Miami Valves, Miami Florida. Cardiovascular Associates of South Florida

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1 Excimer Laser Coronary Angioplasty (ELCA) What Have We Learned? Miami Valves, Miami Florida January 29, 2017 James R. Margolis, MD FACC Cardiovascular Associates of South Florida Coral Gables, Florida

2 Laser Wire for Chronic Total Occlusions Tampa, Florida January 11, 1997 James R. Margolis, M.D. Miami Heart Institute, Miami Beach, Florida USA Going where no wire has gone before... The Laser Wire in Total Occlusions Scottsdale, Arizona February 10, 1997 James R. Margolis, M.D. Miami Heart Institute, Miami Beach, Florida USA Excimer Laser... History, Current Use, Perspectives Zurich Switzerland September 16, 1997 James R. Margolis, M.D. Columbia Miami Heart Institute, Miami Beach, FL Laser Angioplasty for In-Stent Restenosis Tampa, Florida January 11, 1997 James R. Margolis, M.D. Miami Heart Institute, Miami Beach, Florida USA DCA Rotablator Miami Heart Institute Rotablator ELCA Calcium POBA DCA Stent WHICH DEVICE? ELCA DCA Rotablator ELCA POBA ELCA

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4 Excimer Laser Excimer Laser for Coronary Angioplasty Stent Restenosis Past, Present and Future Frankfurt, Germany December 6, 1996 James R. Margolis, M.D. Miami Heart Institute, Miami Beach, Florida USA Eindhoven, Netherlands December 14, 1996 James R. Margolis, M.D. Miami Heart Institute, Miami Beach, Florida USA

5 After 25+ years of clinical experience, Laser is like Moses in the desert. It sees the promised land, but cannot enter. Why is this so? It promised too much: Expectations were too great. Disappointments caused overreaction. Technology developed too slowly. Other technologies supplanted its use.

6 A concatenation of recent events suggests that Laser may yet enter the promised land. Even if that land is not all that was promised. As Interventional cases become more complex, the importance of de-bulking is becoming apparent. Improved technology has made it possible to do cases that could not have been done in former times. This is especially true in the CTO arena. New applications are being discovered, and old ones are re-discovered.

7 Pacer Lead Extraction Peripheral Vascular Disease Total occlusions of Femoral and Iliac Arteries Infra-popliteal disease/critical limb ischemia Debulking In-stent Restenosis Diffuse disease Uncrossable lesions pre-brachytherapy Thrombus removal New catheters = new coronary applications E.g., Laser wire

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10 Two previous CABG operations Previous stent procedures Failed PCI of large LCX Class 3 angina

11 Difficult guiding catheter cannulation only AL1.5 catheter works. Take-off of LCX > 90. Two - LCX lesions Lesion just prox to OMB tortuous and calcified Disease involves bifurcation

12 Problem Guiding catheter problems >90 bend at takeoff of LCX Tortuous calcified disease 1.25 mm balloon does not cross. Why not Rotablator? Solution Once seated AL1.5 stable. PT Graphix wire Cross lesions with low profile balloon. 0.9 laser catheter crossed easily Have to re-wire with Rotawire (probably not possible)

13 1.25 mm Balloon would not cross distal lesion, but 0.9mm Excimer Laser crossed easily.

14 Post laser balloon crosses easily.

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19 ELCA Helped Only a Little, but created a channel for introduction of filter. Pre-ELCA Post-ELCA Thrombus removed by ELCA

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23 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 2 mm balloon at 20 bar. Similarly, a 4 mm balloon exerts twice the wall tension of a 2 mm balloon at the same pressure. If one de-bulks extensively before stenting, the effective balloon expansion will be greater for a given pressure. This is particularly important in: Calcified vessels Diabetic macrovascular disease In-stent restenosis

24 Laser Technique for Under-deployed Stents Causes of Underdeployment Failure to evaluate artery with IVUS or OCT Failure to prepare artery with debulking device and/or: High pressure balloon Cutting or scoring balloon Inexperienced operators invariably choose undersized balloons and stents, because they think they are safer.

25 Laser Technique for Under-deployed Stents Consequences of Under-deployment Continuing symptoms In-stent restenosis Early and late Stent thrombosis Problem was untreatable prior to introduction of laser technique.

26 Laser Technique for Under-deployed Stents With properly deployed stents, pathology (if present) is inside the stent. With under-deployed stents pathology and constraint are both inside and outside the stent. Pathology inside the stent can be treated with: Laser Rotablator Cutting or scoring balloons High pressure balloons Brachytherapy Pathology outside the stent can only be addressed with laser or bypass surgery.

27 Laser Technique for Under-deployed Stents Theory Purpose is to break up material outside the stent, especially calcium by maximizing the acoustic component of excimer laser ablation. Acoustic effect is generally considered an undesirable side effect that can lead to dissection. Acoustic effect can be minimized by injection of saline during lasing. Injection of contrast during lasing magnifies acoustic effect.

28 Saline Contrast

29 Laser Technique for Under-deployed Stents Technique Use undersize laser catheter at maximum power (fluence) and maximum rate. Inject contrast during lasing. Repeat two, three or more times. Confine lasing to inside the stent. Follow with generously sized high pressure balloon until it is fully expanded. If high pressure balloon will not fully inflate, repeat lasing.

30 Laser Technique for Under-deployed Stents

31 1991 Balloon wont cross Diffuse disease In-stent restenosis Thrombus removal? 2016 Balloon wont cross Diffuse disease In-stent restenosis Thrombus removal Under-deployed stents

32 1991 Balloon wont cross Diffuse disease In-stent restenosis Thrombus removal? 2016 Balloon wont cross Diffuse disease In-stent restenosis Thrombus removal Under-deployed stents

33 Originally developed for treatment of coronary artery disease, the Excimer laser is universally accepted for pacer lead extraction and for management of critical limb ischemia. Although its acceptance for treatment of coronary artery disease is not universal, there are unquestionable niche applications in which the laser is superior to other devices. Interestingly, these niche applications have changed little over the past 25 years. Use of the Excimer laser to treat under deployed stents is a relatively new application, which holds great promise for this otherwise untreatable problem.