Excimer laser in management of underexpansion of a newly deployed coronary stent

We report the successful management of underexpansion of a newly deployed coronary stent refractory to balloon dilatations. Direct stenting was performed for a lesion in the mid left anterior descending artery (without angiographically apparent heavy coronary calcification). The stent remained underexpanded despite repeated balloon dilatations including with high‐pressure inflations. Subsequently, an excimer laser catheter was used in an attempt to vaporize the plaque by the accoustomechanical effect of the rapidly exploding bubbles. The overall angiographic result was good after further balloon dilatation with ordinary pressure and full stent expansion was achieved. Management of underexpansion of a newly deployed stent is a potential indication of laser angioplasty. © 2013 Wiley Periodicals, Inc.     

Successful excimer laser angioplasty following unsuccessful primary balloon angioplasty

We report five patients where excimer laser coronary angioplasty facilitated successful balloon dilatation of heavily calcified lesions that could not be dilated by conventional angioplasty techniques alone. In each case, the lesion was crossed successfully with a guide wire. Conventional angioplasty failed because of inability to cross the lesion with a balloon (four lesions) or inability to dilate the lesion with balloon inflation (two lesions). These cases illustrate an indication for excimer laser coronary angioplasty as an adjunctive procedure in heavily calcified coronary stenoses. © 1993 Wiley-Liss, Inc.     

Trapping as retrieval technique to resolve a ruptured and entrapped coronary balloon catheter

A 69 year old male, with a previous percutaneous revascularization of the mid‐circumflex with a bare metal stent in 2007 was admitted to our centre for unstable angina. The angiography showed a severely calcified coronary tree with a functionally severe plaque on the proximal left anterior descending artery (LAD) and a critical focal lesion on the proximal right coronary artery. After a high pressure predilation on the proximal LAD, the balloon ruptured causing a retrograde LAD‐left main (LM) dissection that was rapidly sealed with three overlapping zotarolimus‐eluting stents from medial LAD to LM. We then used a new non‐compliant balloon for successive aggressive postdilation. After a difficult handling, when the balloon catheter was pulled out of the body and we realized that the tip and membranous part of the balloon‐catheter was separated from the rest, and entangled at the LM. After a first approach to retrieve the dislodged balloon with a snare, the ruptured balloon was successfully removed by trapping and withdrawing the whole system, including the guiding catheter and the wire.     

Accidental retrieval of a fully deployed stent: A case report

We describe a case of accidental retrieval of a fully deployed stent in ostial left anterior descending (LAD) artery. This occurred while attempting stent delivery in obtuse marginal (OM) artery due to entrapment of a wire which inadvertently had passed through the struts of ostial LAD stent. The proposed mechanism and recommendations to avoid this rare complication are discussed. © 2015 Wiley Periodicals, Inc.     

单中心准分子激光冠状动脉消融术治疗复杂冠状动脉病变的安全性和有效性分析

目的 探讨准分子激光冠状动脉消融术(ELCA)在复杂冠状动脉病变中的安全性和有效性。方法 纳入2018年12月—2021年1月江苏大学附属医院心内科行ELCA辅助介入治疗的复杂冠状动脉病变病例5例共6处病变,观察ELCA成功率、PCI成功率和临床成功率,以及PCI并发症、术后住院期间和6个月随访期主要不良心脏事件(MACE)。结果 6处病变均为支架内再狭窄,其中完全闭塞病变3处,严重钙化病变1处,三支病变比例40.0%。ELCA成功率、PCI成功率和临床成功率均为100%,PCI并发症为0。光学相干断层扫描见ELCA处理后局部内膜撕裂(7.00±3.46)处,PCI后相较ELCA处理后无论最小管腔直径(MLD)[(2.56±0.27) mm比(1.47±0.37) mm,P=0.006]还是最小管腔面积(MLA)[(6.48±1.16) mm²比(2.14±0.62) mm²,P=0.005]均明显增加。住院期间MACE发生率为0,6个月内发生MACE 3例,其中2例心绞痛,1例心肌梗死,均行靶血管血运重建。结论 ELCA辅助治疗复杂冠状动脉...     

Excimer laser facilitated percutaneous coronary intervention of a nondilatable coronary stent.

A patient is described in which excimer laser percutaneous coronary intervention is performed inside a suboptimally expanded stent due to nondilatable calcified plaque. The use of excimer laser facilitated full expansion of the stent with a balloon.     

