Laser Angioplasty

Light amplification by stimulated emission of radiation (LASER) angioplasty utilizes highly organized light emitted from optical fibers at the catheter tip to destroy obstructing atherosclerotic tissue. The two types of systems currently available are the excimer laser coronary angioplasty (ELCA), which emits light with wavelength 308 nm, and the holmium yttrium-aluminum-garnet (Ho:YAG), which emits light with wavelength 2100 nm. The specific effects on atherosclerotic tissue (vaporization, direct molecular breakdown, or ejection of debris) depend on the source of energy used. Laser angioplasty requires adjunctive balloon angioplasty to achieve an optimal angiographic result in greater than 90% of cases (11), giving rise to the term "laser-facilitated angioplasty." The New Approaches to Coronary Intervention (NACI) registry of 1000 lesions in 887 patients reported a high procedural success rate (84%) and low rates of death (1.2%), Q wave MI (0.7%), and CABG surgery (4.5%) with ELCA (12). Three randomized controlled trials have been performed using laser angioplasty. In the Laser Angioplasty vs Angioplasty (LAVA) trial (13), 215 patients were randomized to PTCA or laser-facilitated angioplasty. Compared to conventional PTCA, excimer laser-facilitated angio-plasty resulted in a more complicated hospital course, including a significantly higher rate of nonfatal MI (4.3 vs 0%, p = 0.04) without immediate or long-term clinical benefits. In the Excimer Laser Rotablator and Balloon Angioplasty for the treatment of Complex Lesions (ERBAC) trial (14), 620 patients with complex lesions were random ized to rheolytic, excimer laser-facilitated, or PTCA therapy. In this trial, there was an increased risk for target vessel revascularization in the ELCA group (46 vs 32% for PTCA, p = 0.013), though rates of procedural success were similar. Finally, the Amsterdam-Rotterdam (AMRO) trial (15) randomized 308 patients with stable coronary artery disease (CAD) and complex lesions with length >10 mm to laser-facilitated or stand-alone balloon angioplasty. Angiographic and procedural success rates were similar, but there was a trend towards an increase in restenosis at 6 mo with laser (51.6 vs 41.3%, p = 0.13).

The technique of laser-facilitated angioplasty is primarily used to treat complex lesions (i.e., diffuse, ostial, and vein-graft lesions) not suited for conventional PTCA and stenting, and it is relatively contraindicated with heavily calcified and tortuous vessels. Failure to achieve large residual lumen diameters without adjunctive PTCA is a significant limitation of ELCA. Dissection is the major complication associated with this procedure, although it usually does not result in acute vessel closure, and has been reduced by the use of saline solution flush techniques during the procedure (16). Special training required in laser safety for operators and cardiac catheterization laboratory personnel also limits its use.

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