Laser angioplasty versus balloon angioplasty: The need for imaging

The current state of clinical laser angioplasty is reviewed. Compared to balloon dilation at the beginning of the past decade, both peripheral and coronary laser angioplasty devices produce better results. Compared to current balloon angioplasty techniques, however, laser angioplasty does not seem to offer improved initial or long term results. Intravascular ultrasound imaging may help to improve laser ablation of atherosclerotic plaque. It remains to be established, however, whether precise debulking of the obstruction will result in a reduced restenosis rate compared to balloon angioplasty.     

Excimer laser coronary angioplasty: Initial experience at St. Thomas' Hospital

Photochemical ablation of coronary artery atheroma using pulsed xenon-chloride excimer laser has, over the past 18 months produced promising results. Worldwide experience amounts to some 2000 cases.In the first 6 months following installation of the Dymer 200+ laser (Advanced Interventional Systems, Irvine, California, USA) at St. Thomas' Hospital, 53 procedures have been performed in 49 patients. Of these, 52.8% were high risk (triple vessel disease, unstable angina, LV ejection fraction <35%, need to treat sole remaining coronary conduit).Complications were two in hospital deaths (18 and 48 h post-procedure-3.8%); one ELCA related myocardial infarct (1.9%); two haemorrhage requiring transfusion (3.8%); no emergency bypass graft surgery (0%).Current indications for the use of laser include: (1) long-segment diffuse disease; (2) proximal or ostial stenoses in coronary artery or graft; (3) restenosis after balloon angioplasty; (4) total occlusions crossed by a guidewire; (5) severe stenoses crossed by guidewire but not balloon; and (6) bifurcation lesions or stenoses compromising an important side-branch.Potential complications include: arterial perforation; aneurysm formation; peripheral embolization by plaque material; abrupt thrombotic closure; dissection; late sudden occlusion; spasm; and restenosis.Minor problems at the start of the programme involved: modifications to the machine to meet local laser safety requirements; special gases required for the machine; supply and design of fibre optic catheters; guiding catheters; heparin dose; dissection of the coronary artery (major and minor); and selection of patients.     

Applications and limitations of laser-assisted angioplasty

Laser-assisted angioplasty is rapidly evolving into a promising adjunct to or replacement for standard vascular procedures. A protocol was devised to evaluate the technique in a non-selected, consecutive patient population to define the applications and limitations of the technique. In a 12-month period, 358 lower-limb atherosclerotic lesions were treated with laser/balloon angioplasty [percutaneously (52%) or open (48%)] in 206 consecutive patients. Overall, the laser/balloon technique recanalised 234 lesions (65% laser success), judged clinically effective by a greater than 0.15 improvement in the ankle/brachial index and elimination of symptoms. Operative complications included: perforation (15, 4.2%); thrombosis (16, 4.5%); spasm (5, 1.4%); and false aneurysm at the puncture site (7, 2.0%). Of the 124 failures (35%) categorised for analysis, the most common cause was inability to cross the lesion in 20 cases. This experience has identified three significant clinical limitations to successful laser recanalisation: calcification, inadequate distal circulation, and inability to control restenosis/reocclusion (collapsible lesions and accelerated plaque deposition). Further research is needed to determine if thermal injury seriously compromises the safety and long-term outcome of laser-assisted angioplasty.     

Current multicentre studies with the excimer laser: design and aims

. Excimer laser ablation to remove atherosclerotic plaque has been used for over a decade as a methodology to treat cardiovascular disease. Improvements in the technique and technology of excimer laser angioplasty, coupled with the recognition of new clinical opportunities for this treatment modality, have resulted in a resurgence of interest in the laser. Three clinical trials are now being conducted to explore potential applications, including the LARS trial of excimer laser versus balloon angioplasty to treat in-stent restenosis, the PELA trial of excimer laser angioplasty in occluded superficial femoral artery disease, and the LACI trial of excimer laser angioplasty in limb-threatening ischaemia. This article describes the rationale and objectives of these new approaches to some of the more challenging problems in cardiovascular disease.     