The effectiveness of excimer laser coronary atherectomy with contrast medium for underexpanded stent: The findings of optical frequency domain imaging

Stent underexpansion is a risk factor for in‐stent restenosis (ISR) and stent thrombosis. Although excimer laser coronary atherectomy (ELCA) with contrast medium was shown to be effective to improve stent underexpansion in undilatable lesions, precise mechanism of this technique was not well understood. We report a case of ISR with stent underoptimal implantation within a circumferential‐calcified atherosclerotic plaque beneath the stent strut that could not be dilated by repeated high‐pressure balloon inflations. After rotational atherectomy, the mechanism of the underexpanded lesion could be obtained by optical frequency domain imaging (OFDI). High‐pressure balloon could not dilate the underexpanded stent. Since ELCA with saline flush only gave intimal erosions and minor dissections, additional high‐pressure balloon was also ineffective. Finally, ELCA with contrast medium could disrupt the calcific lesion beneath the underexpanded stent. The angiographic and OFDI findings confirmed the full stent expansion could be accomplished by further balloon dilatation with an ordinary pressure. ELCA with contrast medium is feasible to improve stent underexpansion by disrupting the calcified plaque behind the stent strut. © 2015 Wiley Periodicals, Inc.     

Intracoronary embolization and retrieval of radio-opaque ring marker on the ACS multi-link stent sheath

We report a case of intracoronary embolization of a ring marker on a stent sheath. The Microsnare device was unsuitable because of the distal position of the marker. After failing to retrieve the marker using an over-the-wire balloon and the two-wire technique, we succeeded in removing the marker using a balloon-on-wire system. Cathet. Cardiovasc. Diagn. 43:306–307, 1998. © 1998 Wiley-Liss, Inc.     

Novel use of a high‐energy excimer laser catheter for calcified and complex coronary artery lesions

This study was designed to evaluate safety and effectiveness of the 0.9 mm excimer laser coronary catheter with increased laser parameters. We report a prospective trial of 100 calcified and/or balloon‐resistant lesions where a new 0.9 mm excimer laser catheter was used at standard or higher energy level to facilitate angioplasty. Standard in‐hospital clinical and angiographic parameters were collected and measured. Laser technical success was obtained in 87 lesions (92%), procedural success was reached in 88 lesions (93%), and clinical success in 82 lesions (86%). Increased laser parameters were used for 29 resistant lesions. This new 0.9 mm excimer laser coronary catheter using higher energy parameters seems to be safe and effective for management of calcified and nondilatable lesions. Catheter Cardiovasc Interv 2004;62:155–161. © 2004 Wiley‐Liss, Inc.     

Lost and found: Coronary stent retrieval and review of literature

A 61‐year‐old man with a history of percutaneous coronary intervention (PCI) of the mid right coronary artery (RCA) with a drug eluting stent (DES), presented with non‐ST segment elevation myocardial infarction. Coronary angiography demonstrated complex disease of the distal RCA as well as in‐stent stenosis of the previously placed mid RCA stent. The patient underwent bifurcation PCI of the distal RCA followed by attempted intervention with a DES on the mid RCA lesion. The stent could not cross the lesion and eventually became dissociated from its delivery system. The lost stent was successfully retrieved using two different snaring systems. The procedure was terminated without further attempts for stent delivery. The patient had an uneventful recovery and underwent successful PCI of the mid RCA lesion one month later.     

Evaluation of the long-term functional outcome assessed by myocardial perfusion scintigraphy following excimer laser angioplasty compared to balloon angioplasty in longer coronary lesions

Objectives: Evaluation of the long-term functional outcome assessed by exercise myocardial perfusion imaging following excimer laser angioplasty compared to balloon angioplasty in coronary lesions >10 mm in length. Background: Previous randomized studies evaluating the effect of coronary interventions mainly focused on the long-term clinical and angiographic outcome. The functional outcome, assessed by myocardial perfusion scintigraphy, has not been evaluated in a randomized setting. Methods: A total of 308 patients with stable angina and a longer coronary lesion (>10 mm) were randomized to excimer laser angioplasty or balloon angioplasty. A ^99mTechnetium-2-methoxy isobutyl isonitrile (MIBI) single-photon emission computed tomography (SPECT) study was performed in 139 patients before the initial angioplasty procedure and at 6 months follow-up (73 patients in the laser group versus 66 patients in the balloon group, respectively). Exercise tolerance at follow-up was compared to baseline values by means of exercise duration and double product at peak exercise. Myocardial perfusion of the randomized vascular bed was assessed semi-quantitatively on the MIBI SPECT images. The reversible defects were graded as mild, moderate or severe. Myocardial perfusion at follow-up was expressed as a percentage reduction in incidence and grading of the reversible defects compared to baseline values. Results: Forty-four (61%) patients assigned to laser angioplasty were asymptomatic at 6 months follow-up compared to 34 (52%) patients assigned to balloon angioplasty (p = NS). Improvement in exercise duration and double product were 0.7 ± 2.1 min and 4.3 ± 6.2 min/mmHg/1000, respectively, in the laser group, versus 0.3 ± 2.5 min and 3.1 ± 5.5 min/mmHg/1000, respectively, in the balloon group (both p = NS). The percentage reduction of reversible defects was 23% in patients assigned to laser angioplasty vs. 29% in patients assigned to balloon angioplasty (Relative risk [RR]: 0.79, 95% confidence interval [CI]: 0.40–1.57; p = 0.50). The mild, moderate and severe reversible defects improved in 44.4, 63.6 and 66.6%, respectively, in the laser angioplasty group vs. 66.6, 53.8 and 90%, respectively, in the balloon angioplasty group. None of the comparisons were significantly different. Conclusion: Excimer laser angioplasty compared to balloon angioplasty in coronary lesions >10 mm in length yields a similar long-term functional outcome assessed by anginal status, exercise tolerance and myocardial perfusion.     

