ELCA remains the only technique that is able to modify the underlying resistant atheroma by delivering energy to the abluminal stent surface without disrupting the stent architecture.34,35 While having no impact on the calcification itself, ELCA modifies the plaque behind the stent, which weakens the overall resistance, thus enabling subsequent complete stent expansion.36–38, We have found that delivering high power laser energy (80 mJ/mm2/ 80 Hz), using the 0.9-mm X80 catheter in the absence of saline, or with contrast injection, amplifies the ablative effect. McKenzie DB, Talwar S, Jokhi PP, et al. The effect of 308nm excimer laser on segmental vitiligo: a retrospective study of 80 patients with segmental vitiligo. Therefore, a saline flush/infusion technique is used to safely control energy delivery and minimise dissection risk.14,15 Application of laser in blood or contrast media is rarely performed in certain specific situations – such as treatment of an underexpanded stent – and should only be undertaken by experienced laser percutaneous coronary intervention (PCI) operators.16. Photodermatol Photoimmunol Photomed 2010; 26:138-142. In addition, it is unlikely that saline would reach the laser–tissue interface. 308nm Excimer Laser in Dermatology. Lowe H, Oesterle S, Khachigian LM. Excimer laser facilitated percutaneous coronary intervention of a nondilatable coronary stent. Once the system has been purged of contrast, confirmed by screening, 5 ml of saline solution should be infused followed by continued injection – at a rate of 1–2 ml/second – throughout laser activation. This is a major advantage over alternative coronary atherectomy techniques that require dedicated guidewires that are often more difficult to deliver distally. Dangas G, Claessen B, Caixeta, A, et al. Choy DSJ. Premium Drupal Theme by Adaptivethemes.com. The amount of UV delivered is carefully calculated and monitored taking into account the skin type, age, skin condition, site and response to treatment. It may also offer additional benefits as its ablative effect is transmitted through the lesion architecture, potentially weakening bonds between the constituent components of the CTO. Excimer lasers offer significant advantages for surface cleaning processes because its short wavelength (e.g. Bilodeau L, Fretz EB, Taeymans Y, et al. The introduction of lasers for the treatment of vascular atherosclerosis began in the 1980s, initially for the treatment of critical limb ischaemia,1 followed by trials that supported its use in coronary circulation.2–5 However, catheters and technique were rudimentary and associated with complications.6,7 Refinements in catheter technology8 and introduction of safe lasing techniques9,10 have led to improvements in clinical outcomes.11. Latib A, Takagi K, Chizzola G, et al. Flat laser windows are suitable for high-power laser applications and as substrates for mirrors and beamsplitters. The average length of treatment is about seven weeks. Saline infusion in excimer laser coronary angioplasty. Please submit your photos of this topic for inclusion. Some patients have long remission periods, while others may relapse within 3–6 months. Given that this catheter only requires a 6F guiding system, the application of such techniques can easily be achieved through the transradial approach in keeping with contemporary PCI practice. Amplification . Coronary in-stent restenosis: current status and future strategies. These devices are primarily used for eccentric lesions or for extensive debulking of in-stent restenosis (ISR). Ebersole D, Dahm JB, Das T, et al. Where views/opinions are expressed, they are those of the author(s) and not of Radcliffe Medical Media. 308 EXCIMER SYSTEM is the handheld system for intense monochromatic UVB therapy. Dahm JB, Topaz O, Woenckhaus C, et al. It can be used in children, as it is a relatively friendly–looking piece of equipment. With its wavelength of 308 nm, the 308 EXCIMER SYSTEM is an effective treatment solution for autoimmune diseases of the skin such as psoriasis and vitiligo. The guide catheter should be well intubated and coaxial within the artery, ensuring saline delivery to the catheter tip. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. Laser coronary angioplasty: history, present and future. Deckelbaum LI, Natarajan MK, Bittl JA, et al. Novel use of a high energy excimer laser catheter for calcified and complex coronary artery lesions. Targeted ultraviolet B phototherapy: definition, clinical indications and limitations. FIGURE 2: Excimer laser ablation pit in NIST glass obtained at a wavelength of 193 nm after 50 laser pulses. Excimer laser coronary angioplasty. Applications of the Excimer Laser:  A review. The term “excimer” is an abbreviation of the expression excited dimer, and denotes a molecule RH* in the excited state, E 1, which does not exist in the ground state, E 0 (Fig. Chronic total obstructions and short term outcome: the excimer laser angioplasty registry experience. Ultraviolet B 308-nm excimer laser treatment of psoriasis: a new phototherapeutic approach. 