Endovascular excimer laser atherectomy techniques to treat complex peripheral vascular disease: an orderly process.

Peripheral vascular disease represents the largest obstructive subsegment within the vascular system. Advances in equipment, techniques, biochemical treatments, and the influx of multiple specialties into this arena indicate a coming tidal wave of change to the standard treatment plan for patients with claudication and especially critical limb ischemia. Initial attempts in the 1980s to utilize the "laser" to treat peripheral vascular disease led to a clinical debacle: wavelengths and methods were not optimized; tissue heating was excessive, resulting in restenosis. Since then the "laser" has fallen from grace for endovascular treatment, although it has an infinite set of potential wavelengths, energy levels, and delivery methods. The xenon chloride, excimer laser, a pulsed 308-nm system, has overcome many of these early catastrophes. The long, ongoing success of this method of photoablating thrombus and plaque represents a true step forward in the endovascular treatment of occlusive disease. Although only a tool, the excimer laser provides a means to utilize electromagnetic energy instead of shearing mechanical force to resolve occlusions. With its active element at the tip, the excimer laser requires much less mechanical translation force to cross total occlusions, find the distal lumen, and thereby cause less plaque destabilization. In addition, removing the firm surface layer of plaque, decapping, and some of the plaque volume, debulking, exposes the softer subsegments of the plaque to balloon angioplasty. Utilizing this method, more complex lesions can be approached safely, with a high likelihood of successful revascularization and a low risk of potentially limb-threatening complication.

Stenting of an unprotected left main coronary artery stenosis in cardiogenic shock and ventricular fibrillation: three-year follow-up.

We describe a case of stenting an unprotected left main coronary artery stenosis in an octogenarian patient with cardiogenic shock complicating acute myocardial infarction. Our patient had no in-stent restenosis of the left main for three years and remains asymptomatic. Since, in the octogenarian patient, the surgical risk for emergent coronary artery bypass graft is extremely high, coronary artery stenting of the unprotected left main for myocardial infarction complicated by cardiogenic shock is an alternative treatment in selected patients.