Area ablation: a new lasing concept provides significantly enhanced acute and long-term results for treatment of in-stent restenosis

BACKGROUND AND OBJECTIVES: Debulking is still a technique of choice for in-stent restenosis (ISR). Excimer laser debulking has enabled high procedural success with very low complication rates, but has demonstrated markedly heterogeneous results owing to differences in lasing and laser technology, and selected patient populations. Since new area-ablation technique enables ablation of larger areas than its own device size, we have evaluated their effectiveness and safety in an uncontrolled study. STUDY DESIGN/MATERIALS AND METHODS: Fifty-three patients with diffuse ISR were treated by laser area ablation, followed by adjunctive balloon angioplasty. Primary endpoint was percent of binary stenosis at 6-month follow-up; secondary endpoints were procedural success; target lesion revascularization (TLR); major adverse cardiac events (MACE); diameter stenosis (DS); and minimal lumen diameter (MLD) before and after laser debulking, and at 6-month follow-up. RESULTS: Laser debulking was feasible (as defined as < or =30% residual stenosis) in 98.1% of patients. At 6-month follow-up, binary stenosis was 26.4%; angiographic TLR, 20.7%; and MACE, 3.7%. DS decreased from 87+/-17% to 20 +/- 9% after laser debulking, and to 9+/-7% after PTCA; it was 29+/-14% at follow-up (P-values in comparison to baseline: 0.0047; 0.0036; 0.0064). MLD increased from 0.6+/-0.3 to 2.4+/-0.5 mm after laser debulking, to 2.8+/- 0.6 mm after adjunctive PTCA, and to 1.9 +/- 0.4 mm at follow-up (P-values in comparison to baseline: 0.0059; 0.0031; 0.0088). CONCLUSIONS: Owing to a significantly greater MLD, area ablation facilitates significantly enhanced immediate and follow-up results for diffuse ISR, including a simpler and more effective laser-debulking procedure than former lasing techniques.     

Initial experience with the "Smart" laser in the treatment of atherosclerotic occlusions

A dual laser system capable of distinguishing atherosclerotic plaque from components of normal arterial wall was used to deliver laser energy to cut a channel through occluded vessels. This system was used to facilitate balloon angioplasty of short (3-17 cm) total occlusions of the superficial femoral or popliteal arteries in 17 patients. In 10 patients the occluding lesion was traversed by the laser wire and patency was effectively restored by balloon angioplasty. Satisfactory luminal patency has persisted for 2 to 12 months (mean 6 months) in 9 cases; the lesion in the tenth patient restenosed at 3 months. The laser procedure was unsuccessful in all 3 cases with occlusions over 10 cm and in 4 others. There were no clinically important complications. This experience suggests that most patients who presently require interventional treatment can be managed by standard angioplasty methods and/or require a bypass operation. The "Smart" laser is safe and effective short-term in facilitating angioplasty in some patients in whom standard angioplasty techniques are not feasible. The implications of these findings are discussed.     

Recanalization of infrainguinal vessels: silverhawk, laser, and the remote superficial femoral artery endarterectomy

There are multiple endovascular options to achieve percutaneous revascularization of chronic superficial femoral artery (SFA) stenoses and occlusions. Most rely on forceful displacement of plaque via balloon angioplasty, either as a stand-alone therapy or supplemented by cold thermal injury (cryoplasty), microtome assistance (cutting balloon angioplasty), nitinol stent deployment, or expanded polytetrafluoroethylene-lined nitinol stent deployment. Excellent technical success rates are routinely described in the literature. The essential problem associated with these techniques is the predictable compromise of the initial result by neointimal hyperplasia leading to poor long-term results. An alternative to forceful displacement techniques is use of directional atherectomy or excimer laser to debulk the atheromatous lesion, with the addition of low-pressure angioplasty or stent deployment as needed. Currently, directional atherectomy is performed using the Silverhawk Plaque Excision System (FoxHollow, Redwood City, CA), while laser atherectomy is frequently performed with the CLIRpath Excimer Laser (Spectranetics Corp., Colorado Springs, CO). While both techniques can be utilized for de novo atherosclerotic lesions, even eccentric lesions or ostial lesions, proponents of these devices have also shown good short-term results in the treatment of restenoses. Remote SFA endarterectomy with the Aspire stent (Vascular Architects, San Jose, CA) is a hybrid surgical and endovascular technique that is useful for debulking plaque from the SFA with adjunctive stenting of the distal SFA. We present a review of various alternative techniques to forceful balloon dilation used in the recanalization of the SFA with potential pitfalls and complications, along with a review of literature associated with each of these techniques.     