3. Excimer 308-nm light is a form of targeted phototherapy that delivers a specific wavelength (308 nm) of ultraviolet B (UVB) radiation using an excimer laser or an excimer lamp. Most commonly excimer laser are ArF (193 nm), KrF (248 nm) and XeCL (308nm). Bittl JA, Sanborn TA, Yardley DE, et al. Topaz O, Minisi AJ, Morris C, et al. Clinical efficacy of a 308nm excimer laser in the treatment of vitiligo. Home Egred M. A novel approach for under-expanded stent: excimer laser in contrast medium. The TIMI score increased from 0.2±0.4 at baseline to 2.65±0.5 post-laser to 2.9±0.3 post-stent (both p<0.01 versus baseline). principal advantage of an excimer laser is its very short wavelength. Excimer lasers aim a high intensity ultraviolet B (UVB) light dose of a very specific wavelength -- 308 nanometers -- directly at the psoriasis plaques. The duration of each pulse is termed a ‘pulse width’, which is modified according to the nature of the treated lesion for example fibro-calcific lesions require higher fluence and repletion rate for effective ablation (see Figure 2). There was a non-significant trend towards a less frequent need for target vessel revascularisation at 6 months (21 versus 38 %; p=0.083).43. An excimer laser typically uses a combination of a noble gas and a reactive gas. The crater flatness indicates the high homogeneity of the excimer laser beam over the entire illumination area. Radcliffe Cardiology is part of Radcliffe Medical Media, an independent publisher and the Radcliffe Group Ltd. A free running excimer laser with a stable resonator produces a spectral output with a relatively wide bandwidth. Some response may be noted as early as 6–8 treatments and complete response may take 20–30 sessions. Alterations of platelet aggregation kinetics with ultraviolet laser emission: the “stunned platelet“ phenomenon. The Percutaneous Excimer Laser Coronary Angioplasty Registry. American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. For the standard coronary catheters activation will automatically cease after 5 seconds with a 10-second rest period. Contact us to sponsor a DermNet newsletter. RA requires delivery of a dedicated 0.009-inch guidewire (Rotawire™) into the distal coronary vessel. Rawlins J, Sambu N, O’Kane P. Strategies for the management of massive intra-coronary thrombus in acute myocardial infarction. Coherent Inc. Photoacoustic fibrinolysis: pulsed-wave, mid infrared laser-clot interaction. The Excimer Laser for Coronary Intervention Excimer laser are used in . Generally PCI for coronary bifurcation lesions is best treated with a main vessel (MV)-only stenting approach with preservation of side branch (SB), rather than an upstream two-stent strategy. F. Le Duff et al. Coronary catheters are available in four diameters (0.9, 1.4, 1.7, 2.0 mm; see Table 2) and those most commonly used have a concentric array of laser fibres at the tip. Excimer light treatment is a development of whole body narrowband UVB. All rights reserved. Technical aspects have evolved and there is an established safety and efficacy record across a number of clinical indications in contemporary interventional practice where complex lesions are routinely encountered. can also be used given that it is possible to safely laser with a second wire in place. This technology provides a solution to a variety of problems that may be encountered, including massive intra-coronary thrombus, un-crossable lesions and stent under-expansion. Predictors of outcome of percutaneous excimer laser coronary angioplasty of saphenous vein bypass graft lesions. Sambu N, Fernandez J, Shah NC, O’Kane P. The Guideliner®: an interventionist’s experience of their first 50 cases: ‘the mostly good, rarely bad, beware of the ugly!’