The therapeutic effects of excimer laser coronary atherectomy therapy for in-stent restenosis chronic total occlusions.

OBJECTIVES: To evaluate the safety and efficacy of excimer laser coronary atherectomy (ELCA) in patients with in-stent restenosis chronic total occlusions (ISR CTOs). BACKGROUND: ISR CTOs are a challenge in percutaneous coronary intervention (PCI). Although they can be treated by ELCA, limited data are available on the effects of ELCA treatment in these patients. METHODS: Fifty-nine consecutive patients underwent PCI for ISR CTOs at Beijing Hospital between December 2017 and September 2020. According to whether or not ELCA was performed, they were divided into two groups. Quantitative coronary angiography (QCA) analyses were performed routinely, including measurement of the minimal lumen diameter and calculation of the percentage diameter stenosis. The procedural success rate, the frequency of peri-procedural complications, and the incidence rates of major adverse cardiac events (MACEs) over nine months were assessed. The primary endpoint in the study was the percentage diameter stenosis. RESULTS: Procedure success was achieved in most patients in both groups (75.9%). Patients in the ELCA group exhibited a lower percentage diameter stenosis (24.5 ± 9.09 vs. 35.1 ± 18.6, p = 0.048) and a larger minimal lumen diameter (2.36 ± 0.29 mm vs. 1.78 ± 0.64 mm, p < 0.001) than those in the control group and the 9-month incidence rates of MACEs did not differ (9.5% vs 15.8%, p = 0.699). CONCLUSIONS: This study demonstrated that ELCA may be a safe and effective technique in the treatment of ISR CTOs, and the use of ELCA can achieve good immediate angiographic results, as measured by QCA, without increasing peri-procedural complications or the incidence rates of 9-month MACEs.

The rotational atherectomy with a guide extension catheter for calcified and tortuous lesions in left anterior descending artery: a case report.

BACKGROUND: The interventional treatment of calcified lesions with severe tortuosity in the left anterior descending artery (LAD) was challenging and the report of rotational atherectomy with mother-and-child technique has been scarce. CASE PRESENTATION: An 84-year-old woman was hospitalized for non-ST-segment acute coronary syndrome. Coronary angiography revealed a calcified nodule in the LAD. During rotational atherectomy of the calcified and tortuous lesion in the proximal LAD, eccentric cutting due to wire bias nearly caused perforation. The burr seemed to protrude from the contrast media during angiography. Intravascular ultrasound imaging revealed that extremely eccentric ablation almost reached the adventitia. We successfully ablated the distal calcified nodule by preventing proximal overcutting of the tortuous lesion with support from a guide extension catheter, i.e., the mother-and-child technique, followed by the deployment of the drug-eluting stent. The patient was discharged without chest symptoms and no symptom recurred during 12-month follow-up. CONCLUSION: This case demonstrated that safe ablation of a calcified nodule located distal to a tortuous and calcified lesion in the proximal LAD with the mother-and-child technique.

Prediction of optimal debulking segments before rotational atherectomy based on pre-procedural intravascular ultrasound findings.

This study evaluated whether intravascular ultrasound (IVUS) examination before rotational atherectomy (RA) can predict the optimal route of passage of the RA burr along the vessel. 30 patients with calcified lesions who underwent IVUS before and immediately after RA were enrolled. IVUS analyses were performed at the minimum lumen area (MLA) site and at 0.5 mm intervals. Each IVUS cross-section was divided into 4 quadrants around the center of the lumen, and pre- and post-RA IVUS cross-section images were merged. Of 1140 cross-sections, 498 (44%) contained debulked regions. When the guidewire and IVUS were located within the same quadrant, the debulked region were distributed within the same quadrant in 96% of cross-sections. The debulked region and the guidewire were distributed within the same quadrant in 81% and the debulked region and the IVUS in 72% of cross-sections, in case the guidewire and IVUS were located in different quadrants. When the guidewire and the IVUS was apart > 1.0 mm, the debulked regions were distributed within the same quadrant as the guidewire in 100% and the IVUS in 0% of cross-sections. The position of the guidewire rather than that of the IVUS catheter on pre-RA IVUS images could predict the course of the RA burr's passage, especially when the guidewire and IVUS catheter were located apart from each other.

Comparison of Neointimal Response between Durable-Polymer Everolimus-Eluting Stent and Bioabsorbable-Polymer Everolimus-Eluting Stent for Severely Calcified Lesions Requiring Rotational Atherectomy.