Next generation catheters for excimer laser coronary angioplasty

. In response to the need for maximising debulking in complex lesions, three new excimer laser coronary angioplasty catheter designs have been introduced. The eccentric laser catheter features a fibreoptic bundle disposed opposite the guide-wire lumen at the catheter tip and a torque mechanism that allows the user to rotate the fibre bundle toward the lesion mass. Residual lumens 50% larger than the catheter tip diameter have been obtained when multiple passes were made, with each pass performed using a different tip rotation. A recent case series utilising this catheter in restenosed stents resulted in larger lumens and lower 6-month restenosis rates. The optimal spaced (OS) laser catheter features a fibre bundle placed concentrically around the guide-wire lumen. The 61 μm diameter core fibres are spaced at a nominal centre-to-centre distance of 90 μm, resulting in a 40% increase in ablative area as compared to previous concentric catheter designs. In vitro testing and clinical evaluation demonstrated OS catheters routinely achieve an ablated area ≥90% of the catheter tip size. The 0.9 mm catheter features a high-density fibre pack composed of 65 fibres. Peripheral dead space has been minimised to maximise penetration of calcified plaque. When combined with laser parameters of up to 80 mJ/mm², and 80 Hz pulse repetition rate, the catheter demonstrated improved hard tissue and calcified tissue penetration in vitro. Clinical evaluation in Canada revealed a 94% lesion recanalisation rate in high-grade stenoses with angiographic evidence of calcification, chronic total occlusions, and lesions which have failed balloon angioplasty.     

Excimer laser revascularisation: current indications, applications and techniques

. The ultraviolet pulsed excimer laser (308 nm wavelength) is currently the only laser approved by the FDA for percutaneous intervention in patients with ischemic coronary artery disease. The clinical presentation of the treated patients varies from stable and unstable angina to acute myocardial infarction. Potential advantages of excimer laser revascularisation in acute coronary syndromes and in ischaemic obstructive peripheral vascular disease include concomitant plaque debulking and thrombus removal; absence of systemic lytic state; shortened thrombus clearing time and facilitation of adjunct balloon angioplasty and stenting. Improved understanding of laser–tissue interactions and positive clinical outcomes through the use of safe lasing techniques have led to expansion of indications/applications for laser angioplasty. These include stent restenosis, complex lesions and thrombotic stenoses, bifurcation lesions, balloon failure, total occlusions, focal saphenous vein graft lesions and peripheral arterial obstructions. The excimer laser can be effectively utilised in patients with depressed left ventricular ejection fraction and does not require implantation of a temporary pacemaker as no-reflow phenomenon and severe arrhythmias are rarely encountered. Careful case selection, proper utilisation of equipment and incorporation of efficient lasing techniques play a crucial role in effective and safe cardiovascular laser applications.     

Indications of coronary angioplasty and stenting in 2003: what is left to surgery?