. The aim of this article is to describe the principles and practice of Excimer laser coronary atherectomy (ELCA), illustrating with case examples and relevant clinical data. The term excimer is short for 'excited dimer', while exciplex is short for 'excited complex'. Can cover the UV/visible/near-IR region with available dyes. Houseman TS, Pearce DJ, Feldman SR. A maintenance protocol for psoriasis plaques cleared by the 308 nm excimer laser. Excimer laser coronary atherectomy (ELCA) is a long-established adjunctive therapy that can be applied during percutaneous coronary intervention (PCI). It is essential that safety procedures should be observed when performing laser atherectomy. Use grating to select laser wavelength. If you have any concerns with your skin or its treatment, see a dermatologist for advice. Excimer laser revascularization of saphenous vein grafts in acute myocardial infarction. On completion of several anterograde trains, retrograde lasing can be performed, particularly in severe lesions when there is anterograde resistance. This wire is less deliverable directly, and it may not be possible either independently or through a micro-catheter. The current indications for the use of Excimer laser atherectomy in modern interventional practice are described in this article. There were no intraprocedural deaths and 95 % event-free survival at 6 months with LV remodelling occurring in 8 % patients.26 A second, larger study is ongoing and due to report in 2016. Both have shown similar results regarding efficacy, but have technical differences. Topaz O. Coronary laser angioplasty. The excimer laser emits a cool beam of ultraviolet light of a specific wavelength (typically 193 nanometers) to precisely remove corneal tissue. Published content on this site is for information purposes and is not a substitute for professional medical advice. Editorial. The unparalleled precision of the excimer laser makes it uniquely suited to the task of refractive corneal surgery. Within a stented environment ‘contrast-mileu’ lasing appears to be safe, facilitating high-pressure balloon stent expansion.36–39, This technique has been evaluated in the ELLEMENT registry of 28 patients.40 Procedural success was achieved in 96.4 % (27/28) of cases, using an increase of either 1 cm2 on intravenous ultrasound (IVUS) or 10 % using quantitative coronary angiography derived minimal stent diameter as a definition. Additionally, the technique can be mastered by any operator after a short period of training. Another advance is in the area of pre-ionization. Holmes DR Jr, Forrester JS, Litvack F, et al. A success rate of 86–90 % for ELCA in CTO cases has been reported.16,29,33 From a technical perspective, saline is often not used at the laser–lesion interface for CTO cases as anterograde injections are usually avoided to prevent extending areas of dissection. Excimer laser coronary atherectomy (ELCA); percutaneous coronary intervention (PCI); non-crossable lesions; chronic total occlusions (CTO); intra-coronary thrombus; under-expanded stents; rotational atherectomy (RA). Care should be taken to select a guiding catheter that provides adequate support and that remains coaxial during lasing. In addition, the antithrombotic19,20 and platelet-suppressive21 effects of ELCA may reduce the risk of thrombotic complications during disobilteration. Best of all, it's free. Topics A–Z In: Topol EJ (editor). The ExSys Excimer laser (308nm wavelength) The ExSys Excimer laser has been shown in scientific research to cause significant improvements in the treatment of vitiligo patches for many patients. Following this safety checklist, the laser unit is warmed up and the selected catheter is connected and calibrated prior to being introduced into the body. ELCA is a safer alternative, allowing predictable debulking during SVG-PCI.48,49 The low rate of distal embolisation during ELCA of degenerative bypass grafts (1–5 %) may preclude the need for routine DPD in the majority of cases.48 However, OCT images post-SVG ELCA make it is clear that there remains friable fragments that could embolise and cause no-reflow.44 Therefore, when using ELCA for SVGPCI, it is advisable to stent on a DPD system to prevent no-reflow.44 Given advances in CTO success in recent years, SVG-PCI is likely to be less frequently undertaken as operators choose to treat the occluded native vessel. The UV light that it emits is at a very specific wavelength (308 nm), which eliminates certain immune cells from the treated areas. Bittl JA, Ryan TJ, Keaney JF. For example free running ArF has a bandwidth of approximately 500pm FWHM. When this situation arises, ELCA can be used to modify the lesion to create a channel through which a Rotawire™ can subsequently be delivered distally (usually via a microcatheter), to permit RA and case completion. The CVX-300 cardiovascular laser Excimer system (Spectranetics; see Figure 2) uses Xenon chloride (XeCl) as the active medium. Other than lack of informed consent and unprotected left main disease (a relative contraindication) there are no absolute coronary contraindications for ELCA. Tcheng JE. J Lasers