Sustained Safety and Success: Long-Term Data Support the Role of Excimer Laser Atherectomy
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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Cath Lab Digest or HMP Global, their employees, and affiliates.
Akiva Rosenzveig, MD1; Robert S. Dieter, MD, RVT, ALM2; Ayesha Nawaz, MD1; Merlin Nikita, MD1; Thomas Callahan, MD1; Aravinda Nanjundappa, MD1
1Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Cleveland, Ohio
2Loyola University and Hines VA, Maywood, Illinois
Disclosures: Drs. Rosenzveig, Dieter, Nawaz, and Nikita report no conflicts of interest regarding the content herein. Dr. Callahan reports serving as a consultant to Philips, Abbott, Medtronic, Shockwave, and Boston Scientific. Dr. Nanjundappa reports serving as a consultant and speaker for Philips.
The authors can be contacted via Aravinda Nanjundappa, MD, at nanjuna@ccf.org.
Coronary artery calcification, fueled by an aging population and increasing comorbidities such as diabetes and kidney disease, presents significant hurdles for interventional cardiologists.1 Calcified lesions impede the delivery of balloons, stents, and imaging devices while limiting optimal stent expansion, leading to poorer prognosis and worse clinical outcomes.2 To overcome these challenges, plaque modification devices (PMDs) have become essential for optimizing lesion preparation.3 Excimer laser coronary angioplasty (ELCA), introduced in the 1980s, is one such PMD that, despite early setbacks, is experiencing a resurgence due to improved technology and contemporary practices like dual antiplatelet therapy and drug-eluting stents.4-6
In this issue of Cath Lab Digest, Scalone et al’s study, “Long-Term Outcomes of Excimer Laser Coronary Angioplasty in Severely Calcified De Novo Coronary Lesions,” adds valuable evidence to the ELCA literature. In a retrospective, single-center study of 50 patients, the authors report a 96% procedural success rate, with minimal lumen diameter improving from 0.40 mm² (IQR 0.1-0.9) to 1.1 mm² (IQR 0.4-1.8). Over a median follow-up of 85 months, all-cause mortality was 20%, with no cardiac-related deaths. Procedural complications were limited to three dissections (6%), all managed with stent placement. Notably, the cohort was older (mean age 76.6 ± 8.2 years), 76% had acute coronary syndromes (ACS), and 72% had uncrossable lesions with a median length of 28 mm (IQR 23-42). These results, despite the small sample size, underscore ELCA’s durability in challenging cases.
ELCA uses ultraviolet light to ablate atherosclerotic plaque, disrupt molecular bonds, and enhance vessel compliance through acoustic and mechanical effects. A cavitation bubble further aids in debulking soft plaque or thrombus. These properties make ELCA particularly effective for complex coronary scenarios, including in-stent restenosis, stent under-expansion, thrombotic lesions, and uncrossable lesions.
Early enthusiasm for ELCA waned after the AMRO and LAVA trials in the late 1990s, which showed no benefit over balloon angioplasty alone, and reported higher rates of dissections and periprocedural myocardial infarction.4,5 However, device advancements and modern interventional practices have revitalized ELCA’s role. Recent observational studies highlight its efficacy. For example, Tomasello et al reported a 97% success rate and 4.7% major adverse cardiovascular events (MACE) in 320 patients over a median of 841 days, though their cohort was younger (71 ± 9 years) and primarily had chronic coronary syndrome.7 Similarly, Iiya et al’s study of 586 ACS patients showed improved MACE and target lesion revascularization (TLR) at 2 years in the ELCA group compared to a propensity-matched non-ELCA cohort.8 A larger retrospective study of 448 patients reported 38% all-cause mortality and 17% TLR at nearly 10 years, with propensity-matched analyses indicating that outcomes were driven by lesion complexity rather than ELCA itself.9 Scalone et al’s findings align with this growing evidence, reinforcing ELCA’s long-term benefits.
ELCA in the Plaque Modification Device Landscape
ELCA is one of several plaque modification devices, alongside rotational atherectomy (RA), orbital atherectomy (OA), and intravascular lithotripsy (IVL). The ROLLER COASTR-EPIC22 trial, which randomized 171 patients with severe calcification to RA, ELCA, or IVL, found no differences in procedural or 1-year outcomes, including MACE, death, TLR, or stent thrombosis.10 Despite its small sample size, this trial supports the safety and efficacy of these plaque modification devices. The 2024 Society for Cardiovascular Angiography and Interventions (SCAI) Expert Consensus Statement provides guidance on plaque modification device use for calcified lesions, but does not specify a preferred device for uncrossable or undeliverable lesions, highlighting the need for further research to define optimal strategies.11
The primary limitation of Scalone et al’s study is its small sample size, which constrains its statistical power. Nevertheless, its findings are consistent with broader evidence supporting ELCA’s role in modern practice. Randomized, controlled trials are urgently needed to compare ELCA with stent deployment alone or other plaque modification devices, particularly in the context of advanced stents, intracoronary imaging, and dual antiplatelet therapy. Such studies will clarify ELCA’s optimal indications and potential synergies with other plaque modification devices.
Scalone et al’s study provides robust evidence for ELCA’s role in managing severely calcified coronary lesions, offering long-term durability and a favorable safety profile. As calcified coronaries remain a formidable challenge, ELCA emerges as a vital tool in the interventionalist’s arsenal. Clinicians should consider ELCA for complex lesions, while researchers must prioritize randomized trials to refine its application and enhance patient outcomes in this evolving field.
References
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