Excimer laser coronary angioplasty in the Netherlands: preamble for a randomized study

The immediate outcome of ELCA by XeCl excimer laser radiation is described in 53 patients who were selected to undergo ELCA from December 1990 to September 1991 in two centers that are currently performing ELCA in the Netherlands. Immediate success rates on the basis of visual assessment of the angiogram were as follows. Laser success (> 20% reduction of diameter stenosis after ELCA alone) was observed in 77% of patients, procedural success (< 50% residual stenosis after ELCA with or without adjunctive balloon dilatation [PTCA]) in 91%, and clinical success (procedural success without clinical complications) in 83% of patients. Quantitative coronary angiography by automated contour detection was performed in 31 patients who underwent ELCA in the Thoraxcenter. The minimal luminal diameter (mean +/- SD) of the treated coronary segments increased from 0.77 +/- 0.41 mm to 1.24 +/- 0.25 mm after ELCA and further to 1.67 +/- 0.29 mm after adjunctive PTCA in 25 patients. The present experience is put in perspective of results initially reported by other centers and compared with data from multicenter registries of ELCA. Finally, a short description is given of the design of a prospective, randomized trial of ELCA versus conventional PTCA (AMRO trial)

Response of conductance and resistance coronary vessels to scalar concentrations of acetylcholine: Assessment with quantitative angiography and intracoronary Doppler echography in 29 patients with coronary artery disease

Abnormal vasoreactivity of the large conductance arteries has been observed in the presence of impaired endothelial function. More recently, experimental and clinical reports have shown that in early coronary atherosclerosis the impairment of the endothelium-mediated vasodilatation also involves the resistance arteries. The aim of this study is the correlation of endothelium-dependent vasodilatation of conductance and resistance vessels in coronary arteries without significant stenoses. In 29 patients (aged 57 +/- 9 years, 24 men and 5 women) undergoing coronary angioplasty, a Doppler guide wire and a perfusion catheter were introduced into the proximal segment of an artery with less than 30% diameter stenosis. Selective infusions of papaverine (bolus of 7 mg), acetylcholine (continuous infusion of 0.036, 0.36, and 3.6 micrograms/ml at a flow rate of 2 ml/min), and isosorbide dinitrate (bolus of 3 mg) were sequentially performed. Heart rate, aortic blood pressure, and blood flow velocity were continuously measured. Mean cross-sectional areas of a proximal and a distal arterial segment were measured in baseline conditions, at the end of each infusion of acetylcholine, and at the peak effect of isosorbide dinitrate with quantitative angiography (CAAS System; Pie Medical Data, Maastricht, The Netherlands). Coronary blood flow was calculated from the time-averaged flow velocity and the cross-sectional area at the site of the Doppler sample volume. Coronary flow resistance was calculated as mean aortic pressure divided by coronary flow. All of the concentrations of acetylcholine induced a significant vasoconstriction of the studied artery. At the maximal concentration of acetylcholine all but three patients (90%) showed a reduction of cross-sectional area (-24% +/- 20% and -22% +/- 20% for the proximal and distal segments, respectively, p < 0.00001). Flow velocity showed a significant increase only with the two highest concentrations of acetylcholine. The maximal concentration induce

Immediate and late outcome of excimer laser and balloon coronary angioplasty: A quantitative angiographic comparison based on matched lesions

Objectives.This study sought to compare acute lumen changes and late lumen narrowing during and after excimer laser-assisted balloon angioplasty, measured by quantitative coronary angiography, with the immediate and long-term outcome of balloon angioplasty alone.Background.Although excimer laser coronary angioplasty is used as an adjunct or alternative to balloon angioplasty, limited comparative data exist regarding the immediate and long-term efficacy of excimer laser-assisted balloon angioplasty versus balloon angioplasty alone.Methods.A series of 53 lesions in 47 consecutive patients successfully treated with excimer laser-assisted balloon angioplasty were individually matched after completion of 6-month follow-up angiography with 53 successfully treated balloon angioplasty lesions according to vessel location, preprocedural minimal lumen diameter and reference diameter. Immediate and long-term angiographic results were assessed by an automated lumen contour detection algorithm.Results.Before intervention in the laser and balloon angioplasty groups, respectively, minimal lumen diameter (mean ± SD) was 0.73 ± 0.47 and 0.74 ± 0.46 mm, and reference diameter was 2.71 ± 0.42 and 2.72 ± 0.41 mm. Laser angioplasty was followed by adjunctive balloon dilation in 50 lesions. Mean balloon diameter at maximal inflation was similar in both treatment groups (2.61 ± 0.32 and 2.65 ± 0.38 mm, respectively), resulting in similar minimal lumen diameters after intervention of 1.77 ± 0.41 and 1.78 ± 0.34 mm, respectively. At follow-up angiography, minimal lumen diameter after excimer laser-assisted balloon angioplasty was 1.17 ± 0.63 mm, and that after balloon angioplasty alone was 1.46 ± 0.67 mm (p = 0.02). The angiographic restenosis rates at follow-up using the 50% diameter stenosis cutoff criterion were 57% and 34%, respectively (p = 0.02).Conclusions.Quantitative angiographic analysis of a matched group of 106 successfully treated coronary lesions showed a similar immediate outcome but reduced long-term efficacy of excimer laser-assisted balloon angioplasty compared with that after balloon angioplasty alone