Cutting-balloon angioplasty before drug-eluting stent implantation for the treatment of severely calcified coronary lesions

Background Severely calcified coronary lesions respond poorly to balloon angioplasty, resulting in incomplete and asymmetrical stent expansion. Therefore, adequate plaque modification prior to drug-eluting stent （DES） implantation is the key for calcified lesion treat- ment. This study was to evaluate the safety and efficacy of cutting balloon angioplasty for severely calcified coronary lesions. Methods Ninety-two consecutive patients with severely calcified lesions （defined as calcium arc 〉 180% calcium length ratio 〉 0.5） treated with bal- loon dilatation before DES implantation were randomly divided into two groups based on the balloon type： 45 patients in the conventional balloon angioplasty （BA） group and 47 patients in the cutting balloon angioplasty （CB） group. Seven cases in BA group did not satisfactorily achieve dilatation and were transferred into the CB group. Intravascular ultrasound （IVUS） was performed before balloon dilatation and after stent implantation to obtain qualitative and quantitative lesion characteristics and evaluate the stent, including minimum lumen cross-sectional area （CSA）, calcified arc and length, minimum stent CSA, stent apposition, stent symmetry, stent expansion, vessel dissection, and branch vessel jail. In-hospital, 1-month, and 6-month major adverse cardiac events （MACE） were reported. Results There were no statistical differences in clinical characteristics between the two groups, including calcium arc （222.2° ± 22.2° vs. 235.0° ± 22.1 °, p=0.570）, calcium length ratio （0.67 ± 0.06 vs. 0.77± 0.05, P = 0.130）, and minimum lumen CSA before PCI （2.59 ±0.08 mm2 vs. 2.52 ± 0.08 mm2, P = 0.550）. After stent implantation, the final minimum stent CSA （6.26 ± 0.40 mm2 vs. 5.03 ± 0.33 mm2; P = 0.031） and acute lumen gain （3.74 ±0.38 mm2 w. 2.44 ± 0.29 mm2, P = 0.015） were significantly larger ila the CB group than that of the BA group. There were not statis tically differences in stent expansion, stent symmetry, incomplete stent apposition, vessel dissection and branch vessel jail between two groups. The 30-day and 6-month MACE rates were also not different. Conclusions Cutting balloon angioplasty before DES implantation in severely calcified lesions appears to be more efficacies including significantly larger final stent CSA and larger acute lumen gain, without increasing complications during operations and the MACE rate in 6-month.     

Safety and feasibility of orbital atherectomy for the treatment of calcified coronary lesions

Objective: The ORBIT I trial evaluated the safety and performance of an orbital atherectomy system (OAS) for the treatment of de novo calcified coronary lesions. Background: Severely calcified coronary arteries pose an ongoing treatment challenge. Stent placement in calcified lesions can result in stent under expansion, malapposition, and procedural complications. OAS treatment may change calcified lesion compliance to reduce procedural complications and facilitate stent placement. Methods: The ORBIT I trial, a prospective, nonrandomized study, was conducted in two centers in India. Fifty patients with de novo calcified coronary lesions were enrolled. Patients were treated with the OAS followed by stent placement. Results: The average age of the patients was 57.4 years and 90% were male. Mean lesion length was 13.4 mm. The average number of OAS devices used per patient was 1.3. Device success was 98%, and procedural success was 94%. The cumulative major adverse cardiac event rate was 4% in‐hospital (two non–Q‐wave myocardial infarctions), 6% at 30 days (one additional non–Q‐wave myocardial infarction leading to target lesion revascularization), and 8% at 6 months (one additional event of cardiac death). Angiographic complications were observed in seven patients (six dissections and one perforation). Conclusion: The ORBIT I trial suggests that the OAS may offer an effective method to change compliance of calcified coronary lesions to facilitate optimal stent placement in these difficult to treat patients. A larger trial is required to establish safety and overall effectiveness of the OAS in treating calcified coronary lesions. © 2012 Wiley Periodicals, Inc.     

