This study aimed to evaluate the efficacy and safety of excimer laser coronary atherectomy (ELCA) prior to paclitaxel-coated balloon angioplasty for de novo coronary artery lesions. This retrospective observational study analyzed 118 eligible patients with de novo coronary artery disease whose only percutaneous coronary intervention was a drug-coated balloon angioplasty (i.e., no subsequent stent placement). Data related to our primary outcomes of interest-incidence of major adverse cardiovascular and cerebral events (MACCE), and incidence of procedural complications (bailout stenting and minor complications)-were collected and retrospectively analyzed. ELCA was used significantly more often in the cases of main branch and ostial lesions (i.e., of the circumflex, right coronary, or left anterior descending arteries, or high lateral branch), normally associated with poor treatment outcomes (55.6% vs. 14.3%, p < 0.0005). However, the two groups were not different in terms of cumulative incidence as estimated by the Kaplan-Meier method (log-rank test, p = 0.603) and a causal relationship between ELCA and MACCE was not identified (OR, 2.223; 95% CI, 0.614-8.047; p = 0.223). This study confirms the safety of ELCA prior to paclitaxel DCB angioplasty to treat de novo coronary artery lesions. While difficult-to-treat lesions were significantly more prevalent in the group treated by ELCA, the study revealed similar efficiency as conventional pre-dilation methods. Our findings provide grounds for a prospective randomized trial with consistent lesion and procedural characteristics to evaluate the potential benefits of combining paclitaxel DCB angioplasty following ELCA for de novo coronary artery lesions.
Excimer laser coronary angioplasty (ELCA) is a unique revascularization modality that can vaporize plaque and thrombus. Compared to thrombus aspiration therapy, ELCA is reported to provide better microcirculation and reduced peripheral embolism in treatment for acute coronary syndrome. Excimer laser catheters come in various sizes, and we sought to compare the 0.9-and 1.4-mm-diameter catheters. We retrospectively enrolled 90 acute myocardial infarction (AMI) patients who underwent primary percutaneous coronary intervention with excimer laser from August 2013 to March 2017 in our hospital. Patients were grouped by diameter of catheter that had been used, the 0.9 mm group (n = 51) and 1.4 mm group (n = 39). We evaluated myocardial perfusion, procedural success rate, short-term outcome, lesion crossability, and complications between the two groups. The percentage of patients whose final thrombolysis in myocardial infarction (TIMI) grade was 3 (0.9 mm 86.3% vs 1.4 mm 89.7% p = 0.75) and final myocardial blush grade (MBG) was 3 (0.9 mm 72.5% vs 1.4 mm 69.2% p = 0.82) was similarly high for both groups. Procedural success rate, in-hospital major adverse cardiac events (MACE), lesion crossability, and complications were also similar. This study showed that efficacy of 0.9 and 1.4 mm excimer laser catheter was equivalent in ELCA for AMI patients. If one takes into account lesion crossability, debulking effects, and the stunned platelets phenomenon, the 0.9 mm excimer laser catheter is sufficient for ELCA in AMI patients.
