

The use of endovenous laser treatment in toddlers.

The use of endovenous laser ablation therapy in children is limited. Klippel-Trenaunay syndrome (KTS) is associated with persistent ectatic anomalous veins within the affected extremity, with increased risk of thromboembolism. The present report describes four toddlers (<20 kg) with KTS of the lower extremity who underwent a total of five endovenous laser procedures for treatment of ectatic anomalous marginal venous system, without complications.

Vaporizing thrombus with excimer laser before coronary stenting improves myocardial reperfusion in acute coronary syndrome.

BACKGROUND: Mechanical reperfusion has proven to be an unquestionably superior treatment strategy over that of thrombolytic therapy in patients with acute coronary syndrome (ACS). Excimer laser coronary angioplasty (ELCA) is a unique revascularization device that has a lytic effect on thrombus, in addition to its debulking effect on the atherosclerotic plaque beneath the thrombus. METHODS AND RESULTS: This single-center retrospective analysis consisted of consecutive ACS patients treated with ELCA (n=50) and age- and sex-matched ACS patients treated with manual aspiration (n=48) without use of a distal protection device. Success rate was judged by lesion crossability, procedure complications, and significant reduction of stenosis. Tissue-level perfusion was assessed on antegrade Thrombolysis In Myocardial Infarction (TIMI) flow grade, myocardial blush grade (MBG), and ST-segment elevation resolution (STR). Short-term outcome was evaluated according to occurrence of in-hospital major adverse cardiac events (MACE; myocardial infarction, target lesion revascularization, coronary artery bypass graft, and death). Lesion crossability was higher in the ELCA group than in the aspiration group (96.2% vs. 82.6%, P=0.04). Attainment of TIMI 3 flow (86.0% vs. 68.8%, P=0.04) and MBG 3 (76.0% vs. 54.2%, P=0.02) was also higher in the ELCA group than in the aspiration group. Complete STR was similar between the 2 groups. In-hospital MACE were significantly more frequent in the aspiration group. CONCLUSIONS: ELCA is feasible, safe, and effective for the treatment of patients with ACS and appears to be useful as an adjunctive lesion preparation device.

Histological evaluation of vascular changes after excimer laser angioplasty for neointimal formation after bare-metal stent implantation in rabbit iliac arteries.

BACKGROUND: Excimer laser is used to treat coronary artery disease, especially in case of lesions with thrombus and in-stent restenosis (ISR). However, there are no in vivo preclinical studies that have evaluated the pathological reactions of the vessel wall after excimer laser ablation. METHODS: Bare-metal stents were placed in the external iliac arteries of six healthy rabbits. Twenty-eight days later, excimer laser ablation was performed with low-power (45 (fluency)/25 (rate)) in one side, and high-power (60/40) in the opposite side, followed by optical coherence tomography (OCT) evaluation. Rabbits were sacrificed 15 min after the procedure, and histological assessment was performed. RESULTS: Morphometry analysis of OCT showed similar stent and lumen size between low-power and high-power group. Histological evaluation suggested endothelial cell loss, fibrin deposition, and tissue loss. The low-power group showed significantly less pathological changes compared with the high-power group: angle of endothelial cell loss, 32.4° vs. 191.7° (interquartile range, 8.8°-131.7° vs. 125.7°-279.5°; p < 0.01); fibrin deposition, 1.1° vs. 59.6° (0.0°-70.4° vs. 31.4°-178.4°; p = 0.03); and tissue loss 0.0° vs. 18.2° (0.0°-8.7° vs. 0.0°-42.7°; p = 0.03). CONCLUSIONS: The pathological changes in neointima were more prominent after high-power excimer laser ablation than after low-power excimer laser. To improve safety in clinical practice, understanding the pathological changes of tissues after excimer laser in lesions with ISR is essential.

Devices to treat peripheral chronic total occlusions.