For many years, coronary artery by-pass graft (CABG) remained the only effective treatment of multivessel disease compared to medical treatment. The first technical revolution was in 1977 when Gruentzig introduced balloon percutaneous transluminal coronary angioplasty (PTCA), the 2nd in the 90's with the developments of stents and antiaggregant protocols. The equipment for PTCA became more and more sophisticated, and the skill of cardiologists greater. In the 90's, interventional cardiology played a predominant role in revascularization as the number of CABG decreased at the same time, and emergency CABG for bail out almost disappeared (0% to 0.5%). Systematic stenting decreased the need for repeat revascularization to about 18-20% nowadays in the majority of centers, except in diabetic patients. Despite this fact restenosis remains the pitfall of angioplasty, mostly in diabetic patients presenting multivessel disease in which surgery with "all arterial grafts" gives good long term RESULTS: The first studies comparing PTCA and CABG are favourable to surgery (BARI), then late ones using stents (ARTS, ERACI 2) showed that stenting was at least equivalent to CABG, in terms of mortality or serious complications (major acute coronary events, MACE), despite a higher target vessel revascularisation (TVR) mainly due to restenosis in the angioplasty cohort. The same results are observed by stenting a high risk lesion as the unprotected left main stenosis can be, until then treated surgically. However, high volume centers studies treating by PTCA+stent the unprotected left main artery (LMA) shows that the 1 year survival rate is similar to surgery, but always related to a restenosis rate of 20% at 6 months in the stent group, which represents the only significant difference in terms of MACE; the new drug eluting stents lead us to expect, according to SIRIUS and TAXUS II studies, to reduce the restenosis rate, and by the way, the MACE could be dramatically lowered from 50% to 60%. Randomised studies would be necessary, but the extrapolation of the actual data, more particularly results of subgroups with a high risk of restenosis, diabetic patients and small vessels, lead us to think that stenting could come in first intention before surgery if TVR is significantly reduced. A complex anatomy, failed attempted chronic occlusion, several lesions on tortuous vessels, would remain the last surgical indication if CABG provides a more complete revascularization. The impact of these new drugs seems promising. However, we should await early results of studies in diabetic patients and bifurcations. But in high volume experienced centers, CABG indications would be reduced in the future to the technical pitfalls of stenting (complex or tortuous anatomy, chronic occlusions) or to the adverse additional cost of this device, unless reduction of restenosis or TVR could also cancel this extra cost. We expect randomised studies CABG versus stented angioplasty using drug eluting stents to confirm these preliminary data.     

Coronary revascularization in heart transplant recipients by excimer laser angioplasty

BACKGROUND AND OBJECTIVE: Aggressive development of allograft coronary artery disease is a major cause of death in heart transplant recipients. Percutaneous balloon angioplasty is considered suboptimal for complex lesions in native coronary vessels and heart transplant recipients, alike. Excimer laser energy (308-nm wavelength) can successfully remove and vaporize atherosclerotic plaques in native coronary vessels; however, its application in heart transplant recipients has not been studied clinically yet. STUDY DESIGN/MATERIALS AND METHODS: Six heart transplant recipients underwent percutaneous excimer laser (CVX-300, Spectranetics, Colorado Springs, CO) coronary angioplasty for treatment of a total of 10 discrete, obstructive coronary artery lesions. By using concentric or eccentric multifiber laser catheters, energy parameters were set at a fluence of 45 mJ/mm(2) or 60 mJ/mm(2) with a frequency of 25 Hz and 40 Hz, respectively, with a pulse duration of 135 ns and output of 200 mJ/pulse. The "saline flush" and "pulse and retreat" lasing techniques were used. In each case, adjunct balloon angioplasty was performed; in five lesions, an intracoronary stent was implanted. Angiographic evaluation was performed by visual assessment. RESULTS: Each procedure was successful as defined by laser recanalization of the target lesion (reduction of target lesion stenosis in more than 20%) and subsequent adequate final luminal patency (reduction of target lesion stenosis to less than 50%) and absence of any major in-cardiac catheterization complication (such as perforation, acute closure, dissection, emergency coronary artery bypass surgery), or in-hospital complications (such as death, myocardial infarction, cardiac enzyme elevation, major bleeding), or need for surgical revascularization. A 92 +/- 5% preprocedural percent diameter stenosis was reduced by laser to 35 +/- 16% and by adjunct balloon angioplasty in all lesions and stenting in five lesions, to final residual stenosis of 2 +/- 6%. Angiographic follow-up between 2 and 6 months after the procedure demonstrated a target lesion restenosis rate of 22%. CONCLUSION: Percutaneous excimer laser is safe and efficacious in the treatment of focal obstructive lesions caused by allograft coronary artery disease. These data represent an early clinical experience; thus, the long-term outcome of this revascularization method in recipients of heart transplantation will have to be determined by a large scale prospective, randomized, multicenter clinical study.     

