Overview of new technologies for lower extremity revascularization.

Lower extremity peripheral arterial occlusive disease poses a unique challenge to traditional angioplasty-based endovascular therapies. The diffuse nature of lower extremity atherosclerotic disease, the presence of chronic total occlusions, poor distal runoff, and the presence of critical limb ischemia all have contributed to the disappointing results of balloon angioplasty for complex infrainguinal arterial disease. These challenges have spawned the development of a host of new technologies in an attempt to improve the safety and effectiveness of percutaneous revascularization for lower extremity peripheral arterial occlusive disease. This review summarizes the recent advances in available technologies, including novel angioplasty balloons; nitinol stents, stent grafts, and drug-eluting stents; excisional, laser, and rotational atherectomy devices; devices for crossing total occlusions; true-lumen reentry devices; thrombectomy catheters; and embolic protection devices.

A retrospective analysis of laser endartherectomy assisted balloon angioplasty for popliteal and infrapopliteal peripheral arterial disease.

OBJECTIVES: To describe our single center experience with the use of laser endartherectomy assisted balloon angioplasty in popliteal and infrapopliteal arterial disease. BACKGROUND: Peripheral arterial disease (PAD) carries significant morbidity to patients. Some patients may have multiple comorbid conditions potentially limiting therapeutic options for PAD. Endovascular interventions are aimed at decreasing arterial disease symptoms, improve wound healing and ultimately limb salvage. There is limited data on below the knee PAD and simultaneous laser endartherectomy use in this anatomic location. METHODS: The cohort comprised 41 patients that underwent laser assisted balloon angioplasty from 2010 to 2013. All patients had popliteal and infrapopliteal arterial disease. Outcomes evaluated were limb salvage and symptom relief 12months following the procedure. A comparison between the patients that underwent amputation and those with limb salvage was also performed. RESULTS: All the patients had TASC II (Trans Atlantic Inter-Society Consensus) type D lesions. Most patients reported persistent PAD symptoms by six months, with 17% remaining symptom free by 12months. Affected limb salvage was 69%. Five patients (12%) died and one third of the patients had a new peripheral angiogram. In the repeat angiogram, most patients showed initial target vessel occlusion. No statistically significant differences were found between the patients that preserved their limb to those who underwent amputation. CONCLUSIONS: Laser assisted balloon angioplasty use for complex popliteal and infrapopliteal arterial disease is a therapeutic option when limb salvage is the goal. Despite this, symptom recurrence and the need for repeated angiography continue to be high.

Pulmonary vein isolation with a novel endoscopic ablation system using laser energy.

Pulmonary vein isolation (PVI) is the basis of all ablation techniques for paroxysmal atrial fibrillation. Performing conventional radiofrequency ablation for PVI is time consuming and sometimes challenging when using point-by-point applications to create continuous lesions. Small electrically conducting gaps evolving in the ablation lines may cause recurrences of atrial fibrillation or regular atrial re-entry tachycardias. Development of novel anatomically designed ablation catheters for PVI aim to facilitate the ablation procedure, to produce continuous and durable lesions with a limited number of ablation impulses and to reduce the complication rate. The endoscopic laser balloon ablation system (HeartLight® EAS, Cardiofocus Inc.) is the first system that allows direct visual guidance of energy delivery at the antral level of each pulmonary vein and uses a completely new energy source for ablation.

Devices for chronic occlusion.

Interventional cardiology has advanced into domains once believed to be beyond the reach of percutaneous procedures. As technologic advances continue to push the limits of the interventionalist's capabilities, several areas still exert considerable resistance to this forward momentum. These technically difficult frontiers include bifurcated lesions, small-vessel disease, multivessel disease, diffuse disease, and chronic total occlusions.

Limitations and pitfalls of laser angioplasty.

Overall, the initial and long-term results of LABA have been disappointing. Poor initial recanalization rates and high restenosis and hemodynamic failure rates have caused investigators to reevaluate the indications for LABA. This reevaluation has resulted in an appropriate limitation of the indications for LABA. At present, LABA is probably indicated only for the treatment of patients with symptomatic, isolated arterial occlusions in whom conventional balloon angioplasty cannot be done because mechanical recanalization using a guidewire is not possible. Other uses of LABA in patients with peripheral vascular disease are discouraged and should be considered experimental. New innovations in technology, including improved arterial imaging techniques and better laser delivery systems, are required before LABA can become a standard therapy for the treatment of patients with peripheral vascular disease. A search for an "ideal" laser wavelength for arterial recanalization is futile until these developments occur. Once these innovations are in use, laser angioplasty may be an important technique in the treatment of peripheral vascular disease. This potentially valuable tool for the vascular surgeon should not be abandoned. Rather, it should be laid aside until it is better developed.