Excimer Laser Coronary Angioplasty (ELCA)Excimer Laser Coronary Angioplasty (ELCA)

What Have We Learned?What Have We Learned?Miami Valves, Miami Florida

January 29, 2017January 29, 2017

James R. Margolis, MD FACCJames R. Margolis, MD FACCCardiovascular Associates of South Florida

Coral Gables, FloridaCoral Gables, Florida

Laser Wire for ChronicTotal Occlusions

The Laser Wire inThe Laser Wire inGoing where no wire has gone before . . .Going where no wire has gone before . . .

Total Occlusions

Tampa, FloridaJanuary 11, 1997

Tampa, FloridaJanuary 11, 1997

James R. Margolis, M.D.

The Laser Wire inTotal OcclusionsThe Laser Wire inTotal Occlusions

James R. Margolis, M.D.

Scottsdale, ArizonaFebruary 10, 1997

Scottsdale, ArizonaFebruary 10, 1997

ELCADCA

Rotablator

RotablatorELCA Calcium

WHICH DEVICE?WHICH DEVICE?

James R. Margolis, M.D.Miami Heart Institute, Miami Beach, Florida USA James R. Margolis, M.D.

Miami Heart Institute, Miami Beach, Florida USA

Laser Angioplasty forIn-Stent Restenosis

Laser Angioplasty forIn-Stent Restenosis

Excimer Laser ...Excimer Laser ...

History, Current Use , PerspectivesHistory, Current Use , PerspectivesRotablator

Rotablator

ELCA

POBADCA

Stent

DCA

POBAELCA

Miami Heart Institute

In-Stent RestenosisIn-Stent Restenosis

James R. Margolis, M.D.Miami Heart Institute, Miami Beach, Florida USA

Tampa, FloridaJanuary 11, 1997

Tampa, FloridaJanuary 11, 1997

James R. Margolis, M.D.

Columbia Miami Heart Institute, Miami Beach, FL

Zurich SwitzerlandZurich Switzerland

SeptemberSeptember 16, 199716, 1997

Miami Heart InstituteMiami Heart InstituteColumbia Miami Heart Institute, Miami Beach, FL

Excimer Laser forExcimer Laser

Excimer Laser forStent Restenosis

Frankfurt, GermanyDecember 6, 1996

Excimer LaserCoronary AngioplastyPast, Present and Future

Eindhoven, NetherlandsDecember 14, 1996

James R. Margolis, M.D.Miami Heart Institute, Miami Beach, Florida USA

December 6, 1996

James R. Margolis, M.D.Miami Heart Institute, Miami Beach, Florida USA

December 14, 1996

• After 25+ years of clinical experience, Laser• After 25+ years of clinical experience, Laseris like Moses in the desert.– It sees the promised land, but cannot enter.– It sees the promised land, but cannot enter.

• Why is this so?– It promised too much:– It promised too much:

• Expectations were too great.

• Disappointments caused overreaction.– Technology developed too slowly.– Technology developed too slowly.– Other technologies supplanted its use.

• A concatenation of recent events suggests that• A concatenation of recent events suggests thatLaser may yet enter the promised land.– Even if that land is not all that was promised.– Even if that land is not all that was promised.

• As Interventional cases become more complex, theimportance of de-bulking is becoming apparent.

• Improved technology has made it possible to do• Improved technology has made it possible to docases that could not have been done in formertimes….– This is especially true in the CTO arena.– This is especially true in the CTO arena.

• New applications are being discovered, and oldones are re-discovered.ones are re-discovered.

• Pacer Lead Extraction

• Peripheral Vascular Disease• Peripheral Vascular Disease

– Total occlusions of Femoral and Iliac Arteries

– Infra-popliteal disease/critical limb ischemia– Infra-popliteal disease/critical limb ischemia

• Debulking

– In-stent Restenosis

– Diffuse disease

– Uncrossable lesions

– pre-Brachytherapy– pre-Brachytherapy

• Thrombus removal

• New catheters = new coronary applications• New catheters = new coronary applications

– E.g., Laser wire

Two previous CABG operationsTwo previous CABG operations

Previous stent procedures

Failed PCI of large LCX

Class 3 anginaClass 3 angina

• Difficult guiding• Difficult guidingcatheter cannulation –only AL1.5 catheterworks.works.

• Take-off of LCX > 90°.

• Two - LCX lesions• Two - LCX lesions

• Lesion just prox to OMBtortuous and calcifiedtortuous and calcified

• Disease involvesbifurcation

Problem Solution

• Guiding catheter problems

• >90° bend at takeoff of LCX

• Tortuous calcified disease

• Once seated AL1.5 stable.

• PT Graphix wire

• Cross lesions with low• Tortuous calcified disease

• 1.25 mm balloon does not

• Cross lesions with lowprofile balloon.

• 0.9 laser catheter crossed• 1.25 mm balloon does notcross.

• Why not Rotablator?

