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Endovascular therapies have not yet had an ideal effect on thromboangiitis obliterans (TAO) and no data have been published about laser-assisted angioplasty (LA) combined with radiofrequency ablation (RFA) for TAO. This study aimed to investigate the outcome of LA combined with RFA for TAO. Sixteen consecutive patients underwent LA and RFA procedures between June 2018 and March 2019 in this prospective pilot study. The clinical outcomes and complications were assessed at 6, 12, and 18 months after the procedure. The primary endpoint was defined as the limb salvage rate and freedom of target-lesion revascularization (f-TLR) of the limb, and the effect on the outcome was assessed by the ankle brachial index (ABI), numerical rating scores (NRSs), and the EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D). Men accounted for 87.5% of the patients. All patients underwent LA, and following the RFA procedure, two patients received bailout stenting (12.50%). The technique success rate was 100%, and no severe complications occurred. The ABI was significantly higher at the 18-month follow-up than at baseline (P

Objectives To describe our single center experience with the use of laser endartherectomy assisted balloon angioplasty in popliteal and infrapopliteal arterial disease. Background Peripheral arterial disease (PAD) carries significant morbidity to patients. Some patients may have multiple comorbid conditions potentially limiting therapeutic options for PAD. Endovascular interventions are aimed at decreasing arterial disease symptoms, improve wound healing and ultimately limb salvage. There is limited data on below the knee PAD and simultaneous laser endartherectomy use in this anatomic location. Methods The cohort comprised 41 patients that underwent laser assisted balloon angioplasty from 2010 to 2013. All patients had popliteal and infrapopliteal arterial disease. Outcomes evaluated were limb salvage and symptom relief 12months following the procedure. A comparison between the patients that underwent amputation and those with limb salvage was also performed. Results All the patients had TASC II (Trans Atlantic Inter-Society Consensus) type D lesions. Most patients reported persistent PAD symptoms by six months, with 17% remaining symptom free by 12months. Affected limb salvage was 69%. Five patients (12%) died and one third of the patients had a new peripheral angiogram. In the repeat angiogram, most patients showed initial target vessel occlusion. No statistically significant differences were found between the patients that preserved their limb to those who underwent amputation. Conclusions Laser assisted balloon angioplasty use for complex popliteal and infrapopliteal arterial disease is a therapeutic option when limb salvage is the goal. Despite this, symptom recurrence and the need for repeated angiography continue to be high.

Rationale: Recent research shows that in-stent restenosis (ISR) occurs in half of the patients treated with stenting of femoral and popliteal artery for lower extremity arteriosclerotic occlusive disease (LEASO). Combined therapy is mainly used clinically to obtain better medium- and long-term treatment outcomes and reduce the occurrences of reintervention, among which, the combination of excimer laser ablation (ELA) and drug eluting balloon (DEB) is a new and effective choice. Patient concerns: A 76-year-old male patient with ISR of right superficial femoral artery after stent implantation was reported. Diagnosis: Rechecking angiography indicated severe occlusion of the right superficial femoral artery. The physical examination showed that bilateral femoral and popliteal arteries were accessible whereas right dorsalis and posterior tibial arteries are unaccessible. Ankleolus brachial index (ABI) was 0.92 for left and 0.58 for right. Interventions: We performed the operation with ELA and drug balloon DEB on the right superficial femoral artery under local anesthesia and treated with oral antiplatelet drugs after operation. Outcomes: The combination treatment was very successful, and postoperative lower extremity arteriogram showed the blood flow was fluent and fast. No recurrence was discovered 3 months after the operation and he had no obvious symptom of claudication. Lessons: The combination of ELA and DEB is useful and effective for ISR of peripheral vessel after stent implantation, and this surgical method is worthwhile but need further clinical research for safety confirmation.

In der „Abciximab Intracoronary versus intravenously Drug Application in ST- Elevation Myocardial Infarction“ (AIDA STEMI) Hauptstudie mit 2065 eingeschlossenen Patienten konnte 90 Tage nach Infarkt eine Reduktion neu aufgetretener Herzinsuffizienz in der intrakoronaren Abciximabgruppe aufgezeigt werden. Ziel der vorliegenden Magnetresonanztomographie (MRT) Substudie war es einen möglichen Benefit des intrakoronaren Abciximabbolus gegenüber der standardisierten peripher-venösen Bolusapplikation im Hinblick auf die Langzeitprognose anhand von MRT-Parametern zu untersuchen. Für die AIDA STEMI MRT Substudie wurden 117 Patienten in zwei Gruppen randomisiert. Zusätzlich zum regulären Studienprotokoll der AIDA STEMI Hauptstudie wurde eine MRT Untersuchung initial nach Myokardinfarkt sowie nach 6 Monaten durchgeführt, um anhand von Veränderungen der Infarktnarbe und der Ejektionsfraktion (EF) Unterschiede bezüglich des klinischen Outcomes in den beiden Randomisationsarmen zu untersuchen. Die kardiale Bildgebung wies in beiden Randomisationsarmen der MRT Substudie keine signifikanten Unterschiede auf. Auch im Hinblick auf „Major Adverse Cardiac Events“ (MACE) innerhalb von 12 Monaten nach Myokardinfarkt zeigten sich keine signifikanten Unterschiede. Bei der Analyse von Hoch-Risiko-Patientengruppen konnten bei Patienten mit Diabetes mellitus signifikante Unterschiede in Bezug auf die EF initial (p=0,038) als auch nach 6 Monaten (p=0,037) gemessen werden. Hinsichtlich einer Verbesserung der EF bei Hoch-Risiko-Patienten nach 6 Monaten ergaben sich keine signifikanten Unterschiede zwischen intrakoronarer und intravenöser Abxicimabgabe. Zusammenfassend kann man sagen, dass in der vorliegenden Magnetresonanztomographie-Substudie ein intrakoronarer Abciximabbolus gegenüber der standardisierten peripher-venösen Bolusapplikation zu keiner signifikanten klinischen Verbesserung der Langzeitprognose führte. Ein limitierender Faktor der AIDA STEMI Studie ist die geringe Zahl an Hochrisikopatienten, welche in die Studie eingeschlossen wurden und folglich nur eine begrenzte Aussagekraft bezüglich Unterschiede der beiden Applikationsverfahren in dieser Patientenpopulation zulassen. Daher sollten sich zukünftige Studien vor allem auf Hochrisikopatienten konzentrieren. Eine Alternative zum intrakoronaren Bolus bietet die direkte Abciximabapplikation in das betroffene Koronargefäß mit speziellen Kathetersystemen, wie dem Clear Way Perfusionskatheter. In kleineren Studien konnten geringe Vorteile gegenüber der intrakoronaren Bolusgabe demonstriert werden. Trotz potenziell positiver Effekte, werden weitaus größere Studien benötigt, um die Auswirkungen der intraläsionalen Applikationsroute auf klinische Endpunkte zu untersuchen.