ography and intervention. 11 Similarly, although Spargias et al reported that ascorbic acid protected against CIN in high-risk patients undergoing a coronary procedure, 12 the REMEDIAL trial could not prove the superiority of ascorbic acid. 13 No published studies have examined the efficacy of combined i.v. sodium bicarbonate and ascorbic acid for the prevention of CIN. The aim of the current prospective randomized trial was therefore to determine whether i.v. sodium bicarbonate and ascorbic acid, in addition to a saline hydration protocol, provided more effective prevention of CIN than saline hydration alone in CKD patients undergoing elective catheter procedures. A cute renal dysfunction is a serious complication of contrast agent use. 1 This contrast-induced nephropathy (CIN) occurs more commonly in patients with pre-existing renal dysfunction. 2-4 Once CIN occurs, patients are more likely to experience in-hospital death and have a markedly less favorable long-term prognosis. 2,4-6 The incidence of CIN is <2% in patients with normal renal function, 7 but 11-45% in patients with diabetes or chronic kidney disease (CKD). 8,9 Given that non-nephrotoxic contrast agents are currently unavailable, prevention of the onset of CIN is extremely important, especially for CKD. In a study of CKD patients who underwent an elective coronary procedure, Tamura et al noted that a single i.v. bolus of sodium bicarbonate (20 mEq), in addition to standard hydration, prevented CIN more effectively than standard hydration alone. 10 The PREVENT trial, however, suggested that hydration with sodium bicarbonate was not superior to hydration with sodium chloride in preventing CIN in patients undergoing coronary or endovascular angi-
Methods
Patients
Patient: Male, 71Final Diagnosis: Silent myocardial infarctionSymptoms: DynpneaMedication: —Clinical Procedure: —Specialty: CardiologyObjective:Unusual or unexpected effect of treatmentBackground:Previous case reports have shown that regardless of the etiology, multiple channel structures can be treated successfully by routine percutaneous coronary intervention. However, there are no general recommendations for intervention because multiple channel structures are complex and rarely diagnosed.Case Report:A 71-year-old male was admitted to our hospital due to bronchial pneumonia. After admission, the patient experienced acute decompensated heart failure. Coronary angiogram revealed 3 diseased vessels with heavy calcification. Although the patient’s syntax score was high, we performed percutaneous coronary intervention (PCI) on each vessel based on his request and in consideration of his dementia. After PCI for the left circumflex and descending arteries, we performed PCI for the right coronary artery (RCA) using optical frequency domain imaging (OFDI). A multiple channel structure and calcified nodule were observed by OFDI. We performed rotational atherectomy (RA) on the RCA, and the 2 structures were ablated. After RA, we dilated the lesions with a scoring balloon and deployed a drug-eluting stent.Conclusions:RA was effective in ablating partition walls of the multiple channel structure observed using OFDI.
A 72-year-old man who previously underwent percutaneous coronary intervention with a drugeluting stent implantation from the left main trunk and extending to proximal left anterior descending artery was admitted to the documented hospital for angina pectoris. Coronary angiography (CAG) revealed 90% stenosis at the ostium of the left circumflex artery (LCX) (Fig. 1A). Excimer laser coronary angioplasty (ELCA) was performed using a 0.9 mm concentric laser catheter at a pulse rate of 25 Hz and energy output of 45 mJ/mm 2 , 35 Hz and 55 mJ/mm 2 , and 45 Hz and 60 mJ/mm 2 for a total of 5200 pulses and balloon angioplasty using a drugcoated balloon (DCB) under the guidance of optical frequency domain imaging (OFDI), which revealed fibrous plaque and eccentric severe calcification ( Fig. 1B). After ELCA, minimum lumen area (MLA) increased from 1.4 mm 2 to 2.6 mm 2 (Fig. 1C) and on final OFDI to 3.9 mm 2 along with minor plaque dissection ( Fig. 1D). Final CAG demonstrated optimal result without flow limitation ( Fig 1E). After discharge, no significant clinical events were reported. Eight months later, follow-up CAG and OFDI were performed. Follow-up CAG demonstrated no restenosis at the ostium of the LCX (Fig. 1F). OFDI showed that the MLA slightly decreased from 3.9 mm 2 to 3.5 mm 2 and that the minor dissection had clearly improved (Fig. 1G). The DCB is efficacious in de-novo coronary artery lesions [1], which mainly contributed to suppress the restenosis in this case; however, although OFDI after ELCA demonstrated a slight increase in MLA, ELCA might be attributed to the lesion debulking and modification leading to optimal balloon expansion. A similar mechanism was previously reported in the case of in-stent restenosis [2]. For acute myocardial infarction, the combined use of ELCA and DCB for de-novo coronary artery disease works synergistically to reduce restenosis [3]. Stent-less strategy employing ELCA and DCB may be an effective revascularization of large vessel denovo lesions, when traditional stent deployment is not a viable option.Informed consent was obtained from the patient in accordance with the Helsinki Declaration.
AcknowledgementsThe authors wish to thank Dr. Richard H. Kaszynski for reviewing and revising this manuscript.
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