The clinical significance of coronary angioscopy in patients with coronary heart disease

Summary The feasibility and safety of coronary endoscopy was evaluated in three sets of investigations: in 7 cadaver hearts, in 11 patients undergoing coronary bypass surgery, and in 30 patients during routine cardiac catheterization prior to coronary balloon angioplasty (PTCA). In three of the seven cadaver hearts the lumen of the arteries appeared normal. In three diffuse atherosclerotic lesions, and in one, a high-grade, tight stenosis were observed. In nine of eleven patients in the operation room, the lesions of interest could be visualized, and high-grade stenoses were found in all. In addition, in three patients with unstable angina pectoris, fresh thrombi were seen at the site of stenosis. In six of the nine patients, the periphery of the native coronary vessel was found to have no further stenotic regions. During cardiac catheterization in 17/30 patients, the lesion of interest could be examined angioscopically, and in 13 instances the stenosis appeared excentric and irregularly shaped. In three instances, multiple ulcerations were seen in the stenotic area. In two of the five patients, intimal ruptures were found following PTCA, which could not be documented angiographically. Coronary endoscopy provides valuable additional information on the nature and appearance of atherosclerotic lesions. It can be performed clinically without great harm to the patients. Despite some limitations, it will probably become a routine diagnostic tool in patients undergoing routine coronary angiography, balloon angioplasty or high-frequency angioplasty, and coronary bypass grafting.     

Percutaneous recanalization of arteries: Status and prospects of laser angioplasty with modified fibre tips

Percutaneous balloon dilatation of arterial stenoses is a firmly established non-surgical treatment of ischaemic disease. The number of percutaneous transluminal coronary angioplasties performed per year in the USA approaches the number of coronary artery bypass graft operations. A great number of novel percutaneous recanalization schemes address the major problems of balloon angioplasty: failure to cross the stenosis (occlusion), failure to dilate effectively (15–20%), acute complications (5%) and re-stenosis within six months (30–40%). Laser energy can effectively evaporate atheromatous plaque, but delivery by an unmodified bare fibre creates only a small channel and carries a high risk of vessel-wall perforation in the coronary arteries. It appears impossible to maintain an axial position in small, tortuous and moving arteries with multiple side-branches. Coronary lesions are anatomically and structurally heterogeneous. Reduction of the perforation risk is being approached by four strategies: (a) optimization of the power source; (b) enhancement of laser-light absorption by plaque relative to artery wall; (c) improvement of plaque recognition; and (d) modification of the delivery system, which is discussed in detail. Recanalization of occluded femoropopliteal arteries with the 2.0-mm metal laser probe has proved to be safe and effective in more than 100 patients. The 2.2-mm rounded sapphire contact probe has been used with success in the peripheral arteries of over 30 patients. The recanalization mechanism of both probes is not yet fully understood. Closed-chest attempts at recanalization of coronary arteries by the 1.7-mm metal laser probe have been reported in 13 patients, with success in the majority. There were no complications requiring emergency surgery. The possible occurrence of embolism or spasm in three cases warrants a cautious approach to application of the metal laser probe in the coronary catheterization room. The primary benefit of laser recanalization with modified fibre tips is the possible transformation of a candidate for surgery into a candidate for balloon angioplasty. It remains to be established whether prior laser debulking of the atheroma will reduce the incidence of acute complications of balloon dilatation and will reduce restenosis in the subsequent year. In the past two years an avalanche of laser and non-laser recanalization schemes have been developed. In peripheral arteries, early results of most methods have shown an acceptably low incidence of acute perforations or other complications. The human arterial wall can take a heavy beating, both mechanically and thermally. In the next decade, catheter intervention techniques will progressively contribute to the treatment of peripheral and coronary artery disease.     

Peripheral laser-assisted balloon angioplasty. Initial multicenter experience in 219 peripheral arteries

In this multicenter clinical series of peripheral laser-assisted balloon angioplasty with an argon laser-heated, metallic-capped fiberoptic, angiographic and clinical success was achieved in a total of 155 (71%) of 219 attempted lesions. When the anatomy of the lesion was subjectively categorized by the angiographer into those considered possible or impossible to treat by conventional balloon angioplasty, clinical success was achieved in 116 (78%) of 149 lesions considered possible to treat with balloon angioplasty (39 [95%] of 41 stenoses and 77 [71%] of 108 occlusions). More importantly, clinical success was achieved in 39 (56%) of 70 lesions considered impossible to treat by conventional means. The incidence of complications, including vessel perforation (4.1%), with this new technique was equal to that reported for conventional balloon angioplasty, decreased with operator experience, and was less than that reported for argon laser angioplasty with bare fiberoptics. Thus, laser thermal angioplasty with a laser-heated, metallic-capped fiberoptic is a safe procedure that is easily learned by physicians skilled in interventional techniques. It allows for nonsurgical treatment of lesions considered difficult or impossible to treat by conventional balloon angioplasty.     