BACKGROUND The incidence of pulmonary vein stenosis (PVS) after AF ablation following contemporary procedures remains unclear. We compared the incidence of PVS/narrowing (PVS/N) after PV isolation (PVI) for (1) 3-D mapping-guided wide-area encircling irrigated radiofrequency current (RFC) ablation; (2) first-third-generation big cryoballoon (CB1-3) ablation; and (3) laser balloon (LB) ablation.Methods and Results:All patients undergoing a second procedure between January 2012 and November 2016 were subgrouped according to index ablation (PVI): RFC; CB; or LB. PVS/N was classified using PV diameter ratio (second/index procedure) on selective PV angiogram performed before ablation: mild, 25-49%; moderate, 50-74%; or severe, ≥75%. A total of 344 patients (1,362 PV) were analyzed (RFC, n=211; 840 PV; CB1, n=21; 82 PV; CB2,3, n=64; 250 PV; LB, n=48; 190 PV). In the LB group, 45 patients (94%) were treated with dose ≥8.5 W. Second procedures were performed on average 14.9±14.1 months after the index procedure. Mild PVS/N was observed in 18.4%, 9.5% and 3.6% of PV in the LB, RFC and CB groups, respectively (P

Aim An innovative xenon–chlorine (excimer) pulsed laser catheter (ELCA X80) has been recently used for the treatment of complex coronary lesions, as calcified stenosis, chronic total occlusions and non-compliant plaques. Such complex lesions are difficult to adequately treat with balloon angioplasty and/or intracoronary stenting. The aim of this study was to examine the acute outcome of this approach on a cohort of patients with coronary lesions. Methods and Results Eighty patients with 100 lesions were enrolled through four centers, and excimer laser coronary angioplasty was performed on 96 lesions (96%). Safety and effectiveness data were compared between patients treated with standard laser therapy and those treated with increased laser therapy. Laser success was obtained in 90 lesions (93.7%), procedural success was reached in 88 lesions (91.7%), and clinical success in was obtained in 87 lesions (90.6%). There was no perforation, major side branch occlusion, spasm, no-reflow phenomenon, dissection nor acute vessel closure. Increased laser parameters were used successfully for 49 resistant lesions without complications. Conclusions This study suggests that laser-facilitated coronary angioplasty is a simple, safe and effective device for the management of complex coronary lesions. Furthermore, higher laser energy levels delivered by this catheter improved the device performance without increasing complications.

Purpose: To examine whether laser atherectomy combined with drug-coated balloons (laser + DCB) can improve the outcomes of femoropopliteal (FP) in-stent restenosis (ISR). Methods: A dual-center retrospective study was conducted of 112 consecutive patients (mean age 70.3±10.6 years; 86 men) with Tosaka class II (n=29; diffuse stenosis) or III (n=83; occlusion) FP-ISR lesions. Sixty-two patients (mean age 68.5±10 years; 51 men) underwent laser + DCB while the other 50 patients (mean age 72.5±10.8 years; 35 men) had laser atherectomy plus balloon angioplasty (laser + BA). Critical limb ischemia was the indication in 33% of the interventions. The average lesion length was 247 mm. A Cox regression hazard model was developed to examine the association between laser + DCB vs laser + BA; the results are presented as the hazard ratio (HR) and 95% confidence interval (CI). One-year target lesion revascularization (TLR) and reocclusion were estimated using the Kaplan-Meier method. Results: Overall procedure success was 98% and was similar between groups. Bailout stenting was less often required in the laser + DCB group (31.7% vs 58%, p=0.006). The combination of laser + DCB was associated with improved 12-month estimates for freedom from TLR (72.5% vs 50.5%, p=0.043) and freedom from reocclusion (86.7% vs 56.9%, p=0.003). Among patients with Tosaka III FP-ISR, combination therapy with laser + DCB was also associated with increased freedom from reocclusion (87.1% vs 57.1%, p=0. 028). On multivariable analysis, treatment with laser + DCB was associated with a significantly reduced risk of reocclusion (HR 0.08, 95% CI 0.17 to 0.38; p=0.002). Conclusion: When used for treatment of complex FP-ISR lesions, DCB angioplasty combined with laser atherectomy is associated with significantly reduced 1-year TLR and reocclusion rates.

Excimer coronary laser atherectomy (ECLA) has been shown to be both well tolerated and effective for plaque modification. Its technology is based on ultraviolet energy and is capable of disintegrating atheroma, without burning or grossly fragmenting it. ELCA has proven effective in the percutaneous treatment of a variety of complex lesions. Here we present a case of multiple heavy calcified lesions successfully prepared with ELCA and finally treated with the implantation of multiple bioresorbable scaffolds.