Chronic total occlusions occur in approximately 40% of patients with peripheral vascular disease and are a difficult lesion subset to treat by endovascular approaches. The challenge lies in the difficulty in placing a wire across the site of occlusion and remaining in an intraluminal position. Conventional percutaneous transluminal balloon angioplasty for chronic total occlusions involves advancing a stiff wire through the site of obstruction, has the chance for vessel dissection and perforation, and is associated with high rates of procedural failure. Several mechanical devices have thus been developed to treat peripheral chronic total occlusions. In this article, we provide a review of the currently available devices that may increase the procedural success of treating peripheral chronic total occlusions.

[Comparative characteristics of laser-mediated and radiofrequency-powered thermal obliteration in varicose disease].

The article deals with a comparative analysis of the two most commonly used methods techniques of thermal ablation used for elimination of truncal varicosis in varicose disease, i. e., endovasal laser-mediated and radiofrequency-powered obliteration, underlining differences in the mechanisms of physical impact of the two competitive methods, clinical peculiarities of their application, as well as economic aspects of these interventions under the conditions of the present-day Russia.

[Endovasal obliteration of the main subcutaneous veins - a mechanism of action].

Active dissemination implementation of endovascular methods has during the past decade been a progressive tendency of the development of surgical treatment management of varicose disease.Amongst these methods, endovasal laser obliteration in Russia occupies the leading place. Despite widespread implementation of this method into clinical practice still there are neither common concepts on the mechanisms of action of laser energy, inducing lesions of the venous wall followed by obliteration, nor, consequently,criteria for administration thereof The search for an optimal method and mode of intravascular intervention is based on study-ing the mechanisms of the damaging action of laser energy on the venous wall. The article contains a literature review of the studies dedicated to investigating the mechanisms of action of endovasal methods of treatment for varicose disease.

A prospective double-blind randomized controlled trial of radiofrequency versus laser treatment of the great saphenous vein in patients with varicose veins.

BACKGROUND: Endovenous ablation of varicose veins using radiofrequency ablation (RFA) and endovenous laser therapy (EVLT) has reported advantages over traditional open surgical treatment. There is little evidence comparing the efficacy and patient-reported outcomes between the 2 endovenous solutions. This study compares the RFA and EVLT strategies in a prospective double-blind clinical trial. METHODS: Consecutive patients with primary unilateral great saphenous vein (GSV) reflux undergoing endovenous treatment were randomized to RFA (VNUS ClosureFAST) or EVLT (810-nm diode laser). The primary outcome measure was GSV occlusion at 3 months after treatment. Secondary outcome measures were occlusion at 7 days, postoperative pain, analgesic requirement, and bruising, assessed at day 7 after surgery. Quality of life (QoL) was assessed preoperatively and 3 months after surgery using the Aberdeen Varicose Vein Questionnaire (AVVQ) and EQ-5D. RESULTS: A total of 159 patients were randomized to RFA (79 patients) or EVLT (80 patients). Groups were well matched for demographics, disease extent, severity, and preoperative QoL. Duplex scanning confirmed 100% vein occlusion at 1 week in both groups. At 3 months, occlusion was 97% for RFA and 96% for EVLT; P = 0.67. Median (interquartile range) percentage above-knee bruise area was greater after EVLT 3.85% (6.1) than after RFA 0.6% (2); P = 0.0001. Postoperative pain assessed at each of the first 7 postoperative days was less after RFA (P = 0.001). Changes in the AVVQ (P = 0.12) and EQ-5D (P = 0.66) at 3 months were similar in both groups. CONCLUSIONS: RFA and EVLT offer comparable venous occlusion rates at 3 months after treatment of primary GSV varices; with neither modality proving superior. RFA is associated with less periprocedural pain, analgesic requirement, and bruising. REGISTRATION NUMBER: ISRCTN63135694 (http://www.controlled-trials.com).

Changing to endovenous treatment for varicose veins: how much more evidence is needed?

