Gary Roubin

Excimer Laser Coronary Angioplasty: The New Approaches to Coronary Intervention (NACI) Experience

In the New Approaches to Coronary Intervention (NACI) registry, 887 patients were electively treated with excimer laser coronary angioplasty (ELCA) for coronary artery disease. The Advanced Interventional System (AIS) system was used in 487 cases; the Spectranetics system, in 400. The mean age was 63.4 years. Most patients had unstable angina (60.3%); 43.7% had a prior myocardial infarction; and 18.6% were high risk or inoperable patients. Mean ejection fraction was 55.4%. A total of 1,000 lesions were treated in the 887 patients. Of the 1,000 lesions treated with ELCA in the 887 patients, 36% were in the right coronary artery; 33%, left anterior descending; 13%, circumflex; 3%, left main; and 16.6%, vein graft. By angiographic core laboratory analysis available for 752 (85%) patients with 839 lesions, lesions were 12.76 mm long. The minimum lumen diameter increased to 1.29 mm after the laser and finally to 1.95 mm after adjunctive percutaneous transluminal coronary angioplasty (PTCA) (which was performed in 93% of all lesions), with a final residual stenosis of 32.1% and Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow in 95%. Dissections of grades B, C, or D were seen after 22.0% of initial laser attempts, and postlaser perforations were noted in 2.6%. Additional such dissections accumulated after adjunctive PTCA but the perforation rate remained low. Procedural success was achieved in 84% of patients, but 1.2% died, 0.7% experienced Q-wave myocardial infarction (MI), and 2.7% required emergency bypass surgery. Multiple logistic regression analysis could not identify any independent predictors of these in-hospital complications. One-year mortality was 5.7% and the cumulative incidence of Q-wave MI was 1.5%. Coronary artery bypass graft (CABG) surgery was performed in 15.0% of patients whereas 25.5% required repeat percutaneous intervention with a target lesion revascularization rate of 31%. Independent predictors of death, Q-wave MI, or target lesion revascularization (which, combined, occurred in 35.6% of patients) were the absence of prior MI, ELCA in the circumflex, perforation after the procedure, and small (<2 mm) final minimal lumen diameter. Considering the large number of patients with high-risk lesions, laser angioplasty was performed with excellent procedural success rates and a reasonable incidence of major complications.

Chapter 59 – Carotid Stenting

Carotid artery stenting has evolved rapidly over the last decade and is currently being practiced in many medical centers. Since the pioneering work of Dotter 1 and Gruentzig 2 on percutaneous vascular intervention some 30 years ago, few procedures have met the vigorous scrutiny and criticism that has been encountered by carotid artery stenting. Given the potential for procedural neurologic complications and the existence of a well-validated surgical therapy, caution has always been warranted. But in the case of carotid artery stenting, opposition based on less valid motives 3 has caused delays in the federal approval of advanced devices and techniques, slowed progress in clinical trials, created confusion in reimbursement policy, and has resulted in inequitable access for patients who might benefit. Despite resistance, carotid artery stenting has become widely accepted as a viable alternative to carotid endarterectomy (CEA). In this chapter, we review the development of the technique, the clinical and technical management of patients who undergo carotid artery stenting, current results, and future directions.