Aim Stents reduce angiographic restenosis in comparison with balloon angioplasty. The rate of in-stent restenosis (ISR), although less frequent than post-angioplasty restenosis, is becoming increasingly prevalent due to the recent exponential increase in the use of intracoronary stents. The aim of this study is to evaluate angiographic and clinical outcomes of PTCA in combination with the use of excimer laser coronary angioplasty (ELCA) and drug-eluting balloon (DEB) in treatment of in-stent restenosis (ISR). Methods and results This multi-centric case-control study evaluated angiographic and clinical outcomes of PTCA with excimer laser coronary angioplasty (ELCA) and drug-eluting balloon (DEB) in 80 patients with in-stent restenosis (ISR). All patients underwent nine months of clinical and a coronary angiography follow-up. This study showed clinical and angiographic long-term success in the 91% of the patients. The incidence of myocardial infarctions and deaths was lower than the rate after plain balloon angioplasty within the stent. Conclusions This study showed that excimer laser coronary angioplasty (ELCA) and drug-eluting balloon (DEB) may be an alternative treatment for in-stent restenosis (ISR).

Background/Objectives Stent underexpansion is a risk factor for in-stent restenosis and stent thrombosis. Existing techniques to optimize stent expansion are sometimes ineffective. The aim of this study was to evaluate the effectiveness and feasibility of Excimer Laser Coronary Angioplasty (ELCA) in improving stent expansion when high-pressure non-compliant balloon inflation was ineffective. Methods and Results ECLA ablation was performed at high energy during contrast injection and only within the underexpanded stent. The primary endpoint of successful laser dilatation was defined as an increase of at least 1mm 2 in minimal stent cross-sectional area (MSA) on IVUS or an increase of at least 20% in minimal stent diameter (MSD) by QCA, following redilatation with the same non-compliant balloon that had been unsuccessful prior to ELCA. Secondary endpoints were cardiac death, myocardial infarction (MI) and target lesion revascularization. Between June 2009 and November 2011, 28 patients with an underexpanded stent despite high-pressure balloon inflation were included. The mean laser catheter size was 1.2±0.4 (range 0.9-2.0mm) and a mean of 62±12mJ/mm 2 at 62±21hertz were required for optimal expansion. Laser-assisted stent dilatation was successful in 27 cases (96.4%), with an improvement in MSD by QCA (1.6±0.6mm at baseline to 2.6±0.6mm post-procedure) and MSA by IVUS (3.5±1.1mm 2 to 7.1±1.9mm 2 ). Periprocedural MI occurred in 7.1%, transient slow-flow in 3.6% and ST elevation in 3.6%. During follow-up, there were no MIs, there was 1 cardiac-death, and TLR occurred in 6.7%. Conclusions The ELLEMENT study confirms the feasibility of ELCA with contrast injection to improve stent underexpansion in undilatable stented lesions.

Despite the use of laser technology over the last decade, there are limited data to show its procedural and clinical success in infra-popliteal disease. We hypothesized that laser-assisted balloon angioplasty (LABA) is at least similar or better in procedural and peri-procedural outcomes compared to balloon angioplasty (BA) alone, despite adverse lesion characteristics prior to intervention. Retrospective chart and angiogram review of consecutive critical limb ischemia (CLI) patients who underwent endovascular revascularization in the popliteal or infra-popliteal vessels between 2007 and 2012 with LABA or BA alone. Data from 731 patients revealed that baseline demographics were similar in the LABA (n = 398) and BA group (n = 333) with minor exceptions. More patients in the LABA group had TASC-D lesions (92.5 vs. 66.7 %; P < 0.0001) and chronic total occlusions (CTOs) in both vessel 1 (86.4 vs. 49.5 %; P < 0.0001) and vessel 2 (78.6 vs. 47.8 %; P < 0.0001). Multivariate analysis performed using logistic regression after adjusting for confounding factors showed use of LABA was associated with a 7 times greater likelihood of achieving

OBJECTIVES To evaluate the association of diabetes mellitus (DM) with clinical and angiographic characteristics and outcomes of patients with popliteal and infrapopliteal peripheral arterial disease (PAD) undergoing peripheral vascular intervention (PVI). BACKGROUND Clinical features and outcomes in patients with DM and popliteal or infrapopliteal PAD undergoing PVI are not well described. METHODS Using the data from the laser in popliteal and infrapopliteal stenosis study, we retrospectively examined the association of diabetes with clinical and angiographic characteristics and risk adjusted short- and intermediate term outcomes (all cause death, major adverse events (MAE) [composite of death, ipsilateral major amputation, or repeat revascularization]) in patients with popliteal and infrapopliteal PAD undergoing PVI for critical limb ischemia treated either with laser-assisted balloon angioplasty or balloon angioplasty alone. RESULTS Of 714 patients, 418 had DM (58.5%). Patients with DM were younger with higher prevalence of history of coronary artery disease, heart failure, end-stage renal disease, and prior contralateral limb amputation compared to those without DM. At 5 years, mean event free survival for all cause mortality (39.9 vs. 45.5 months; P = 0.001), MAE (29.3 vs. 36.8 months; P

Many patients are subjected to the potential risks and morbidity associated with an indwelling inferior vena cava (IVC) filter when standard methods fail to remove the filter. We evaluated the safety and effectiveness of the excimer laser sheath technique for removing embedded IVC filters.Over a 5-year period, 251 consecutive patients undergoing laser-assisted filter retrieval were prospectively enrolled. There were 103 men and 148 women (mean, 46 years; range, 15-82 years). Indications for retrieval included symptomatic acute IVC thrombosis, chronic IVC occlusion, and/or pain from filter penetration. Retrieval was also performed to prevent risks from prolonged implantation and potentially to eliminate the need for lifelong anticoagulation. After retrieval failed using three times the standard retrieval force (digitally measured), treatment escalation was attempted using a laser sheath powered by a 308-nm XeCl laser. Success was defined as complete filter detachment and removal from the body. Primary safety outcomes were major procedure-related complications.Laser-assisted retrieval was successful in 249 of 251 patients (99.2%) (95% CI, 97.2%-99.9%), with a mean implantation of 979 days, range: 37-7,098 days (19 years), among retrievable-type filters (n = 211) and permanent-type filters (n = 40). Average force during failed attempts without laser was 6.7 vs 3.8 lbs during laser-assisted retrievals (P .0001). The major complication rate was 1.6% (95% CI, 0.4%-4.0%), and all were successfully treated. Successful retrieval allowed cessation of anticoagulation in 45 of 46 patients (98%) (95% CI, 88%-99%) and alleviated filter-related morbidity in 55 of 57 patients (96%) (95% CI, 88%-99%).The excimer laser sheath technique is safe and effective for removing embedded IVC filters refractory to standard retrieval and high force. This technique can be used to alleviate or prevent filter-related morbidity and may allow cessation of filter-related anticoagulation.ClinicalTrials.gov; No.: NCT01158482; URL: www.clinicaltrials.gov.

