Long-term evaluation of targeted lesions treated by excimer laser assisted angioplasty does not support routine use. A retrospective evaluation of an outpatient angiosuite experience
Russell H. Samson, MD, Anmol Patel.
Sarasota Vascular Specialists, Sarasota, FL, USA.
Background A proposed rationale for Excimer laser atherectomy assisted angioplasty (ELAA) is that it allows for lower angioplasty inflation pressures thus reducing barotrauma and therefore the requirement for concomitant stents and, possibly, improved long-term patency of unstented lesions. Accordingly, we studied a four-year experience with ELAA of infrainguinal PAD to determine long-term lesion patency. Methods Between 2012 and 2015 five vascular surgeons performed ELAA in a stand-alone outpatient angiography center. Concomitant balloon angioplasty was used uniformly, and bare metal self-expanding stents were supplemented in some. Loss of patency of the atherectomy site was confirmed by falling ABIs, duplex ultrasound and, where appropriate, subsequent arteriography. Univariate and multivariate analysis of variance for variables was conducted. All arteriograms were re-evaluated and compared by the senior author. Results ELAA was utilized for 247 lesions in 225 patients (154 SFA, 1 DFA, 24 AK POP, 12 BK POP, 14AT, 8 PT, 8 PER, 17 tibioperoneal trunks, and nine saphenous vein bypasses). Fifty two in-stent lesions were also treated by ELAA. Indications for intervention were claudication 46.6%, gangrene 12.24%, ulceration 33.06%, and rest pain 11.84%. Balloon inflation pressures were almost uniformly less than the manufacturers’ suggested minimum inflation (median 6 atm., minimum 4 atm., maximum 10 atm.) However, concomitant stents were added to treat 101 lesions (40.9%) of which 94 were for 188 SFA/POP lesions (50%). Inflation pressure as a variable did not impact stenting (P>0.262). Primary patency for 94 non-stented SFA/POP lesions at one, two and three years was 59%, 42%, and 32% respectively. Patency for 34 tibial non-stented lesions was statistically inferior to SFA/POP (P=0.038) with primary patency rates of 44%, 36% and 28%. 87 non-stented lesions required a subsequent ELAA with secondary patency rates of 59%, 42%, and 31%. Primary patency for 52 in-stent stenoses was statistically valid only at one year (46%). The only risk factor for loss of patency was diabetes (RR 1.41). Conclusions Despite low balloon inflation pressures 40.9% of lesions treated by ELAA still required a concomitant stent. Patency rates for non-stented lesions were disappointing and no better than those previously reported for unassisted balloon angioplasty. Only diabetes negatively predicted loss of patency. Anecdotally, ELAA may make angioplasty and stenting technically easier, but the added expense may not justify routine use.
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