Laser Angioplasty and Laser-Induced<br />
Thrombolysis in Revascularization of<br />
Anomalous Coronary Arteries

Anomalous origin of the coronary arteries occurs in only 0.64–1.2% of patients undergoing coronary angiography.1,2 In symptomatic patients with atherosclerotic coronary disease, precise angiographic recognition of the origin and the anatomic course of a target anomalous coronary vessel is important for safe percutaneous revascularization or for coronary bypass surgery. Pulsed excimer laser (308 nm wavelength) is a Food and Drug Administration (FDA)-approved device for debulking and revascularization of complex coronary and peripheral atherosclerotic lesions in symptomatic patients.3–10 Recent clinical experience in patients presenting with acute ischemic-thrombotic coronary syndromes demonstrated that this laser is capable of efficient plaque debulking, thrombus vaporization and facilitation of adjunct balloon angioplasty and stenting.5,6,11,12 To date, the application of laser angioplasty for revascularization of anomalous coronary arteries has not been reported. The purpose of this report is to document and discuss clinical and technical data relevant to excimer laser angioplasty as performed in three symptomatic patients, each having an acute coronary syndrome due to significant obstruction within an anomalous coronary artery. Case Report.Patient #1. A 54-year-old male presented to the emergency department with an acute inferior wall myocardial infarction. Treatment included intravenous t-PA, nitroglycerin, heparin and aspirin. Over the course of the next two hours, the patient continued to experience chest pain and ischemia. Emergency cardiac catheterization revealed patent left main, left anterior descending and circumflex arteries. An anomalous, dominant right coronary artery arose from the left coronary sinus. This was the infarct-related vessel containing thrombus in its proximal segment (Figure 1A). The vessel gave rise to a moderately-sized posterior descending artery and a moderately-sized posterolateral branch, both without significant occlusive disease. The left ventricular ejection fraction was 50–55% with hypokinesis of the inferior basal portion. A decision was made to proceed with percutaneous revascularization. Engagement of the ostium of the anomalous right coronary artery (RCA) with a guiding catheter was challenging. The following guiding catheters were attempted without success to cannulate the ostium: Amplatz right 1; Amplatz right 2; right coronary bypass; multipurpose B1; and multipurpose A1. Eventually, the RCA was successfully engaged with an 8 French AL-1 catheter (Cordis Corporation, Miami, Florida). Utilizing a 0.014´´, extra-support, exchange-length guidewire (Choice PT, Boston Scientific/Scimed, Inc., Maple Grove, Minnesota), the target lesion was crossed without difficulty. A 2.0 Vitesse-C laser catheter (Spectranetics, Colorado Springs, Colorado) was applied with the recommended lasing technique utilizing saline injections and intermittent pulsing.3 A total of 675 pulses (fluence of 45 mJ/m2, 25 Hz) of energy were delivered. A significant reduction in thrombus burden was noted (Figure 1B) and the patientreported that his chest pain had subsided. Following dilatation with a 4.0 x 20 mm balloon, a 4.0 x 18 mm Medtronic GFX coronary stent was deployed. Final angiography revealed no evidence of residual thrombus, no distal embolization or dissection and TIMI grade 3 distal flow (Figure 1C). The patient recovered rapidly without any complications. One year following the procedure, the patient had neither angina nor congestive heart failure. Patient #2. A 74-year-old male patient with hypertension and diabetes was admitted with bilateral pneumonia. While in the hospital, he developed chest pain and ischemic T-wave change in leads V2–V5 and ruled in for a non-Q wave myocardial infarction with peak troponin of 6 ng/ml and total CPK of 478 U/L. Cardiac catheterization demonstrated patent left main artery. The left anterior descending artery exhibited a complex 80% stenosis of the proximal and mid-segments with the plaque extending to the ostium of the second diagonal branch. The circumflex artery was patent. An anomalous right coronary artery arose from the left coronary sinus containing a 90% ulcerated, thrombotic lesion in its proximal segment (Figure 2A). A left ventriculogram revealed severely reduced systolic function. The patient was considered a poor candidate for surgical revascularization; thus, he initially underwent a staged procedure that included a successful balloon angioplasty and stent placement of the left anterior descending and first diagonal