Surgical ligation and stripping of varicose veins has been the accepted treatment for almost a century but within the last decade this has been challenged by endovenous thermal and chemical ablation methods. Surgery is not without significant complications including paraesthesia and has reflux recurrence rates of up to 54% at five years, even though it has been shown to provide significant health-related quality of life benefits cost-effectively. Ultrasound-guided foam sclerotherapy, endovenous laser ablation and radiofrequency ablation are all consistently proving to be at least as beneficial as surgery, without the same complications and with less post-procedure morbidity and more rapid recovery. This article presents a review of the latest published evidence and comparative analysis of vein surgery and it's alternatives. Endovenous treatment under local anaesthesia in a clinic room or office-based setting is now being recognized internationally as an acceptable standard for dedicated venous practice in a cost-effective environment. Although more long-term comparative trials of these innovative methods compared with surgery are desirable, many centres are now conducting trials testing the latest endovenous device technologies with each other to support the development of contemporary pathways of care. Patients are entitled to a range of treatment strategies, particularly when complex and recurrent venous disease has such unacceptably high surgical complication and recurrence rates compared to endovenous alternatives. There is questionable logic in procrastinating until there is more convincing evidence. Now is the time for vascular surgeons to enhance their ultrasound skills and future-proof their venous practice for the benefits of patients and institutions.

Update on the TURBO BOOSTER spectranetics laser for lower extremity occlusive disease.

In the last two decades the endovascular treatment of peripheral arterial occlusive disease (PAOD) has gained a widespread and predominant role. New technologies have developed in the last years as atherectomy devices, self expandible nitinol stents, drug eluting devices (stent and balloons), absorbable stents. In recent years, growing interest has been dedicated to laser technology due to device improvements and literature data reporting safety and efficacy of excimer laser. The role of this new endovascular technique for the treatment of atherosclerotic arterial diseases should be considered with regard to two fields of interest: the claudicatio intermittens (CI) and the critical limb ischemia (CLI). A 20-year history with medical lasers has proven that not all lasers are equal. Lasers used and studied in the late 1980s and 1990s had poor outcomes due to inappropriate laser selection and undefined laser techniques. Over the last 10 years, multicenter studies with the excimer laser confirm that case selection, appropriate utilization of equipment, application of safe lasing techniques, and knowledge of indications and contraindications, all contribute to the successful application of laser-assisted angioplasty in complex coronary and peripheral artery disease. If applied properly, the Excimer Laser is a useful technique to transform complex obstructive arterial disease into more treatable lesions, improving the results of endovascular treatment and lowering the threshold of intervention for ''untreatable'' patients. New larger studies are requested to assess the definitive role of this technique in PAD treatment and limb salvage. This review will discuss the Laser Phisics and application in PAD along with the clinical data available to support the Excimer Laser as a reliable technology for endovascular intervention.

Excimer Laser Coronary Angioplasty (ELCA): Fundamentals, Mechanism of Action, and Clinical Applications.

Laser coronary angioplasty was developed to modify atherosclerotic plaque and help with the acute and longer-term limitations of balloon angioplasty, namely, intimal dissection and restenosis, respectively. Excimer laser debulks and modifies the tissue with its photochemical, photothermal, and photokinetic properties without causing significant injury. With important refinements and advancements, laser has gained a renewed place in treating complex and resistant coronary lesions after a disappointing start. When used in line with the instructions, laser is an important tool that allows the completion of difficult and complicated cases. It is a useful tool in the catheterization laboratory to treat lesions that are uncrossable or undilatable. Laser is also helpful in cases where a stent was deployed but remains under-expanded, with accumulating evidence of its efficacy in such cases. In addition, laser is increasingly used for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) to facilitate modification of the proximal CTO cap to allow penetration with a wire and completion of the procedure. Laser has been used in certain circumstances by experienced operators with simultaneous contrast rather than saline injection, to increase its effect and allow the successful completion of complex PCIs. This article outlines the scientific background, experimental data, practical procedural techniques, and clinical applications of excimer laser coronary angioplasty in the treatment of coronary artery disease.