Visually guided laserballoon (LB) ablation has recently been introduced for pulmonary vein (PV) isolation (PVI). We analyzed efficacy and safety results of the newly introduced LB ablation technique in patients with persistent and longstanding persistent atrial fibrillation (AF), and compared this with an established standard method using the cryoballoon (CB).A total of 35 patients with symptomatic persistent AF underwent LB ablation and were followed-up for 1 year. Results were compared to 35 patients who underwent CB ablation at the same institution and case matched for age, sex, CHAComplete isolation of all PVs was achieved in 68.6% in the LB and 97.1% in the CB group (P0.01). No significant differences were found for AF-free survival after 12 months in the complete cohort of all patients (LB: 53.3% vs CB: 70.4%; P = n.s.) and after excluding patients without complete PVI (LB: 57.8% vs CB: 72.5%; P = n.s.). LB ablation resulted in longer procedure (158.5 ± 37.9 minutes vs 110.9 ± 26.5 minutes; P0.01) and fluoroscopy durations (28.4 ± 11.1 minutes vs 23.5 ± 9.4 minutes; P = 0.04.), and a trend toward more major complications (14.3% vs 2.9%; P = n.s.). Procedure durations and complications declined over time and were level with CB-treated patients when reaching the last quartile of the LB patients.PVI in patients with persistent AF using the LB or the CB resulted in comparable success rates. Initial prolongations in procedure and safety parameters as a result of a learning curve effect for the LB have to be considered before starting to use this technique.

The experience with a new approach of using combined debulking technique for treating heavily calcified coronary artery lesions with both LASER and high speed rotational atherectomy, which is being labeled as RASER PCI, is described. The RASER PCI approach has been used in three different patients with severely calcified, undilatable coronary artery lesions that were unresponsive to either technique alone, with successful and satisfactory outcome.

Background: Few studies have examined whether high-responsiveness to antiplatelet therapy is associated with an increased risk of bleeding in patients receiving dual antiplatelet therapy. MethodsandResults: Elective drug-eluting stent implantation was performed in 184 patients treated with aspirin and a thienopyridine (200 mg/day of ticlopidine or 75 mg/day of clopidogrel). The subjects were divided into 3 groups according to post-treatment platelet reactivity before stenting as measured by the response to adenosine diphosphate: the 1st quartile group was defined as high-responders, the 4th as low-responders, and the other 2 quartiles as middle-responders. Major bleeding occurred more frequently in high-responders than in middle- or low-responders during an average of 16 months' follow-up (15 vs 4, 2%, P=0.02). High-responsiveness was the independent predictor of major bleeding (odds ratio 4.26, P=0.03). Adverse cardiac events were less frequent in high- and middle-responders than in low-responders (24, 16 vs 37%, P=0.02). Middle-responders had better net clinical outcomes, defined as the sum of major bleeding and adverse cardiac events, than did high- or low-responders (21 vs 39, 39%, P=0.02). Conclusions: In the present study high-responsiveness to antiplatelet therapy was associated with an increased risk of bleeding with no reduction in adverse cardiac events. Measuring platelet reactivity may be useful for risk stratification according to bleeding complications, as well as adverse cardiac events, in patients treated with drug-eluting stents. (Circ J 2010; 74: 679-685)

Excimer laser has been successfully applied to complex atherosclerotic plaques in acute coronary syndromes; however, its role in debulking in left main coronary artery disease has not been fully explored. Details of a series of 20 patients who underwent excimer laser revascularization of a spectrum of left main coronary artery lesions are presented. Twenty symptomatic patients who received excimer laser debulking were examined for procedural outcome and follow up results. The left main coronary artery was characterized as protected, semi-protected, poorly protected, or unprotected, depending on the presence or absence of patent bypass grafts to the left anterior descending (LAD) and circumflex (CX) arteries. A fully protected left main coronary artery (LMCA) was present in only 20% of the patients. The target lesions included 11(55%) distal LMCA stenoses, six (30%) ostial stenoses, and one (5%) mid-portion lesions. Two (10%) patients had in-stent re-stenosis of the entire length of the LMCA. Small (0.7 mm-1.4 mm) excimer laser catheters were mostly used. A relatively high number of laser energy pulses (1,334 +/- 643) were required to achieve adequate debulking. Successful LMCA intervention was performed in 19 (95%) patients, while in-hospital complications occurred in only one (5%) patient. Subacute/late stent thrombosis developed 3 months after the procedure in one patient, and two patients died from non-cardiac causes during follow-up. Lesions in LMCAs can be revascularized in selected patients by laser debulking and adjunct stenting. Inadequate protection by bypass grafts and decreased left ventricular function do not contradict utilization of excimer laser. Small laser catheters and high energy levels are required during laser debulking of stenoses of left main coronary arteries.