Effect of midinfrared holmium:YAG laser angioplasty with and without balloon angioplasty on acute outcome and restenosis in atherosclerotic femoral arteries in rabbits

Background and Objective: Pulsed laser may lessen vascular damage and reduce restenosis. This study examined the acute and chronic effects of midinfrared laser angioplasty with and without balloon angioplasty in atherosclerotic femoral arteries in rabbits. Study Design/Materials and Methods: Atherosclerosis was induced in arteries by air desiccation and cholesterol feeding. Arteries were assigned to one of four groups: (1) laser angioplasty with a Thullium/Holmium/Chromium:YAG infrared laser (Eclipse), (2) balloon angioplasty, (3) laser followed by balloon angioplasty and (4) no intervention. Arteries were examined angiographically and histologically at 2 hours and 28 days. Results: Intervention groups had significant initial gain, but this gain was less with laser alone than after balloon or after laser plus balloon. At 2 hours, laser alone caused greater arterial damage and thrombosis compared to controls. At 28 days, arteries treated with laser plus balloon had greater narrowing compared with arteries treated with balloon angioplasty. By multivariate regression analysis, the severity of the pre-intervention stenosis (P = 0.001) and intervention with laser plus balloon (P = 0.01) correlated independently with the severity of luminal narrowing at 28 days. Conclusion: Midinfrared Ho:YAG laser angioplasty resulted in substantial acute damage with increased frequency of thrombus formation in this rabbit model. Arteries treated with laser alone had suboptimal initial gain and more obstruction by plaque at 28 days compared to nonintervened arteries. The adjunctive use of balloon angioplasty improved initial gain, but correlated with smaller luminal diameters and more severe narrowing by plaque at 28 days. © 1995 Wiley-Liss, Inc.     

The role of percutaneous transluminal coronary angioplasty in heart transplant recipients.

OBJECTIVES: Review the acute and late results of percutaneous transluminal coronary angioplasty (PTCA) in heart transplant recipients and examine the factors predictive of restenosis. BACKGROUND: Coronary graft disease (CGD) is the main factor responsible for late graft loss. Medical treatment, surgical revascularization, or retransplantation gives only suboptimal results in this regard. Therefore, PTCA has been attempted in this situation. METHODS: More than 332 heart transplantations in our institution have been performed since 1992, the date of the first PTCA in our patients. We are currently in charge of 450 patients. All the characteristics, procedure-related information, and clinical outcome of patients needing PTCA were assessed by review of each patient's clinical records. All coronary angiograms were reviewed by an independent cardiologist. RESULTS: Since 1992, 53 coronary sites have been dilated in the course of 39 procedures in 29 patients. Indication for PTCA was asymptomatic angiographic coronary graft disease in 35 sites (64.8%), angina in 9 (16.6%), silent ischemia in 2 (3.7%), acute myocardial infarction in 1 (1.8%), and CHF in 7 (12.9%). Primary success (< 50% residual stenosis) was obtained in 50 (94.3%) of 53 lesions. No periprocedural death occurred. Procedural complications were 1 transient acute renal failure and 1 persistent bleeding at the puncture site. Six months restenosis rate (defined as percent stenosis > 50%) was 32.5% (14/43). Mean follow-up was 1.27 year +/- 1.2 (SD). Five deaths (17. 2%) occurred in follow-up and were all in relation to coronary graft disease. Mean time separating PTCA from death was 0.9 year +/- 1.3 (SD). We also sought to look at factors predictive of restenosis. By multivariate analysis, a positive recipient's serology for cytomegalovirus (CMV) before the graft was the only factor found protective against restenosis (odds ratio 22.4; confidence interval 1.1 to 443.4). CONCLUSION: PTCA in heart transplant recipients allows a high level of primary success with a low periprocedural-complication rate. Restenosis rate seems equivalent to restenosis rate in native coronary arteries. Mortality during follow-up is increased in this population and is the consequence of a high level of coronary events. Recipient positivity for CMV before the graft is associated with a protective effect from restenosis.     