arteries. One day later, he underwent right coronary artery intervention whereby several guiding catheters were utilized but could not appropriately cannulate the ostium of the anomalous vessel. This included 8 Fr JR-4, 8 Fr AL-1, 8 Fr Voda VR-2, and 8 Fr ATR catheters. Eventually, the artery was successfully cannulated with an 8 Fr (0.086´´) AL-2 guiding catheter (Cordis Corporation). The lesion was crossed with a flexible guidewire (Shinobi, Cordis Corporation). A 2.0 mm rapid exchange laser catheter (Vitesse C; Spectranetics) was advanced across the thrombotic lesion emitting a total of 1,000 pulses with fluence of 45 mJ/m2 at 25 Hz (Figure 2B). Adequate recanalization was achieved (Figure 2C). A 3.5 x 15 mm balloon was inflated followed by deployment of a 4.0 x 12 mm GFX coronary stent (Medtronic). Final angiogram revealed marked patency of the treated vessel with 0% residual stenosis and TIMI grade 3 distal flow. There was no evidence of dissection or distal embolization (Figure 2D). No procedural or in-hospital complications were reported and the patient was discharged the next day. He was asymptomatic at one-year clinical follow-up. Patient #3. A 74-year-old man was admitted to the Cardiac Care Unit with a non-Q wave myocardial infarction. His past medical history included chronic renal failure with dialysis and dilated cardiomyopathy with left ventricular ejection fraction of 28%. A non-invasive perfusion study revealed ischemia in the infero-lateral apical region. The patient underwent cardiac catheterization, which revealed the following: an anomalous left anterior descending coronary artery arising separately from the right coronary sinus (engaged with an Amplatz R-1 catheter) traversing between the great vessels without evidence of compression or atherosclerotic obstructive disease. This vessel retrogradely filled the distal RCA. An anomalous circumflex artery originated from the right coronary sinus as well (separate ostium; engaged with Amplatz R-2 catheter) traversing in a retroaortic course. This was a codominant vessel that exhibited a 100% thrombotic occlusion of a large obtuse marginal branch (Figure 3A), which was the infarct-related vessel. The right coronary artery originated from the right coronary sinus as well; however, it was a small, non-dominant, diffusely diseased vessel. Utilizing an 8 Fr Cordis AR-2 guiding catheter, the anomalous circumflex artery was cannulated for percutaneous revascularization. Several guidewires were used, but failed to penetrate the resistant total occlusion. Eventually, a 0.014´´ Cordis ATW guidewire crossed the obstruction, serving as a platform for excimer laser angioplasty with a 0.9 mm over-the-wire Vitesse catheter at a fluence of 50 mJ/mm2 at 30Hz for 1,050 pulses, which created a pilot channel within the obstruction (Figure 3B). This was followed by adjunct balloon angioplasty and stenting with a 2.5 x 9 mm GFX stent. The lesion severity was reduced to 0% and TIMI 3 flow was gained within the target vessel (Figure 3C). There were no complications and the patient was discharged the next day. Discussion. Proper equipment selection is a major determinant of procedural success in percutaneous coronary interventions. Target vessel anatomy and lesion morphology govern the choice of guiding catheters, guidewires, balloons and various mechanical debulking devices, as well as stents. In both normal and anomalous coronary arteries, the vessel’s orifice configuration and its exit angulation from the aorta affect the ability to cannulate the target artery. The course of a target anomalous vessel and the location and morphology of the target lesion affect delivery of debulking devices and stents. Indeed, previous reports of percutaneous revascularization of anomalous coronary arteries (Table 1), including balloon angioplasty, rotational atherectomy and stenting, have repeatedly documented considerable technical difficulty related to the location of the ostium of the anomalous artery, as well as its anatomic course and morphology. The initial angiographic obstacle is caused by the origin of the target vessel. Tedious, multiple attempts at cannulation of the ostium of the anomalous vessel with various guiding catheters are commonly required. A considerably long fluoroscopic time may be needed before adequate cannulation and coaxial, stable guiding catheter position can be satisfactorily achieved.13–31 Over the years, improved guiding catheter configurations (mainly those of the Amplatz shape) have helped to overcome these difficulties. Also, supportive guidewires, rapid-exchange low-profile balloons, and flexible, low-profile debulking devices and stents