Background Pulsed-wave ultraviolet excimer laser light at 308 nm can vaporise thrombus, suppress platelet aggregation, and, unlike other thrombectomy devices, ablates the underlying plaque. Aim To evaluate both safety and efficacy of laser ablation in patients presenting with Acute Myocardial Infarction (AMI) complicated by persistent thrombotic occlusion. Methods From May 2003 to October 2006, we enrolled 66 AMI patients (age 59±11 years; 57 men) presenting complete thrombotic occlusion of the infarct related vessel. All patients were treated with laser. Primary acute angiographic end-points was corrected TIMI frame count. Secondary echocardiographic end-point was left ventricular remodeling defined as an increase in end-diastolic volume ≥20% 6 months after infarction. Tertiary clinical endpoint was event-free survival at 6 months follow-up. Results There were no intra-procedural death or coronary perforation. One primary angiographic failure was observed during lasing. Major dissection occurred in 1 (1.5%) and distal embolization in 4 patients (6%). Corrected TIMI frame count was 100 at baseline, 29±0.6 after lasing and 22±3 after stenting. At 6-months follow-up, left ventricular remodeling occurred in 8% patients. Event-free survival was 95% at 6-months follow-up. Conclusion Laser angioplasty is feasible, safe and effective for the challenging treatment of patients with AMI and thrombus-laden lesions. The acute effects on coronary epicardial and myocardial reperfusion are excellent.

Lower extremity peripheral arterial occlusive disease poses a unique challenge to traditional angioplasty-based endovascular therapies. The diffuse nature of lower extremity atherosclerotic disease, the presence of chronic total occlusions, poor distal runoff, and the presence of critical limb ischemia all have contributed to the disappointing results of balloon angioplasty for complex infrainguinal arterial disease. These challenges have spawned the development of a host of new technologies in an attempt to improve the safety and effectiveness of percutaneous revascularization for lower extremity peripheral arterial occlusive disease. This review summarizes the recent advances in available technologies, including novel angioplasty balloons; nitinol stents, stent grafts, and drug-eluting stents; excisional, laser, and rotational atherectomy devices; devices for crossing total occlusions; true-lumen reentry devices; thrombectomy catheters; and embolic protection devices.

BACKGROUND Asymmetric dimethylarginine, an endogenous inhibitor of nitric oxide synthase, is a systemic marker of endothelial dysfunction. Although experimental evidence indicates that asymmetric dimethylarginine may play an important role in atherogenesis, local asymmetric dimethylarginine levels have not been measured in vivo. OBJECTIVES We sought to determine whether: (i) asymmetric dimethylarginine is elevated locally at sites of coronary lesions, (ii) systemic asymmetric dimethylarginine concentrations correlate with local levels, and (iii) percutaneous coronary intervention produces immediate local asymmetric dimethylarginine elevation. METHODS In patients undergoing percutaneous coronary intervention (n=15), blood samples were obtained from a peripheral venous site, the coronary ostium proximal to the lesion and the coronary vessel distal to the lesion, before percutaneous coronary intervention. Samples were also obtained distal to the coronary lesion immediately after percutaneous coronary intervention and from the peripheral venous line 24 h after percutaneous coronary intervention. RESULTS Asymmetric dimethylarginine gradients were present across the coronary bed: local asymmetric dimethylarginine (micromol/l) was significantly higher distal to coronary lesions compared with proximally (2.39+/-1.27 vs. 1.52+/-0.68, P=0.005), and to systemic venous levels (2.39+/-1.27 vs. 1.17+/-0.72, P=0.001). Local asymmetric dimethylarginine did not increase immediately after percutaneous coronary intervention (1.88+/-0.89 vs. 2.39+/-1.27, P=0.11). Peripheral venous percutaneous coronary intervention levels 24 h after percutaneous coronary intervention were similar to baseline values (1.17+/-1.2 vs. 1.17+/-0.72, P=0.98). CONCLUSION Asymmetric dimethylarginine gradients exist across coronary lesions, suggesting asymmetric dimethylarginine release at the plaque site. Local asymmetric dimethylarginine accumulation may contribute to the endothelial dysfunction associated with high-grade coronary lesions. Peripheral asymmetric dimethylarginine is a marker of generalized endothelial dysfunction, but our findings highlight its limitation in detecting focal injury.

Until recently, extracranial involvement of moyamoya disease (MMD) had not been fully elucidated. The purpose of this study was to determine the prevalence and clinical implications of renal artery stenosis in pediatric MMD patients.This retrospective study included 101 pediatric (18 years old) MMD patients who visited our hospital from July 2008 to May 2013. All patients had legible abdominal or renal angiography. Baseline characteristics, including hypertension (HT) and angiographic findings, were retrospectively evaluated.The median age was 8 (range 2-16) years. Six patients (5.9%) had HT. Renal artery stenosis was identified in 8 patients (7.9%). Five of 8 renal artery stenosis patients had HT. Statistical analysis showed that advanced stages of MMD and HT were associated with renal artery stenosis (p 0.05).Renal artery stenosis was not uncommon in pediatric MMD. Renal artery evaluation could help determine the cause of HT in advanced pediatric MMD cases. Further prospective and large-scale studies may be helpful in elucidating the extracranial manifestation of MMD.

