The effectiveness of excimer laser angioplasty to treat coronary in-stent restenosis with peri-stent calcium as assessed by optical coherence tomography

Abstract

Aims:We aimed to evaluate the effectiveness of excimer laser coronary angioplasty (ELCA) to treat instent restenosis (ISR) due to peri-stent calcium-related stent underexpansion as assessed by optical coherence tomography (OCT). Methods and results:We studied 81 patients (81 lesions with ISR, stent underexpansion, and peri-stent calcium >90°) who underwent OCT imaging both pre and post percutaneous coronary intervention and compared lesions treated with ELCA (n=23) vs. without ELCA (n=58). ELCA use was associated with more calcium fracture (ELCA: 61%, non-ELCA: 12%, p<0.01), larger final minimum lumen area (ELCA: 4.76 mm 2 [3.25, 5.57], non-ELCA: 3.46 mm 2 [2.80, 4.13], p<0.01), and a larger previously implanted stent area (ELCA: 6.15 mm 2 [4.83, 7.09], non-ELCA: 4.65 mm 2 [3.84, 5.40], p<0.01). In the multivariable model, ELCA use was associated with peri-stent calcium fracture (odds ratio 46.5, 95% confidence interval: 6.8, 315.9, p<0.001) that, in turn, was associated with final larger lumen and stent dimensions. Finally, contrast injection during ELCA was associated with multiple calcium fractures and fractures even in thicker calcium.Conclusions: ELCA is effective for treating ISR with underexpansion by disrupting peri-stent calcium, facilitating better expansion of the previously implanted stent.

Contemporary Approach to Heavily Calcified Coronary Lesions

“…[78] The main application of this technique remains in the treatment of severe in-stent restenosis, with positive results reported in a recent OCT study. [79]…”

New Modalities of Treatment for Coronary Calcific Lesions

“…[50][51][52] The clinical use of coronary laser is limited to being a "bail-out strategy" in uncrossable/undilatable lesions and underexpanded stents. 53 The CVX 300 System (Philips) uses xenon chloride to produce a light emitted in the ultraviolet B spectrum (308 nm) with a penetration depth of 30 to 50 μm. A combination of excimer laser and RA was recently described (the RASER technique).…”

Lesion Preparation with Orbital Atherectomy

“…[26–29] However, the primary role for ELCA in treating calcified plaque is for in-stent restenosis due to an underexpanded stent with significant peri-stent calcification. [30,31] An algorithmic approach for the management of calcified lesions can help ensure adequate lesion preparation has been achieved prior to stent implantation ( Figure 3 ). We herein focus on the treatment of calcified plaque with orbital atherectomy.…”