Clinical outcomes after percutaneous coronary intervention (PCI) for severely calcified lesions remain poor. The purpose of this study was to investigate the neointimal response after everolimus-eluting stents (EES) for severely calcified lesions treated with rotational atherectomy (RA) using optical coherence tomography (OCT).We retrospectively analyzed 34 lesions in which PCI was performed with EES deployment following RA and OCT was performed immediately after PCI and at follow-up (nine months). The EES was either durable-polymer (DP) EES (22 lesions) or bioabsorbable polymer (BP) -EES (12 lesions). Strut coverage and malapposition were evaluated at 1-mm intervals of cross-section (CS) by serial OCT analysis. Malapposed strut was defined as having the distance from luminal border > 100 µm.A total of 11,823 struts immediately after PCI and 11,720 struts at follow-up were analyzed. Immediately after PCI, the strut-level analysis showed no significant differences in the percentage of malapposed struts between the DP-EES group and the BP-EES group. At follow-up, the BP-EES group showed a more prevalent covered strut compared with the DP-EES group (strut-level analysis: 95% versus 97%, P = 0.045; CS-level analysis: 97% versus 100%, P < 0.01; lesion-level analysis: 27% versus 83%, P < 0.01, respectively).In severely calcified lesions requiring RA, the BP-EES group achieved better neointimal coverage than the DP-EES group at nine months. Additional prospective studies are needed.

Clinical outcomes of PCI with rotational atherectomy: the European multicentre Euro4C registry.

AIMS: Despite the use of rotational atherectomy (RA) in interventional cardiology for over three decades, data regarding factors affecting the clinical outcomes of the RA procedure remain scarce. The aim of the present study was to describe the contemporary use and outcomes of RA in Europe. METHODS AND RESULTS: We conducted, for the first time, a prospective international registry in 8 European countries and 19 centres and included patients treated by percutaneous coronary intervention with RA. Between October 2016 and July 2018, 966 patients with complete data were recruited. Mean age was 74.5 years, 72.4% were male and 43.4% had diabetes. Initial presentation was an acute coronary syndrome (ACS) for 25.1% of the patients. Clinical success was observed in 91.9% of the procedures. The rate of in-hospital major adverse cardiac events (MACE) - defined as cardiovascular death, myocardial infarction, target lesion revascularisation, stroke and coronary artery bypass grafting - was 4.7%. At one year, the rate of MACE was 13.2%. Factors independently associated with the occurrence of MACE at one year were female gender, renal failure, ACS at admission, depressed left ventricular ejection fraction (LVEF) and presence of a significant left main coronary artery (LMCA) lesion. CONCLUSIONS: Despite the high level of complexity of the studied population, RA turned out to be an effective procedure with a low rate of in-hospital complications and demonstrated good immediate and midterm results.

Orbital Atherectomy and Heavily Calcified Saphenous Vein Graft Intervention.

Percutaneous coronary intervention in the diseased saphenous vein graft differs significantly from that in the diseased native coronary artery. After being exposed to arterial pressures over time, vein grafts have substantially different plaque characteristics, with more inflammatory cells, more diffuse disease, and less calcification. Severe calcification of saphenous vein grafts, although uncommon, poses a high risk of stent underexpansion. Orbital atherectomy for treatment of de novo calcified coronary lesions has been associated with better outcomes at 5-year follow-up. However, there are no published data on the use of orbital atherectomy to treat severely calcified saphenous vein graft lesions. We present the case of a 77-year-old woman with non-ST-segment-elevation myocardial infarction who underwent successful orbital atherectomy to prepare a severely calcified saphenous vein graft lesion for stent implantation.

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.

Is crossability of the classic crown with the glide assist superior to the micro crown in the Diamondback 360® coronary orbital atherectomy system?

The Diamondback 360® coronary orbital atherectomy system (OAS) can safely debulk calcified lesions by pullback of the crown, if the crown is advanced to the distal of the lesion. The aim of this study was to compare crossability with two types of crown in OAS. Thirty-six consecutive severely calcified lesions in 33 patients who underwent percutaneous coronary intervention with the coronary OAS were included. The micro crown was used in 18 consecutive lesions from April 2018 to February 2019, and the classic crown with the glide assist was used in 18 consecutive lesions from March 2019 to August 2019. Good crossability was defined as the ability to cross the lesion before orbital atherectomy or to cross the lesion with a first session of orbital atherectomy. We also tried to elucidate whether the crown could cross the lesion without using the glide assist in 13 consecutive lesions at the end of the classic crown cases. Good crossability was more often observed in cases with the classic crown (17 of 18 lesions, 94%) than the micro crown (6 of 18 lesions, 33%) (P < 0.001). In 13 consecutive lesions at the end of the classic crown cases, the crown could cross the lesion in 4 lesions (31%) without use of the glide assist or orbital atherectomy, and in 11 lesions (85%) with only use of the glide assist (P = 0.005). The classic crown with the glide assist is superior to the micro crown in terms of crossability for severely calcified lesions.