Balloon catheters have been designed to facilitate pulmonary vein (PV) isolation in patients with paroxysmal atrial fibrillation (AF). The visually guided laser balloon (VGLB) employs laser energy to ablate tissue under direct visual guidance.This study compared the efficacy and safety of VGLB ablation with standard irrigated radiofrequency ablation (RFA) during catheter ablation of AF.Patients with drug-refractory paroxysmal AF were enrolled in a multicenter, randomized controlled study of PV isolation using either the VGLB or RFA (control). The primary efficacy endpoint was freedom from protocol-defined treatment failure at 12 months, including symptomatic AF occurring after the 90-day blanking period. The primary efficacy and safety endpoints were powered for noninferiority.A total of 353 patients (178 VGLB, 175 control) were randomized at 19 clinical sites. The mean procedure, ablation, and fluoroscopy times were longer with VGLB compared with controls. The primary efficacy endpoint was met in 61.1% in the VGLB group versus 61.7% in controls (absolute difference -0.6%; lower limit of 95% confidence interval [CI]: -9.3%; p = 0.003 for noninferiority). The primary adverse event rate was 11.8% in the VGLB group versus 14.5% in controls (absolute difference -2.8%; upper limit of 95% CI: 3.5; p = 0.002 for noninferiority), and was mainly driven by cardioversions. Diaphragmatic paralysis was higher (3.5% vs. 0.6%; p = 0.05), but PV stenosis was lower (0.0% vs. 2.9%; p = 0.03) with VGLB.Despite minimal prior experience, the safety and efficacy of VGLB ablation proved noninferior to RFA for the treatment of paroxysmal AF. (Pivotal Clinical Study of the CardioFocus Endoscopic Ablation System-Adaptive Contact [EAS-AC] [HeartLight] in Patients With Paroxysmal Atrial Fibrillation [PAF] [HeartLight]; NCT01456000).

Laser-assisted balloon angioplasty (LABA) has been shown to be more effective in achieving angiographic success for treatment for below knee peripheral artery disease (PAD) compared with balloon angioplasty alone(BA). However, long-term outcomes of LABA compared with BA for popliteal and infrapopliteal PAD are unknown.We evaluated data on 726 patients undergoing LABA (n = 395) and BA (n = 331) for popliteal and infrapopliteal PAD retrospectively at a single center (2007-2012). Outcomes included long-term ipsilateral major limb amputation, revascularization and mortality (median follow-up = 36 months).Baseline features were similar in two groups with the exception of more TASC-D lesions (92.4 vs. 66.5%; P 0.0001) and chronic total occlusions (86.4 vs. 49.5%; P 0.0001) in LABA group. Angiographic success was higher in LABA compared with BA (97.7 vs. 89.2%; P 0.0001). Ipsilateral major limb amputation (4.1 vs. 5.1%, P = 0.48) and repeat revascularization (25.1 vs. 23.3%, P = 0.47) were similar in LABA and BA patients despite unfavorable baseline angiographic characteristics in the former. Compared with BA, death was more frequently in LABA group (35.2 and 26.3%, P = 0.01), a reflection of higher comorbid conditions in this group (adjusted HR 1.05, 95% CI 0.79-1.39).Despite worse baseline angiographic characteristics compared with BA, LABA was associated with higher angiographic success and similar ipsilateral major amputation, repeat revascularization, and long-term mortality. Future randomized clinical trial should evaluate the efficacy of LABA compared with BA (particularly drug-eluting) in improving limb salvage and reducing repeat revascularization in these high-risk PAD patients.

To report our experience with excimer laser-facilitated recanalization of acute and subacute thrombotic occlusions of hemodialysis shunts.Twenty-one patients (16 women; mean age 54+/-19 years, range 31-76) presented with acute and subacute thrombotic occlusions of their hemodialysis shunts (4 Cimino, 17 prosthetic; 18 forearm, 3 upper arm); mean occlusion time was 4.1+/-3 days (range 1-14), and the thrombotic occlusion measured a mean 17.4+/-9 cm (range 5-27). Fresh thrombus was observed in addition to the total shunt occlusion in all cases. All patients were treated initially with a pulsed ultraviolet (308-nm) excimer laser. Eighteen (85.7%) patients received adjunctive local thrombolysis for treatment of residual thrombus. Nineteen (90.5%) patients underwent angioplasty of the underlying anastomotic stenosis.The angiographic occlusion was reduced from 100% to 63%+/-28% after laser treatment and to 36%+/-18% after 1 hour of thrombolytic therapy (20 mg tissue plasminogen activator). TIMI flow increased significantly from grade 0 to 2.7+/-0.5 following laser ablation (p0.001) and to 3.0+/-0.2 upon completion of the angioplasty procedure (p0.001 versus baseline). The immediate procedural success was 95.2% (20/21). Detectable thrombotic embolization and laser-related complications were not observed in any case. Primary patency was 85%; 3 patients had abnormal Doppler flow within 6 weeks and underwent reintervention (secondary patency 100%). All successfully treated shunts were usable for further dialysis at the 6-week follow-up.Percutaneous excimer laser-facilitated thrombus vaporization is safe and effective for recanalization of acute and subacute thrombotic occlusions of hemodialysis shunts.

Interventional cardiology has advanced into domains once believed to be beyond the reach of percutaneous procedures. As technologic advances continue to push the limits of the interventionalist's capabilities, several areas still exert considerable resistance to this forward momentum. These technically difficult frontiers include bifurcated lesions, small-vessel disease, multivessel disease, diffuse disease, and chronic total occlusions.

To evaluate the effectiveness of laser-assisted angioplasty for patients with critical limb ischemia (CLI) who were poor candidates for surgical revascularization.A prospective registry at 14 sites in the US and Germany enrolled 145 patients with 155 critically ischemic limbs; the patients were poor candidates for bypass surgery owing to inadequate target vessel or saphenous vein, prohibitive cardiac disease, or significant comorbidities (ASA class 4). Additional comorbid risk factors included diabetes in 66%, hypertension in 83%, previous stroke in 21%, and myocardial infarction in 23%. Endovascular treatment included guidewire traversal and excimer laser angioplasty followed by balloon angioplasty with optional stenting.Occlusions were present in 92% of limbs. A mean of 2.7+/-1.4 lesions were treated per limb; the total median treatment length was 11 cm (mean 16.2, range 0.2-123). Stents were implanted in 45% of limbs. Procedural success, defined as50% residual stenosis in all treated lesions, was seen in 86% of limbs. At 6-month follow-up, limb salvage was achieved in 110 (92%) of 119 surviving patients or 118 (93%) 127 limbs.Excimer laser-assisted angioplasty for CLI offers high technical success and limb salvage rates in patients unfit for traditional surgical revascularization.