Randomised trial of excimer laser angioplasty versus balloon angioplasty for treatment of obstructive coronary artery disease

BACKGROUND: Excimer laser coronary angioplasty is reported to give excellent procedural results for treatment of complex coronary lesions, but this method has not been compared with balloon angioplasty in a randomised trial. METHODS: Patients (n = 308) with stable angina and coronary lesions longer than 10 mm on visual assessment were included. 151 patients (158 lesions) were assigned randomly to laser angioplasty and 157 (167 lesions) to balloon angioplasty. The primary clinical endpoints were death, myocardial infarction, coronary bypass surgery, or repeat coronary angioplasty of the randomised segment during 6 months of follow-up. The primary angiographic endpoint was the minimal lumen diameter at follow-up in relation to the baseline value (net gain), as determined by quantitative coronary angiography. FINDINGS: Laser angioplasty was followed by balloon angioplasty in 98% of procedures. The angiographic success rate was 80% in patients treated with laser angioplasty compared with 79% in patients treated with balloon angioplasty. There were no deaths. Myocardial infarction, coronary bypass surgery, and repeat angioplasty occurred in 4.6%, 10.6%, and 21.2%, respectively, of the patients in the laser angioplasty group compared with 5.7%, 10.8%, and 18.5% of the balloon angioplasty group. Net mean (SD) gain in minimal lumen diameter was 0.40 (0.69) mm in patients treated with laser angioplasty and 0.48 (0.66) mm in those treated with balloon angioplasty (p = 0.34). The restenosis rate (> 50% diameter stenosis) was 51.6% in the laser angioplasty group versus 41.3% in the balloon angioplasty group (p = 0.13). INTERPRETATION: Excimer laser angioplasty followed by balloon angioplasty provides no benefit additional to balloon angioplasty alone with respect to the initial and long-term clinical and angiographic outcome in the treatment of obstructive coronary artery diseas

Quantitative angiographic comparison of elastic recoil after coronary excimer laser-assisted balloon angioplasty and balloon angioplasty alone.

AbstractObjectives. Coronary lumen changes during and after excimer laser-assisted balloon angioplasty were measured by quantitative coronary angiography, and the results were compared with the effects of balloon angioplasty alone.Background. Reduction of atherosclerotic tissue mass by laser ablation in the treatment of coronary artery disease may be more effective in enlarging the lumen than balloon angioplasty alone.Methods. A series of 57 consecutive coronary lesions successfully treated by xenon chloride excimer laser-assisted balloon angioplasty were individually matched with 57 coronary artery lesions successfully treated by balloon angioplasty alone. The following variables were measured by quantitative coronary analysis: 1) ablation by laser, 2) stretch by balloon dilation, 3) elastic recoil, and 4) acute gain.Results. Matching by stenosis location, reference diameter and minimal lumen diameter resulted in two comparable groups of 57 lesions with identical baseline stenosis characteristics. Minimal lumen diameter before excimer laser-assisted balloon angioplasty and balloon angioplasty alone were (mean ± SD) 0.73 ± 0.44 and 0.74 ± 0.43 mm, respectively. Laser ablation significantly improved minimal lumen diameter by 0.56 ± 0.44 mm before adjunctive balloon dilation. In both treatment groups, similar-sized balloon catheters (2.59 ± 0.35 and 2.56 ± 0.40 mm, respectively) were used. After laser-assisted balloon angioplasty, elastic recoil was 0.84 ± 0.30 mm (32% of balloon size), which was identical to that after balloon angioplasty alone, namely, 0.82 ± 0.32 mm (32%). Consequently, both interventions resulted in similar acute gains of 1.02 ± 0.52 and 1.00 ± 0.56 mm, respectively. Minimal lumen diameter after intervention was equal in both groups: 1.75 ± 0.35 and 1.75 ± 0.34 mm, respectively. The statistical power of this study in which a 25% difference in elastic recoil (0.2 mm) between groups was considered clinically important was 95%.Conclusions. In matched groups of successfully treated coronary lesions, xenon chloride excimer laser ablation did not reduce immediate elastic recoil after adjunctive balloon dilation or improve the final angiographic outcome compared with balloon angioplasty alone using similar-sized balloon catheters