Recanalization of chronic coronary occlusions using a laser wire

Between August, 1993–December, 1994, recanalization of a chronically occluded coronary artery was attempted in 412 patients, with an overall success rate of 77%. The main reason for failure was subintimal tracking of the guide wire. However, in 13 patients, advancing the guide wire was not possible either subintimally or in the former true lumen. In 8 of these 13 patients with failed conventional recanalization, a second attempt was made using a 0.018′ laser wire. The suspected occlusion duration was 6 wk–6 yr, and the occlusion length 6–21 mm. Successful crossing of the occlusion was achieved in 7 of 8 patients. One patient experienced pericardial hematoma without severe clinical consequences. Adjunctive conventional laser angioplasty and/or balloon dilatation led to a residual stenosis of <50% in 7 patients. The laser wire technique may become an important new method for recanalizing chronic total coronary occlusions in selected patients. © 1996 Wiley-Liss, Inc.     

Method of preparing,mounting, and implanting a palmaz-schatz coronary half-stent from the stent delivery system

Full-length 15 mm Palmaz-Schatz coronary stents currently come premounted in a specially designed stent delivery system. A method is described for obtaining a bare half-stent from this system and mounting it onto a balloon catheter. The technique of half-stent delivery and implantation is discussed and is illustrated by a case example. © 1995 Wiley-Liss, Inc.     

Acute closure during coronary excimer laser angioplasty and conventional balloon dilatation: a comparison of management outcome and prediction

Of 523 consecutive patients undergoing elective percutaneoustransluminal coronary angioplasty (PTCA) and 83 patients treatedwith coronary excimer laser angioplasty (ELCA), 17 (3.3%) hadin-laboratory occlusion following PTCA and 25 (30%)followingELCA; they were enrolled into a prospective study. Successfulmanagement (reopened vessel, patency at repeat angiography within24 h, no death, no myocardial infarction (MI), no emergencybypass surgery) including repeat lasing, subsequent PTCA, useof intracoronary nitroglycerin or streptokinase was achievedin 24 (96%) of the 25 patients with acute occlusion during ELCA.An anterior MI occurred in one patient of the laser group. Repeatballoon dilatation was successfully performed in seven of the17 patients (41%) with acute closure during PTCA. Among the10 patients with persistent occlusion after PTCA, five developeda limited myocardial infarction (35%). One patient requiredemergency CABG, and died peri-operatively. Severe spasm priorto occlusion defined by a new coronary flow depression withoutevidence of dissection or thrombus showed a significant positiveassociation with acute occlusion during ELCA (P =0.0008). Thus, in contrast to occlusion during PTCA, subsequent balloondilatation was successfully performed in the majority of patientswith acute occlusion during ELCA, implying that different underlyingmechanisms are responsible for this complication. In this limitedpatient group, occlusion after excimer laser angioplasty wasmuch more frequent than closure during PTCA, but was infrequentlyassociated with major events such as myocardial infarction ordeath.     

Percutaneous closure of a coronary aneurysm with a vein-coated stent

Coronary artery aneurysm is a rare but recognized complication following percutaneous intervention. We report the formation of such an aneurysm after recanalization with Excimer laser wire of a chronic totally occluded left anterior descending coronary artery and stent implantation and its subsequent treatment using an autologous vein graft-coated stent. Cathet. Cardiovasc. Diagn. 43:308–310, 1998. © 1998 Wiley-Liss, Inc.     

Successful retrieval of a firmly stuck rotablator burr by using a modified STAR technique

Rotablator burr entrapment occurring during rotational atherectomy is a rare but serious complication that can lead to coronary occlusion and require emergency cardiac surgery. Although several bailout techniques for stuck burrs have been proposed, no definitive methods for removal have been established. We report here a difficult case of a stuck rotablator burr, in which various techniques failed to retrieve the burr. It was ultimately removed using the subintimal tracking and reentry (STAR) technique with a 3‐g tapered tip hydrophilic wire. This modified STAR technique, which was originally developed for percutaneous coronary intervention for chronic total occlusion, may be useful as a bailout technique in patients with a firmly stuck rotablator burr that cannot be removed by using standard procedures. © 2015 Wiley Periodicals, Inc.