Background and Objectives Excimer laser is used clinically in arterial revascularization procedures. This study evaluated the efficacy of aspirin in reducing platelet aggregation during high-energy excimer lasing. Study Design/Materials and Methods Platelet rich plasma (PRP) from seven rabbits was circulated in a dual organ chamber with aspirin added to one and the other was control. PRP was irradiated using an excimer laser (308 nm; 45 mJ/mm2; 25 Hz; 5 minutes) via a 2.0 mm laser catheter. Platelet aggregation (particle volume) was measured by laser-light scattering. Morphology was evaluated by phase contrast and electron microscopy. Results Baseline platelet volume was 3.4 µm3 for both control and aspirin groups. Following lasing, platelet volume peaked at 102.2 ± 18.5 µm3 for control compared to 43.1 ± 49.2 µm3 for aspirin-treated PRP (P

This study examined from a health service perspective whether percutaneous myocardial laser revascularisation (PMR) plus standard medical management is cost-effective when compared with standard medical management alone in the treatment of refractory angina. This involved a cost-utility analysis using patient-specific data from a single-centre, randomised, controlled trial carried out in the United Kingdom. Of 73 patients diagnosed as having refractory angina and not suitable for conventional forms of revascularisation, 36 were randomised to PMR plus medical management and 37 to medical management alone. We collected costs to the health service of PMR and all secondary sector health care contacts and cardiac-related medication in the 12 months following randomisation. Patient utility, measured using the EuroQol EQ-5D questionnaire, was combined with 12-month survival data to generate quality-adjusted life years (QALYs). The mean 12-month cost per patient for PMR was 8,307 pounds, and that for medical management was 1,888 pounds, giving a cost difference of 6,410 pounds. The mean QALY difference favoured PMR at 0.126, giving an incremental cost per QALY of 50,873 pounds. The cost-effectiveness acceptability curve indicates that the probability of PMR being cost-effective over the first 12 months is quite low. Whilst a longer period of follow-up might indicate continued benefit from PMR, which would make the intervention economically more attractive, PMR could not be considered cost-effective based on 1-year follow-up data.

Percutaneous myocardial laser (PML) reduces symptoms in patients with intractable angina. PML leads to a certain loss of viable myocardium, we therefore assessed if troponin or cardiac markers release may explain the clinical effect, and furthermore assessed the markers release during percutaneous sham procedures.Eighty-two patients with chronic refractory angina were randomized to either percutaneous myocardial laser or a true sham procedure. Cardiac markers were assessed before the procedure, and (1/2), 2, 4, 6, and 10-12 h postprocedure.Troponin I increased to median peak levels (range) of 4 (0.6-43) microg/L in the laser group vs. 1.5 (0.1-5.9) microg/L, p=0.001, and creatine kinase MB to 14 (6-357) microg/L vs. 11 (3-40) microg/L, p0.05, within and between-group comparison, the rise of CK-MB occurred significantly earlier in the sham group, 3.8 vs. 2.5 h. A time-dependent between-group difference was only detected for troponin. 88% of sham and 100% of laser patients had marker levels above reference limits. There was no correlation between the number of laser/sham created channels, biomarker levels postprocedure, and changes in left ventricular ejection fraction or angina improvement during 12 months of follow-up.The release of cardiac markers is not related to relief of angina after myocardial laser. The use of intracardiac catheters induces a considerable marker release, which is not caused by acute ischemia.

Refractory angina pectoris is defined as Canadian Cardiovascular Society class III or IV angina, where there is marked limitation of ordinary physical activity or inability to perform ordinary physical activity without discomfort, with an objective evidence of myocardial ischemia and persistence of symptoms despite optimal medical therapy, life style modification treatments, and revascularization therapies. The patients with refractory angina pectoris may have diffuse coronary artery disease, multiple distal coronary stenoses, and or small coronary arteries. In addition, a substantial portion of these patients cannot achieve complete revascularization and continue to experience residual anginal symptoms that may impair quality of their life and increase morbidity. This represents an end-stage coronary artery disease characterized by a severe myocardial insufficiency usually with impaired left ventricular function. As the life expectancy is increasing, patients with angina pectoris refractory to conventional antianginal therapeutics are a challenging problem. We review the nonconventional therapies to treat the refractory angina pectoris, including pharmacotherapy, therapeutic angiogenesis, transcutaneus electrical nerve and spinal cord stimulation, enhanced external counterpulsation, surgical transmyocardial laser revascularization, percutaneous transmyocardial laser revascularization, percutaneous in situ coronary venous arterializations, and percutaneous in situ coronary artery bypass. These therapies are not supported by a large body of data and have only a complementary role; therefore, the aggressive traditional and proven treatment of angina pectoris should be continued along with these therapies, used on an individual basis.

Venous thromboembolism (VTE) is common, with an incidence of >400 out of 100 000 people in the United States.1 VTE recurrence is also frequent, occurring in 40% of patients,2 with mortality as high as 30%.3 Also, if left untreated, pulmonary embolism (PE) will occur in as many as 40% of all proximal deep vein thrombosis (DVT).4 Although first-line treatment for VTE is anticoagulation, some patients cannot receive this therapy, and others will experience treatment failure. Consequently, inferior vena cava filter (IVCF) use has been steadily rising in the United States and Europe for the past 2 decades.5,6 Article see p 560 Most IVCFs in modern use allow for retrieval once the indication for use has passed. Practically, a variety of devices and techniques with escalating aggressiveness can be used to remove filters, and the Food and Drug Administration recommends that efforts should be made to retrieve these devices as early as possible. When filters are centered in the inferior vena cava and not firmly attached to the caval walls, dedicated filter grasping devices are often all that is required. A problem arises when filter components are embedded into the caval wall. In these cases, more aggressive retrieval techniques need to be used. Existing techniques may include use of endobronchial forceps and, in extreme cases, open surgical removal. Another solution that may be appropriate in cases of caval thrombosis or occlusion is to perform venoplasty and stenting.7 In these cases, the IVCF may be retrieved or restrained between a stent and the caval wall.8 In this issue of Circulation: Cardiovascular Interventions , Kuo et al9 tackle this problem by using a novel technique. They present their prospective experience in 100 consecutive patients in whom laser-assisted removal of embedded IVCF was implemented. Filters …