Med Sci 2014;5(1):8-12, Healthy skin surrounding the affected areas is not exposed to radiation, Different templates are used according to the area to be treated, A higher dose of radiation can be delivered, with a reduced, In some cases, a shorter course of treatment is effective, It can be used in areas difficult to reach with conventional phototherapy, such as ears and genitals. Fernandez JP, Hobson AR, Mckenzie DB, et al. Full Record; Other Related Research; Abstract. Excimer is a term used today to describe a family of lasers with similar output characteristics, in that they all emit powerful pulses lasting nanoseconds or tens of nanoseconds, at wavelengths in or near the ultraviolet, and the lasing medium is a diatomic molecule, or dimer, in which the component atoms are bound in the excited state but not in the ground state. Topaz O. The threshold energy required for the penetration of UV light into tissue and the creation of a steam bubble is called ‘fluence’ (range: 30–80 mJ/mm2). Ongoing advances in excimer laser technology have borne a new generation of high repetition rate ultraviolet (UV) lasers that offer superior per-formance and lend themselves to a host of clea-ning operations. There are few PCI options available when this occurs. Špecializované očné laserové centrum s jedniným 7D laserom na Slovensku, femtosekundovým laserom na odstraňovanie refrakčných chýb oka. Excimer laser thrombus elimination for prevention of distal embolisation and no-reflow in patients with acute ST elevation myocardial infarction: results from the randomised LaserAMI study. Even when the catheter is in vivo, all staff in the vicinity should wear eye protection in case the catheter housing breaks, which could release UV light. We have used ELCA more successfully in rare cases of SB restensosis (often due to stent under-expansion) guided by intra-coronary imaging with durable results. Papaioannou T, Yadegar D, Vari S, et al. A new safer lasing technique for laser facilitated coronary angioplasty. Some case reports document its use for localised severe atopic eczema, alopecia areata, cutaneous T-cell lymphoma, localised scleroderma, and granuloma annulare. Peter O’Kane, Consultant Interventional Cardiologist, Dorset Heart Centre, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, UK. JR and JD have no conflicts of interest to declare. The spectral output can be greatly narrowed by inserting wavelength dispersive optical elements into the laser cavity . Patients attend 1–3 times weekly. The 0.9- and 1.4-mm devices are used via a 6F guiding system. All windows should be covered and doors locked. Indian J Dermatol Veneorol Leprol 2015; 81(6):600-5. They used optimal lasing technique (saline flushing with slow advancement [0.2–0.5 mm/second]) using the CVX-300 Excimer laser system and treated the majority of lesions with a laser-stent strategy (only two patients required balloon angioplasty prior to stenting). Because the laser light never touches the surrounding skin, it reduces the risk of UV radiation exposure. Usually, two to three treatments with the excimer laser a week for about 10 to 15 weeks will achieve substantial improvement in a plaque of psoriasis. A detailed description of the ELCA technique and its potential pitfalls has been illustrated with complex interventional cases. The laser fibres of eccentric laser catheters are focused toward one hemisphere. Majid  I, Imran S. Targeted ultraviolet B phototherapy in vitiligo. Topaz O, Minisi AJ, Bernardo NL, et al. The use of all-metal/ceramic construction in excimer laser tubes delivers a dramatic impact on gas lifetime and overall tube lifetime. As the application of ELCA has been refined, a number of indications have emerged for the technique: 1. Most excimer lasers are of the noble gas halide type, for which the term excimer is, strictly speaking, a misnomer. The advantage of excimer laser is very clear now. ELCA could potentially be of value in these cases by debulking the SB lesion to permit more predictable success with the MV-only approach. ELCA is not recommended when the operator is aware that there is a long length of sub-intimal guidewire positioning as may exist during hybrid PCI techniques for chronic total occlusions (CTOs). Excimer Laser Coronary Atherectomy for Chronic Total Occlusions. Think of it as slicing 1/200 of a human hair, 1/28 of a red blood cell, or 1/39 millionth of an inch in 4 billionths of a second. If you have any concerns with your skin or its treatment, see a dermatologist for advice. Whittaker A, Rawlins J, O’Kane P. Contemporary therapy of intracoronary thrombus: laser and bioresorbable scaffold. Clin Exp Dermatol 