• 0.9 laser catheter crossedeasily

• Have to re-wire withRotawire (probably not

Why not Rotablator?Rotawire (probably notpossible)

1.25 mm Balloon would not cross distal lesion,but 0.9mm Excimer Laser crossed easily.but 0.9mm Excimer Laser crossed easily.

Post laserballoonballooncrosseseasily.easily.

ELCA Helped Only a Little, but created achannel for introduction of filter.channel for introduction of filter.

Pre-ELCA Post-ELCAThrombus removedby ELCAPre-ELCA Post-ELCA by ELCA

• Wall tension is directly proportional to radius (Laplace’s law).

– Thus, a 4 mm balloon at 10 bar exerts the same wall stress as a 2mm balloon at 20 bar.

– Similarly, a 4 mm balloon exerts twice the wall tension of a 2 mmSimilarly, a 4 mm balloon exerts twice the wall tension of a 2 mmballoon at the same pressure.

• If one de-bulks extensively before stenting, the effectiveballoon expansion will be greater for a given pressure.balloon expansion will be greater for a given pressure.

• This is particularly important in:

– Calcified vessels

– Diabetic macrovascular disease– Diabetic macrovascular disease

– In-stent restenosis

Laser Technique for Under-deployed StentsCauses of UnderdeploymentCauses of Underdeployment

• Failure to evaluate artery with IVUS or OCT• Failure to evaluate artery with IVUS or OCT

• Failure to prepare artery with debulkingdevice and/or:device and/or:

– High pressure balloon

– Cutting or scoring balloon– Cutting or scoring balloon

• Inexperienced operators invariably chooseundersized balloons and stents, because theyundersized balloons and stents, because theythink they are safer.

Laser Technique for Under-deployed StentsConsequences of Under-deploymentConsequences of Under-deployment

• Continuing symptoms

• In-stent restenosis• In-stent restenosis

• Early and late Stent thrombosis

• Problem was untreatable prior to introduction• Problem was untreatable prior to introductionof laser technique.

Laser Technique for Under-deployed StentsLaser Technique for Under-deployed Stents

• With properly deployed stents, pathology (if present)is inside the stent.

• With properly deployed stents, pathology (if present)is inside the stent.

• With under-deployed stents pathology and constraintare both inside and outside the stent.are both inside and outside the stent.

• Pathology inside the stent can be treated with:– Laser– Rotablator– Rotablator– Cutting or scoring balloons– High pressure balloons– High pressure balloons– Brachytherapy

• Pathology outside the stent can only be addressedwith laser or bypass surgery.with laser or bypass surgery.

Laser Technique for Under-deployed StentsTheoryTheory

• Purpose is to break up material outside the stent,• Purpose is to break up material outside the stent,especially calcium by maximizing the acousticcomponent of excimer laser ablation.

Acoustic effect is generally considered an• Acoustic effect is generally considered anundesirable side effect that can lead todissection.dissection.

• Acoustic effect can be minimized by injection ofsaline during lasing.saline during lasing.

• Injection of contrast during lasing magnifiesacoustic effect.acoustic effect.

SalineContrast

Laser Technique for Under-deployed StentsTechniqueTechnique

• Use undersize laser catheter at maximum power• Use undersize laser catheter at maximum power(fluence) and maximum rate.

• Inject contrast during lasing.• Inject contrast during lasing.

• Repeat two, three or more times.

• Confine lasing to inside the stent.• Confine lasing to inside the stent.

• Follow with generously sized high pressureballoon until it is fully expanded.

• If high pressure balloon will not fully inflate,repeat lasing.

Laser Technique for Under-deployed StentsLaser Technique for Under-deployed Stents

1991 20161991• Balloon wont cross

• Diffuse disease

2016• Balloon wont cross

• Diffuse disease• Diffuse disease

• In-stent restenosis

• Thrombus removal

• Diffuse disease

• In-stent restenosis

• Thrombus removal

• ? • Under-deployed stents

1991 20161991• Balloon wont cross

• Diffuse disease

2016• Balloon wont cross

• Diffuse disease• Diffuse disease

• In-stent restenosis

• Thrombus removal

• Diffuse disease

• In-stent restenosis

• Thrombus removal

• ? • Under-deployed stents

• Originally developed for treatment of coronary arterydisease, the Excimer laser is universally accepted for pacerOriginally developed for treatment of coronary arterydisease, the Excimer laser is universally accepted for pacerlead extraction and for management of critical limbischemia.

• Although its acceptance for treatment of coronary artery• Although its acceptance for treatment of coronary arterydisease is not universal, there are unquestionable nicheapplications in which the laser is superior to other devices.

• Interestingly, these niche applications have changed little• Interestingly, these niche applications have changed littleover the past 25 years.

• Use of the Excimer laser to treat under deployed stents is a• Use of the Excimer laser to treat under deployed stents is arelatively new application, which holds great promise forthis otherwise untreatable problem.