Outcome and Good Indication of Laser Angioplasty

Transcription

1 The 8th Congress of International YAG Laser Symposium Outcome and Good Indication of Laser Angioplasty Shoichi Takekawa, Hiraku Yodono, Tamaki Kimura, NaokoNishi, Hiroyuki Miura, Hiroshi Noda, Hideya Matsutani, Rikako Sasaki, Akira Anbai Department of Radiology, Hirosaki University School of Medicine, Hirosaki, Aomori, 036 Japan. Abstract: Purpose: To elucidate the good indication of percutaneous transluminal laser angioplasty (PTLA) for arteriosclerosis obliterans (ASO) from the outcome of PTLA. PTLA was carried out using 1064nm continuous wave Nd:YAG laser. In most cases a ceramic tip laser probe was used for contact method for laser irradiation. Twenty to 25 Watts were used and the time of lasing varied for 1 to 2 seconds. Lasing was repeated until a hole was created in the obstructive lesions. The diameter of a hole was aboutthe diameter of the probe, which was 1.8mm. Additional balloon dilatation was done after lasing. During the period of March, 1985 through March 1993, 134 lesions in 77 patients with peripheral ASO were treated by PTLA. Initial success rate was 90.0% during the first 6 years, and 87.3%during the whole 8 years. The cumulative patency rate of total lesions was 89.7% at the end of 6 years, and 67.7% at the end of 8 years. However, those lesions, less than 10cm in length, revealed a good cumulative patency rate, which was more than 80%. The 8-year-cumulative patency rateof the iliac lesions was about 80%. There was no major complication. Dissection of arterial wall was noted in 19.4% of cases. This was caused by balloon dilatation and not by lasing. Distal embolization was noted in 7.5% of cases, but the occurrence of the complication markedly decreased after the application of aspiration of sludge before penetrating the final segment (1cm) of the occlusion. No perforation of the artery was noted. PTLA is especially indicatedto peripheral occlusive arterial disease, less than 10cm in length. PTLA expanded the indication of percutaneous treatment of ASO, since lesions, in which PTA failed, could be treated successfully. Key words: Arteriosclerosis obliteraus, ASO, Laser, Angioplasty Introduction It is the purpose of this communication to elucidate the good indication of percutaneous 245

2 transluminal laser angioplasty (PTLA) for arteriosclerosis obliterans from the analysis of the outcome of PTLA. Methods and Cases PTLA 1)-5) was carried out using 1064nm continuous wavend:yag laser. In most cases a laser probe with a ceramic tip was used for the contact method for laser irradiation. The power of laser ranged from 20 to 25 watts, and the lasing time varied from 1 to 2 seconds. Lasing was repeated until a hole to pass a guidewire was createdin the obstructive lesions. The diameter of a hole was about the diameter of the laser probe, which was 1.8mm in diameter. In a small number of cases a bare ended laser fiber was used alone or combined with additional lasing with a ceramic tip. The bare laser fiber was used in an angiography catheter or in a channel of as angioscope. Following angioscopes were used for this purpose: Olympus PF-28 and PF-25TCX. Balloon dilatation was added following lasing to fully extend the narrowed segment. During the period of March, 1985 through March, 1993, 134 lesions in 77 patients with peripheral ASO were treated by PTLA (Table 1). Results The initial success rate was 90.0% during the first 6-year period, and 87.3% during the whole 8-year period. The cummulative patency rate of total lesions was 89.7% at the end of 6 years (Fig. 1), and 67.7% at the end of 8 years (Fig. 2). However, those lesions less than 10cm in length revealed a good cummulative patency rate, which was more than 80.0% (Fig. 3). There was no major complications directly related to the procedure, such as perforation or immediate death. In one patient intestinal obstruction occured after the procedure and 4 days later he died of presumably pulmonary embolism. The exact cause of death could not be determined because autopsy was not granted. Minor complications are large hematomas at the puncture site (4.5% ), dissection from balloon dilatation (19.4%), distal embolization (7.5%), temporary hypotension from longstanding posture (2.2% ), and reaction to the contrast media (3.0% ). A few cases will be illustrated Case 1. A 77-year-old man with intermittent claudication on the right after walking for 100 to 200 meters. His ankle arm pressure index was 0.59 on the right side, whereas the ankle arm pressure in the left was 0.92 and Femoral arteriogram (Fig. 4a) showed occlusion of theright superficial femeral artery 246