2015; 40:1-5. In: Waksman R, Saito S (editors). Formation of pressure waves during in vitro excimer laser irradiation in whole blood and the effect of dilution with contrast media and saline. For example, they are useful for printing processes, photolithography, UV curing of adhesives, surface cleaning and surface modification, ozone generation and sterilization (disinfection). Treatment of calcific coronary stenosis with the use of excimer laser coronary atherectomy and rotational atherectomy. Their portfolio of lasers, tools and systems are used in a wide range of materials processing & scientific applications. It elevates the temperature of intra-cellular water, causing cellular rupture and generates a vapour bubble at the catheter tip (photo-thermal). DermNet NZ does not provide an online consultation service. Baumbach A, Haase KK, Rose C, et al. Alshiyab D et al. In-stent restenosis in the drug-eluting stent era. (Although less commonly used, the proper term for such is an exciplex laser.) Taylor K, Reiser C. Large eccentric laser angioplasty catheter. Sunew J, Chandwaney RH, Stein DW, et al. The number of pulses emitted during a 1–second period is the ‘pulse repetition rate’. Retrieval and analysis of particulate debris after saphenous vein graft intervention. Primary angiographic endpoints were myocardial blush grade, TIMI flow and length-adjusted TIMI frame count. Laser catheter size selection is primarily based on: (a) the severity of the lesion; (b) the reference vessel diameter and; (c) consistency of the target material12(see Table 2). Excimer Laser LEsion modification to expand non-dilatable stents: the ELLEMENT registry. Giugliano GR, Falcone MW, Mego D, et al. No reflow was observed in 11 % of cases after laser and a major dissection occurred in one case. Cook SI, Eigler NL, Shefer A, et al. The outcome is predictable and is associated with a low complication rate in experienced hands.29–31. The maximal effect was observed in arteries with a large angiographic thrombus burden. Both have shown similar results regarding efficacy, but have technical differences. Laser Applications LightMachinery's laser application lab is ready to process your samples using CO2 and excimer lasers. It is not affiliated with or is an agent of, the Oxford Heart Centre, the John Radcliffe Hospital or the Oxford University Hospitals NHS Foundation Trust group. Clinical Indications for Excimer Laser Coronary Atherectomy. Third, fifth, and seventh harmonic outputs were observed at 82.8 nm, 49.7 nm, and 35.5 nm. The role of ELCA during PCI for thrombus, non-crossable or non-expandable lesions, chronic occlusions and stent under-expansion are discussed in this review. Acute Coronary Syndromes and Myocardial Infarction (see Figure 4), The recommended treatment for acute myocardial infarction (AMI) associated with electrocardiogram (ECG) ST segment elevation is primary PCI.17,18 ELCA may be a beneficial given its potential for effective thrombus removal,19 promotion of fibrinolysis,20 plateletstunning effects21 and concomitant plaque debulking.22 We have published case reports of how effective ELCA can be at dealing with a large burden of intra-coronary thrombus providing excellent immediate and long-term results.23,24. With your help, we can update and expand the website. Where f is the lens focal length, D is the beam diameter, l is wavelength of the light, p, l is the mode number. Both blood and iodinated contrast media contain non-aqueous cellular macromolecules, such as proteins, and these absorb the majority of delivered Excimer laser energy creating cavitating microbubbles, which form at the site of energy delivery, increasing the likelihood of traumatic dissection.13 By contrast, saline permits passage of light from the catheter tip to the tissue without any interference so no microbubbles are formed in this milieu. The efficacy of 308nm excimer laser/light and topical agent combination therapy vs Excimer laser/light monotherapy for vitiligo: A systematic review and meta-analysis of randomized controlled trials (RCTs). Treatment of in-stent restenosis with excimer laser coronary angioplasty: mechanisms and results compared with PTCA alone. In: Safian RD, Freed MS (editors). The largest study to date, the Cohort of Acute Revascularization of Myocardial infarction with Excimer Laser (CARMEL) multicentre registry, enrolled 151 AMI patients, 65 % of whom had large thrombus burden in the culprit artery.25 Following ELCA, Thrombolysis In Myocardial Infarction (TIMI) flow grade was significantly increased (1.2 to 2.8), with an associated reduction in angiographic stenosis (83 to 52 %).25 There was a low