Excimer Laser in Percutaneous Coronary Intervention of Device Uncrossable Chronic Total and Functional Occlusions.

Device uncrossable lesions are a challenge in interventional cardiology and despite improvements in balloon and microcatheter profile, rotational atherectomy is necessary in some circumstances in order to ablate and traverse the lesion. Nevertheless, the application of rotational atherectomy requires utilization of a specific wire, Rotawire, which is not always so easily navigable. Debulking of device uncrossable lesions can be performed by coronary laser over any kind of angioplasty guidewire. We present a series of six patients with chronic total (100%) and functional occlusions (99% stenosis) in whom after successful wire crossing, microcatheter failed to traverse the lesion. After coronary laser performance, 5 out of 6 lesions were successfully dilated, achieving a successful final angiographic result of 83.3%.

The impact of the excimer laser on myocardial salvage in ST-elevation acute myocardial infarction via nuclear scintigraphy.

Data on the efficacy of excimer laser coronary atherectomy (ELCA) for patients with ST-elevation myocardial infarction (STEMI) are limited. Therefore, we sought to evaluate the impact of ELCA on myocardial salvage using nuclear scintigraphy in patients with STEMI. Between September 2014 and April 2017, we retrospectively enrolled 316 consecutive patients undergoing primary PCI (p-PCI) after their first STEMI in our institute. Of those, 72 patients with STEMI, an initial thrombolysis in myocardial infarction (TIMI) flow-0/1, and an onset to balloon time (OBT) < 6 h were included (ELCA, n = 32; non-ELCA, n = 40). The endpoint was the myocardial salvage index (MSI) based on a 17-segment model with a 5-point scoring system. MSI was calculated as: MSI = (∑123I-BMIPP defect score at 3-7 days after p-PCI - ∑99mTc-tetrofosmin defect score at 3-6 months after p-PCI)/∑123I-BMIPP defect score × 100 (%) at 3-7 days after p-PCI. The groups were compatible except in age (ELCA: 62.9 ± 12.4 years vs. non-ELCA: 69.8 ± 11.0 years) and loading antiplatelet drug (prasugrel: 100% vs. 40.0%). Direct implantation of shorter stents more frequently occurred in the ELCA group than in the non-ELCA group. MSI seemed to be better in the ELCA group compared with the non-ELCA group (57.6% vs. 45.6%, p = 0.09). This trend was emphasized when the final TIMI-3 flow was achieved (67.1% vs. 45.7%, p = 0.01). The nuclear scintigraphy results showed that ELCA can potentially improve myocardial salvage in patients with STEMI with OBT < 6 h and initial TIMI flow-0/1.

Association between debulking area of rotational atherectomy and platform revolution speed-Frequency domain optical coherence tomography analysis.

OBJECTIVES: In this study, we sought to investigate the association between revolution speed of rotational atherectomy (RA) and debulking area assessed by frequency domain-optical coherence tomography (FD-OCT). BACKGROUND: The number of patients with severe calcified coronary artery disease requiring treatment with calcium ablation, such as RA, is increasing. However, there is little evidence available regarding the association between debulking area and revolution speed during RA. METHODS: We retrospectively investigated 30 consecutive severely calcified coronary lesions in 29 patients who underwent RA under FD-OCT guidance. The association between preset revolution speed of RA and burr size-corrected debulking area of the calcified lesion was evaluated using a multivariable regression model with nonlinear restricted-cubic-spline, which can help assess nonlinear associations between variables. RESULTS: The median age of study participants was 73 years (quartile 65-78); 82.8% were male. The median burr size was 1.5 mm (1.5-1.75); median total duration of ablation was 120 s (100-180). FD-OCT revealed that the post-procedural minimum lumen area increased significantly from 1.64 mm2 (1.40-2.09) to 2.45 mm2 (2.11-2.98) (p < .001). In addition, the burr size-corrected debulking area increased significantly as the preset revolution speed decreased (p = .018), especially when the revolution speed was less than 150,000 rpm. This result implies that additional lumen gain will be obtained by decreasing rpm when the burr speed is set at <150,000 rpm. CONCLUSIONS: FD-OCT demonstrated that RA with lower revolution speed, below 150,000 rpm, has the potential to achieve greater calcium debulking effect in patients with severe calcified coronary lesions.