3 Fig. 1. Cumulativ1e patency rate of PTLA (March, March, 1991) Fig. 2. Cumulative patency rate of PTLA (March, March, 1993) (SFA) for a distance of 25cm. Laser was irradiated to the atherosclerotic lesions of the right SFA after thrombolysis was carried out. Ten exposures of laser was carried out at the energy of 25W for 1 second each time, using a contact method with a ceramic tip. Balloon dilatation was added. Some irregularity of the dilated wall remained, but the arterial lumen was restored. Fig. 3. Comparision of cumulative patency rate of PTLA, depending on the length of lesions. His right ankle arm pressure index rose to 0.98 and The arterial wall became smoother 50 days after PTLA (Fig. 4b). Case 2. A 51-year-old diabetic man with ischemic right foot and gangrene of the right 4th and 5th toes and foot near these toes. Arteriogram of the right leg showed multiple short segment stenoses of peroneal and anterior tibial arteries (Fig. 5a). PTLA of the right peronealartery was attempted by the request of the patient after his informed consent was obtained regarding the investigative nature of the treatment. A bare ended laser fiber was inserted intoan end-hole angiographic catheter, and laser was irradiated at IOW for I second and the procedure was repeated twice. Then, a 5F Van Andel dilating catheter was applied to the stenotic segmentby original Dotter method. The occluded lumens were restored (Fig. 5b). 247

4 Fig. 4. PTLA of long segment occlusion of the right superficial femoral artery. A. The femoral arteriogram shows occlusion of the right superficial femoral artery for a distance of 25cm. PTLA was carried out after thrombolysis. The femoral artery became patent, but some atheromatous plaque remained in the proximal femoral artery. B. The right femoral arteriogram 50 days after PTLA. The artery remained patent, and the atheromatous plaque in the proximal artery became much smaller. The artery has been patent for more than 4 years. Fig. 5. PTLA of below knee artery A. The arteriogram shows multiple stenoses and occlusion of the right tibial and peroneal arteries. B. A bare ended fiber in an angiographic catheter was used for PTLA. A 5F Van Andel dilating catheter was also used for dilatation of peroneal artery. The stenotic segmant of peroneal artery restored the normal caliber. The collateral flow to the foot increased as shown in the figure. 248

5 Discussion There are varieties of method for percutaneous angioplasty such as atherectomy, rotablator, Kensey catheter, aspiration catheter, metallic stents, laser in addition to conventional balloon angioplasty. A comparative study regarding cumulativepatency rate is desirable, but multiple procedures cannot be performed on a same patient. Besides a double blind test cannot be easily adopted from the stand point of human rights. Therefore, the outcome of each procedure or comparision of two procedures in separate series may be appropriate. Another problem in assessing the effectiveness of each procedure is the difficulty in matching the same background of the disease with similar severity in ASO. More difficult cases are apt to be treated by more sophisticated method, so the background of lesions is different. For example, those stenotic lesions in which a guidewire could not be passed through the lesion can be sometimes treated bylaser angioplasty. So, mere comparison of two modalities such as PTA and PTLA to treat obstructive arterial disease is not adequate, but it seems to be the only way that we can do best. Considering the difference in the background of the lesions, i.e. more difficult cases being treated by PTLA, the cumulative patency rate of PTLA after 5 years is superior to that of PTA. Our results encourage to attempt thrombolysis to treat a long segment occlusion of the femoral artery to see if percutaneous angioplasty is possible by PTA or PTLA. Conclusion 1) Combined use of thrombolysis, laser and balloon dilatation revealed to expand the indication of percutaneous treatment of peripheral occlusive arterial disease. 2) PTLA also revealed a better cumulative patency rate than that of PTA at 5 years. 3) Those occlusive arterial lesions that are less than 10cm revealed a considerablly good long term patency rate. Therfore, such lesions seem to be the best indication for PTLA. Reference 1. Takekawa, S.D., Takahashi, M., Kudo, I., et al.: Combined use of percutaneous transluminal laser irradiation and balloon dilatation angioplastyin the treatment of arteriosclerotic stenoses of iliac and femoral arteries. Nippon Act. Radiol. 45(8) : , Takekawa, S.D., Takahashi, M., Kudo, I., et al.: Laser angioplasty. Fundamental studies and initial clinical experience. Seminars in Interventional Radiology. 3(3): ,

6 3. Takekawa, S.D.: Percutaneous transluminal laser angioplasty. Nippon Act. Radiol. 52(3) : , Takekawa, S.D.: Percutaneous transluminal laser angioplasty. Hirosaki Med.J. 45(1) :1-10, Takekawa, S.D., Yodono, H., Kimura, T. et al.: LaserPTA: Jpn J Clin Radiol 39(11): , 1994