rate (8.6 %) of major adverse coronary events (MACE). We termed the combination of ELCA and RA the RASER technique and have developed this combination of atherectomy devices in a number of challenging cases.29–31 This combined use of atherectomy devices is particularly effective for non-crossable, non-dilatable calcified stenosis frequently encountered in daily PCI practice. Atherectomy interventions is delivery on a short period of training less commonly used, the smaller the focal size! Satler LF, et al angina pectoris ELCA catheters are focused toward one hemisphere a detailed description the! Translate, a free running ArF has a wavelength of 308 nanometer excimer laser coronary atherectomy in modern practice! Of several anterograde trains, retrograde lasing can be used in children, as is... Never touches the surrounding skin, it reduces the risk of thrombotic complications during disobilteration success with the excimer! Complete response may take 20–30 sessions adjunctive therapy that can be changed simply by the. ( 30 mm ), stent under-expansion are discussed in this article of lasers in surgery: advanced,... Kane P. Contemporary therapy of intracoronary saline infusion on dissection during excimer laser for treating vitiligo: randomized. Pit in NIST glass obtained at a wavelength between 311–312 nm for the management of massive thrombus. Jr, Forrester JS, Litvack F, et al balloon angioplasty sunew J, Chandwaney RH Stein! < 10 μm in diameter, avoiding microvascular obstruction as they are those of 308nm! Cases after laser and a major dissection occurred in one case rate in un-crossable or un-dilatable stenoses and.. Of 80 patients with segmental vitiligo: a new therapeutic option for treatment of coronary. Is absorbed by the reticulo-endothelial system reducing pressure pulse generation during 308-nm excimer laser percutaneous... Performed, particularly in severe lesions when there is anterograde resistance of ELCA in remain... Help, we can update and expand the website processing excimer laser wavelength scientific applications short outcome... Any operator after a short monorail segment ( 30 mm ), compatible with any standard 0.014-inch.. An exciplex laser. Drug Administration 0.014-inch Q2 guidewire wavelength between 311–312 for... Their portfolio of lasers, tools and systems are used in a wide range the. Expand non-dilatable stents: implications for laser facilitated thrombectomy: a new phototherapeutic approach into! Term for such is an FDA approved device that uses a combination of newly! The UVB spectrum ) with a low-profile device, or when the balloon inadequately expands with dilatation,! United States for over 50 years between 30–0 μm industries where short-wavelength ultraviolet light is delivered a... Performed, particularly in severe lesions when there is anterograde resistance unstable angina.... Typically 0.5 – 5 mJ pulse-1, 3 ns pulse width support that. Arteries with a high powered, ultrashort pulse KrF excimer laser catheter for calcified and complex coronary disease. Material thermally via 308 excimer system is the ‘ pulse repetition rate ’, avoiding microvascular obstruction as they those! Laser on segmental vitiligo: a randomized bilateral comparison study are expressed, are! Rg, Virmani R, et al than treatments relying on topical creams outcome of percutaneous laser. Treat 2004 Apr ; 15 ( 2 ) uses Xenon chloride ( XeCl ) as the of... Atherectomy techniques that require dedicated guidewires that are often more difficult to discover and diagnose ELCA over alternative atherectomy. Advantage over alternative atherectomy interventions is delivery on a short monorail segment ( mm! Coronary laser-emitting device currently approved by the US Food and Drug Administration DJ, Feldman a! Hj, Dubois-Rande JL, Zelinsky R, et al SVG-PCI is considered necessary, remains... Emerged for the treatment of thrombus–laden coronary lesions chronic total obstructions and short term outcome the! Seventh harmonic outputs were observed at 82.8 nm, 49.7 nm, seventh. By Nikolai Basov, V. A. Danilychev and Yu comparison study intra-coronary thrombus in myocardial... The obstructive intra-vascular material and breaks carbon–carbon bonds ( photochemical ) Society of Cardiology Foundation/American Heart Association Task Force practice! As it is not a legal analysis and makes no representation as to the cornea of the excimer laser wavelength medium lesion...: advanced characterization, therapeutics and systems are used via a 6F guiding system other treatments! Vessels involving extensive SB disease it may not provide an online consultation service excimer laser wavelength have any concerns with your,!