have been introduced and successfully applied. This results in improved access to coronary lesions located within both normal and anomalous coronary vessels. In the first 2 patients described, an anomalous right coronary artery was successfully engaged with an Amplatz left catheter. In the third patient, who had an anomalous circumflex artery, an Amplatz right catheter was successfully applied. This ensured proper angiographic opacification of the ischemic and infarct-related vessels, and provided an adequate platform for guidewire advancement, as well as for delivery of the laser catheter followed by adjunct stenting; thus, proper guiding catheter configuration supported the performance of an efficacious revascularization. The rationale behind the application of laser energy in our patients was two-fold: 1) to produce rapid mechanical thrombolysis of an occlusive clot in the setting of an acute coronary syndrome; and 2) to facilitate adjunct balloon angioplasty and stenting. In each patient, application of laser energy resulted in successful plaque debulking and thrombus removal. Potential device-related complications, such as vessel perforation, dissection, distal embolization or formation of an aggressive, active clot, were not encountered. Thrombolytic therapy is a well recognized treatment modality for acute myocardial infarction; however, a “thrombolytic ceiling” is a considerable clinical limitation.32 An optimal level of antegrade perfusion is achieved by pharmacotherapy in only 50–60% of treated patients; in 10–20% of these patients, reocclusion of the infarct-related artery occurs.33 Failure to respond to pharmacologic treatment therefore often necessitates consideration of a mechanical revascularization device. The success of excimer laser and other wavelength lasers in patients with acute coronary syndromes11,12,34,35 is attributed to the fact that atherosclerotic plaques and thrombi both avidly absorb laser energy in various wavelengths within the optical spectrum.8–10 For example, the investigational mid-infrared (2.1 micron wavelength) holmium: YAG laser was applied in 25 patients with acute myocardial infarction in whom thrombolytic agents either failed or were contraindicated. Successful laser-induced thrombolysis and plaque ablation were achieved in 24/25 patients (96%), resulting in a significant increase in TIMI flow from grade 0.7 to 2.8.7 The dye laser (577 nm wavelength) reportedly works beneficially within these clinical confines.35 The pulsed-wave, ultraviolet excimer laser (308 nm wavelength), which is currently the only FDA-approved system for coronary interventions, was recently applied in 59 patients with acute ischemic-thrombotic coronary syndromes.11 This included 26 patients with acute myocardial infarction and 33 with unstable angina. A 97% procedural success rate was gained in the unstable angina group and 100% procedural success was achieved in acute myocardial infarction patients. Of note, a 96% laser-induced reduction of thrombus burden from the treated lesions was reported. In another recent report, a series of 50 patients with complicated acute myocardial infarction was treated with excimer laser angioplasty for purposes of thrombus dissolution, plaque debulking and facilitation of stenting.12 Twelve percent of the treated patients were already in cardiogenic shock upon presentation to the cardiac catheterization suite. Intracoronary thrombus was identified in 84% of the target lesions. Twenty percent of the patients had total occlusion of the infarct-related artery and 64% had subtotal occlusion (95–99%). The average laser catheter size was 1.6 ± 0.2 mm. Seventy-two percent of the catheters were concentric and 28% were eccentric configuration. A mean of 982 ± 684 pulses were delivered to the target lesion with a fluence of 45 mJ/mm2 at 25 Hz. The application of the laser resulted in an increase in the TIMI flow from baseline of 1.7 ± 1.1 to a final flow of 2.9 ± 0.4. Quantitative coronary arteriography at an independent core lab revealed a markedly increased minimal luminal diameter and adequate reduction of percent diameter stenosis with the application of laser energy. Overall, a 100% procedural success rate was achieved. Conclusion. Excimer laser coronary angioplasty can be effectively and safely applied for plaque debulking and thrombus removal in symptomatic patients presenting with complex atherosclerotic lesions located within an anomalous coronary artery. Adequate revascularization in these instances necessitates proper equipment selection and application of safe and efficacious lasing techniques.

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