Rotational atherectomy with the new RotaPro system over RG3 guidewire in subadventitial retrograde highly calcified CTO PCI.

The following article describes the case report of a 52-year-old man who is affected by a right coronary artery occlusion treated with rotational atherectomy over retrograde guidewire RG3 in subadventitial space.

Optical coherence tomography-guided versus intravascular ultrasound-guided rotational atherectomy in patients with calcified coronary lesions.

AIMS: We aimed to evaluate whether optical coherence tomography (OCT)-guided rotational atherectomy (RA) improves stent expansion and clinical outcomes compared to intravascular ultrasound (IVUS)-guided RA. METHODS AND RESULTS: From our database, we identified 247 de novo calcified coronary lesions that underwent RA between September 2013 and December 2017. Of these, lesions with no intravascular imaging data (n=11), poor image quality (n=7), balloon angioplasty alone (n=16), and complications (two burr entrapments, two perforations) were excluded. Finally, 88 and 121 lesions that underwent OCT-guided and IVUS-guided RA, respectively, were included in the study. The primary endpoint of the present study was percent stent expansion. Burr upsizing was more frequently performed (55% vs 32%, p=0.001) and the final burr size was significantly larger (1.75 [1.50-1.75] vs 1.50 [1.50-1.75] mm, p<0.001) in the OCT-guided RA group. Percent stent expansion was significantly larger in the OCT-guided RA group (83±15% vs 72±16%, p=0.0004). Although TLR at one year was lower in the OCT-guided RA group, there was no statistical difference (6.8% vs 11.6%, p=0.25). CONCLUSIONS: OCT-guided RA for calcified coronary lesions resulted in larger percent stent expansion compared to IVUS-guided RA. OCT-guided RA may be ideal for treating calcified coronary lesions.

An application of RASER technique in the treatment of chronic total occlusion accompanied with stent fracture in right coronary artery: a case report.

BACKGROUND: The interventional treatment of chronic total occlusion (CTO) with stent fracture as well as severe calcification was extremely difficult and no effective technique has been reported. CASE PRESENTATION: A 50-year-old woman was hospitalized for angina, angiography revealed triple vessel disease, CTO accompanied with stent fracture in right coronary artery (RCA). Treatment using conventional coronary intervention was expected to be difficult. Therefore, we performed RASER technique, which was a combination of excimer laser coronary atherectomy (ELCA) with rotational atherectomy (RA), followed by the deployment of drug-eluting stents. Intravascular ultrasound (IVUS) revealed well attachment of the stents, the patient was discharged 3 days after the procedure and no recurrent chest discomfort was reported in a follow-up time of 10 months. CONCLUSION: This case report provided a first report of RASER technique in the treatment of CTO with stent fracture and severe calcification.

Tips and Tricks for Rotational Atherectomy.

The use of debulking devices improved in the last few years, due to the expanding indications to percutaneous coronary angioplasty, involving an elevated number of coronary stenoses with heavy calcification. Rotational atherectomy has become one of the most used devices in this challenging scenario. The aim of this review is to analyze the components and the use of the Rotablator System (Boston Scientific) and to better understand helpful tips and tricks in order to face the most common complications occurring during the procedure.

Initial Experience With GlideAssist to Facilitate Advancement of Orbital Atherectomy Prior to Plaque Modification of Severely Calcified Coronary Artery Lesions.

OBJECTIVES: We report our initial experience with GlideAssist (Cardiovascular Systems, Inc) to facilitate advancement of the orbital atherectomy crown prior to plaque modification of severely calcified coronary artery lesions. BACKGROUND: Severe coronary artery calcification increases the complexity of percutaneous coronary intervention (PCI) and is also associated with worse clinical outcomes compared with PCI of non-calcified vessels. Orbital atherectomy is an effective tool to modify calcified plaque prior to stenting. However, advancement of the orbital atherectomy crown may be technically challenging due to complex coronary anatomy. METHODS: From February 2018 to February 2019, GlideAssist was used in 13 patients at the University of California, Los Angeles Medical Center. The primary endpoint was the 30-day rate of major adverse cardiac and cerebrovascular events, which was the composite of death, myocardial infarction (MI), target-vessel revascularization (TVR), and stroke. RESULTS: Reasons for use of GlideAssist included severe angulation/tortuosity (76.9%), ostial lesion (15.4%), and presence of previously implanted stent proximal to the calcified target lesion (7.7%). All patients who required GlideAssist had successful delivery of the crown to the calcified lesion. One patient experienced a major adverse cardiac and cerebrovascular event, which was due to periprocedural MI that was due to coronary dissection. The same patient experienced subacute stent thrombosis 13 days after the index PCI requiring TVR. No patient died or had a stroke. No other angiographic complication occurred. CONCLUSIONS: The GlideAssist function is a useful feature of the orbital atherectomy system to facilitate successful delivery of the crown in complex coronary anatomy.

