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Subintimal excimer laser coronary atherectomy (S-ELCA) as a bail-out for device-uncrossable chronic total occlusion:
Ahmed Elsherif1, Ameenathul Fawzy1, Sophia Khattak1,2
1Department of Interventional Cardiology, Queen Elizabeth Hospital, Birmingham, University Hospital Birmingham NHS Trust, Mindelsohn Way, Birmingham B15 2GW, UK.
Insights
Subintimal excimer laser coronary angioplasty (SELCA) offers a safe solution for device-uncrossable chronic total occlusions (CTOs) during percutaneous coronary intervention. This technique facilitated vascular healing at the laser site, demonstrating long-term safety in complex CTO cases.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Medical Devices
Background:
- Chronic total occlusions (CTOs) pose significant challenges in percutaneous coronary intervention (PCI), especially when devices cannot cross lesions.
- Excimer laser coronary angioplasty (ELCA) is used for device-uncrossable lesions, but its safety in the subintimal space is not well-established.
Background:
Chronic total occlusion (CTO) that cannot be crossed with balloons or microcatheters despite successful guidewire passage represent one of the most challenging scenarios in percutaneous coronary intervention (PCI). Excimer laser coronary angioplasty (ELCA) is an established adjunct for device-uncrossable lesions; however, the safety of its application within the subintimal space remains limited.
Case Summary:
A 67-year-old male with a complex cardiac history, including prior recurrent interventions and coronary artery bypass grafting, was referred for staged PCI of a right coronary artery CTO because of refractory angina (Canadian Cardiovascular Society class III). Following successful antegrade subintimal wire tracking and re-entry using a Stingray balloon, multiple ultra-low-profile balloons and dedicated microcatheters failed to traverse the subintimal-to-true-lumen transition. A 0.9-mm ELCA catheter at 80 mJ/mm2 and 80 Hz was used in the subintimal space without saline flush, successfully creating a traversable channel. Complete revascularization was achieved using six overlapping drug-eluting stents, optimized with intravascular ultrasound guidance. At two-year follow-up, repeat intravascular ultrasound demonstrated vascular healing at the subintimal-re-entry interface.
Discussion:
This case demonstrates the potential safety and feasibility of subintimal ELCA (SELCA) as a bail-out for device-uncrossable lesions during antegrade dissection re-entry of CTO-PCI, with the first reported evidence of vascular healing at the subintimal laser site at two-year follow-up.