We evaluated the short-term results of percutaneous excimer laser angioplasty in acute myocardial infarction. Of the 18 patients studied, 2 were female and 16 male with a mean age of 56.6 ± 12.1 years. Thrombolysis in myocardial infarction grades 0, 1, and 2 flow was observed in 10, 5, and 3 cases, respectively, prior to the procedure. The degree of stenosis was 97.9% ± 5.1%. The lesion was crossed with a laser catheter in all cases, using a mean number of 808 ± 384 laser pulses. Type C dissection developed in only 1 case (6%). Except for this case, distal flow was grade 3 in all the patients. Following the procedure, ST segment resolution exceeding 70% was achieved in 14 cases (78%) within the first 90 minutes. The success rate of laser ablation was 94% (17 patients). Stent implantation was performed in all the cases. In conclusion, laser angioplasty is an effective and reliable treatment for acute myocardial infarction.

This study was designed to evaluate safety and effectiveness of the 0.9 mm excimer laser coronary catheter with increased laser parameters. We report a prospective trial of 100 calcified and/or balloon-resistant lesions where a new 0.9 mm excimer laser catheter was used at standard or higher energy level to facilitate angioplasty. Standard in-hospital clinical and angiographic parameters were collected and measured. Laser technical success was obtained in 87 lesions (92%), procedural success was reached in 88 lesions (93%), and clinical success in 82 lesions (86%). Increased laser parameters were used for 29 resistant lesions. This new 0.9 mm excimer laser coronary catheter using higher energy parameters seems to be safe and effective for management of calcified and nondilatable lesions.

Diffuse in-stent restenosis remains an important problem in percutaneous transluminal coronary angioplasty (PTCA). In this trial, we studied the early and mid-term outcomes of excimer laser coronary angioplasty (ELCA) on diffuse in-stent restenosis. ELCA was performed in 23 patients (19 males). The mean length of the lesions was 14.3 +/- 3 mm and the mean age was 58 +/- 7 years. The minimal lumen diameter (MLD) was measured by on-line quantitative coronary angiography. Before the procedure, MLD was 0.9 +/- 0.4. The Q/non-Q-wave myocardial infarction (MI), coronary artery bypass graft (CABG), PTCA, and mortality were recorded during the procedure and at 6 months follow up. The fluence of laser emission was 45 mj/m2 and the repetition rate was 25 pulses per second. Adjunctive balloon angioplasty was performed in all of the cases at a mean 7 +/- 2 atm pressure. The procedure was successfully performed in all of the cases. Type-B dissection developed, after ELCA in 1 patient (4%). Perforation, death, cerebrovascular accidents, emergency CABG, PTCA or Q/non-Q wave myocardial infarction were not observed. MLD was 0.9 +/- 0.4 mm before ELCA, 1.8 +/- 0.9 mm (P0.05) after ELCA, and 3.1 +/- 0.7 mm after PTCA. At 6 months follow up, there were 2 (8.7%) Q-wave myocardial infarctions and 2 (8.7%) recurrent anginal pain cases. Control angiography was obtained in 20 cases (87%). Control angiography was not accepted by 3 patients. Their maximal exercise test was negative. Angiographic restenosis was observed in 6 cases (30%). The rate of target lesion revascularization (TLR) was 5 of 23 (22%) in the patients treated with ELCA. It is concluded, ELCA is a safe and efficient debulking technology for treating diffuse in-stent restenosis.

Background and Objectives We assessed quality of life (QOL) after XeCl transmyocardial laser revascularization (TMLR). Study Design/Materials and Methods Thirty patients were randomized to receive XeCl excimer TMLR or optimal cardiac medication (controls). QOL was assessed at baseline, 1, 3, 6, and 12 months using three different questionnaires: The Medical Outcomes Study Short Form-24 (MOS SF-24), the EuroQol Standardized Questionnaire, and the Seattle Angina Questionnaire (SAQ). The primary outcome measure was the change in score between baseline and 12 months. Results TMLR patients scored significantly better compared to controls in the MOS SF-24 social functioning, energy, general health, and bodily pain domains, in the EuroQol usual activity domain and the EuroQol Visual Analogue Scale, and in the SAQ physical limitation, angina frequency and disease perception domains. Conclusions QOL significantly improved after XeCl excimer TMLR compared to medication. These results are similar to reported improvements in QOL after CO2 and Ho:YAG TMLR. Lasers Surg. Med. 33:1–7, 2003. © 2003 Wiley-Liss, Inc.

Purpose: To compare the immediate results, complication rates, and long-term outcomes of percutaneous transluminal laser angioplasty (PTLA) versus balloon dilation alone in the treatment of popliteal artery occlusions. Methods: In a prospective nonrandomized study conducted between December 1994 and June 2000, 215 symptomatic patients with unilateral popliteal occlusions were treated with either dilation alone (88 patients: 52 men; mean age 62 years, range 48–83) or PTLA (127 patients: 70 men; mean age 64 years, range 49–86) using a 308-nm excimer laser followed by dilation. The average occlusion length was 10.4 cm (range 3–14). Results: PTLA was successful in recanalizing 105 (82.7%) arteries, while the recanalization rate for dilation alone was only 70.4% (62/88; p=0.045). After a mean follow-up of 36 months (range 6–52), the primary and secondary patency rates were 21.7% and 50.8%, respectively, in patients with PTLA and 16.3% and 35.2% in the angioplasty group (p=0.762). The complication rates associated with both techniques were similar. Conclusions: Although initial recanalization may be better with PTLA, it does not appear to add any long-term benefit over balloon dilation alone.