Treatment of In-Stent Restenosis by Excimer Laser Coronary Atherectomy and Drug-Coated Balloon: Serial Assessment with Optical Coherence Tomography.

OBJECTIVES: We aimed to compare the results of neointimal modification before drug-coated balloon (DCB) treatment with excimer laser coronary atherectomy (ELCA) plus scoring balloon predilation versus scoring balloon alone in patients presenting with in-stent restenosis (ISR). BACKGROUND: Treatment of ISR with ELCA typically results in superior acute gain by neointima debulking. However, the efficacy of combination therapy of ELCA and DCB remains unknown. METHODS: A total of 42 patients (44 ISR lesions) undergoing DCB treatment with ELCA plus scoring balloon (ELCA group, n = 18) or scoring balloon alone (non-ELCA group, n = 24) were evaluated via serial assessment by optical coherence tomography (OCT) performed before, after intervention, and at 6 months. RESULTS: Although there was significantly greater frequency of diffuse restenosis and percent diameter stenosis (%DS) after intervention in the ELCA group, comparable result was shown in %DS, late lumen loss, and binary angiographic restenosis at follow-up. On OCT analysis, a decreased tendency in the minimum lumen area and a significant decrease in the minimum stent area were observed in the ELCA group between 6-month follow-up and after intervention (-0.89 ± 1.36 mm2 vs. -0.09 ± 1.25 mm2, p = 0.05, -0.49 ± 1.48 mm2 vs. 0.28 ± 0.78 mm2, p = 0.03, respectively). The changes in the neointimal area were similar between the groups, and target lesion revascularization showed comparable rates at 1 year (11.1% vs. 11.4%, p = 0.85). CONCLUSIONS: Despite greater %DS after intervention, ELCA before DCB had possible benefit for late angiographic and clinical outcome.

A Novel Rotablator Technique (Low-Speed following High-Speed Rotational Atherectomy) Can Achieve Larger Lumen Gain: Evaluation Using Optimal Frequency Domain Imaging.

BACKGROUND: While the evaluation of burr speed was discussed regarding platelet aggregation, the association between platform speed and acute lumen gain of rotational atherectomy remains unknown. METHODS: Through the evaluation of the potential of low-speed rotational atherectomy (LSRA) in in-vitro experiments, minimum lumen diameter (MLD) and minimum lumen area (MLA) after conventional high-speed rotational atherectomy (HSRA group) and those after LSRA following HSRA (LSRA+HSRA group) treated by 1.5 mm burrs were measured by optical frequency domain imaging (OFDI) in 30 consecutive human lesions. RESULTS: The in-vitro experiments demonstrated that MLD and MLA after LSRA+HSRA were significantly larger (MLD: LSRA+HSRA=1.50 ±0.05 mm, HSRA= 1.43 ±0.05 mm, p=0.015; MLA: LSRA+HSRA= 1.90 ±0.17 mm2, HSRA= 1.71±0.11 mm2, and p= 0.037), requiring more crossing attempts (LSRA= 134 ±20 times, HSRA= 72 ±11 times, and p< 0.001). In human studies, there was no significance in reference vessel diameter and lesion length before the procedure between two groups. MLDs after LSRA+HSRA were significantly larger than those in HSRA (LSRA+HSRA= 1.22 ±0.16 mm, HSRA= 1.07 ±0.14 mm, and p= 0.0078), while MLAs after LSRA+HSRA tended to be larger (LSRA+HSRA= 1.79 ±0.51 mm2, HSRA= 1.55 ±0.47 mm2, and p= 0.19). There was no significance in the occurrence of in-hospital complication, including slow flow or no reflow, major dissection, and procedural myocardial infarction, between LSRA+HSRA and HSRA. CONCLUSIONS: LSRA can achieve larger lumen gain compared, whereas HSRA can pass calcified lesions easily. Combination of LSRA and HSRA is a safe and feasible strategy for severely calcified lesions in clinical practice.