Laser coronary angioplasty: An evolving technique

Percutaneous laser angioplasty is an established modality for the treatment of severe peripheral vascular disease and is generally used as an adjunct to balloon angioplasty. In the coronary circulation laser angioplasty is feasible, although its efficacy and safety remain to be defined. This article addresses the rationale for laser angioplasty, examines the influences of the various components of the laser system, and considers future direction given the accomplishments to date and the limitations of current instrumentation.     

A case report of entrapment of PTCA balloon catheter caused by its rupture

This is a report of a rare case in which an angioplasty balloon catheter became entrapped within the lumen of the coronary artery after the balloon ruptured during percutaneous transluminal coronary angioplasty (PTCA). The patient was a 69-year-old man who underwent elective PTCA of the circumflex coronary artery (Cx) with USCI 2.5 mm new Probe. The inflation failed to dilate the lesion up to 18 bar; at this pressure, balloon rupture was observed. Any attempt to withdraw the balloon catheter across the lesion was not successful, and then the patient was transferred to the operating room for removal of the balloon catheter. After establishing cardiopulmonary bypass, an arteriotomy in the Cx confirmed that the balloon fragment had become entrapped at a sharp edge of calcific stenosis after balloon rupture. The entrapped catheter was successfully removed from the arteriotomy of the Cx, and coronary bypass grafting was performed to the left anterior descending artery which had restenosis after PTCA 3 months ago. The patient had an uneventful postoperative course and was discharged in excellent condition 30 days after surgery. The balloon rupture of PTCA had been considered a minor problem, however, as this case demonstrated, this seemingly benign complication may lead to potentially disastrous consequences.     

The use of lasers in vascular and cardiac surgery. Clinical review

Use of lasers is routine in medical fields such as ophthalmology and dermatology, but in spite of intensive research in recent years, its role in cardiac and vascular surgery still remains to be determined. Laser energy can vaporize atherosclerotic plaques in human arteries obtained at necropsy. Fiberoptic catheters have been constructed to deliver the laser energy to atheromas at a distance from the arteriotomy. The healing of the arterial wall after laser treatment is rapid and results in complete reendothelialization. Lasers have been used in patients undergoing coronary surgery as well as peripheral vascular reconstructions. In some cases, the percutaneous approach has also been used. In these clinical series, the laser treatment was in almost all cases followed by either transluminal balloon angioplasty or by-pass operation. Complications after laser treatment include vessel perforation, reocclusions, thrombosis, or aneurysm formation. The development of more advanced fiberoptic catheters and better understanding of dosimetric parameters are promising features to avoid these complications as well as development of methods for steering of the laser catheter itself and means for "real time" diagnosis (e.g. angioscopes, spectroscopic diagnosis). The future use of lasers in cardiac and vascular surgery seems promising, especially as an alternative to balloon angioplasty.     

Percutaneous Interventions for Treatment of Iliac Artery Stenoses and Occlusions

Balloon angioplasty is still the main workhorse for percutaneous interventions in the iliac arteries. It is simple to perform, cost-effective, and remarkably safe. If an adequate hemodynamic result has been achieved, patency is acceptable. To monitor the quality of success, intraarterial pressure monitoring is an important tool. Balloon angioplasty may be followed by stent insertion in case of insufficient luminal gain after inadequate balloon angioplasty or occurrence of significant dissection. Percutaneous treatment of chronic iliac occlusions is technically challenging. For chronic occlusions (duration exceeding 3 months), balloon angioplasty alone, thrombolysis with subsequent balloon angioplasty, and elective stenting or mechanical passage of the occlusion followed by primary stent implantation have been described as alternative techniques. In case of in-stent stenosis, directional atherectomy or balloon dilatation is recommended. Stent grafts allow percutaneous exclusion of isolated iliac aneurysms, iatrogenic perforation, rupture, and arteriovenous fistulas, but these cases are rare. Some authors increasingly favor the use of endoluminal graft systems for treating atherosclerotic disease in iliac arteries, but insufficient data are available to prove the benefit of stent grafts in patients with atherosclerotic disease.