Chronic atherosclerotic obstructions are a leading cause of lifestyle-limiting intermittent claudication that occurs in 3% to 20% of the population older than 60 years of age.¹ With the introduction of percutaneous revascularization techniques, management of peripheral artery disease has undergone major changes because percutaneous revascularization allows an alternative to open surgical repair. This is due at least in part to continued improvements and the invention of new techniques.^2–7 Among these is the evolution of rotablation, atherectomy procedures, and laser-assisted angioplasty.^4–8 Percutaneous transluminal angioplasty (PTA) is normally recommended as the primary treatment for short-segment femoropopliteal stenoses and occlusions.^1–3,9 In contrast, lengthy chronic occlusions are still mainly treated surgically, especially those of the superficial femoral artery.¹ Primary and secondary success rates of PTA still have various limitations. Vessel occlusion, long lesions, and the presence of vessel calcification decrease the technical success rates and long-term patency after recanalization with balloon angioplasty.

Laser-assisted angioplasty was first evaluated in the late 1980s to overcome these limitations.10–15 The pulsed excimer laser has been extensively evaluated for its ability to debulk atherosclerotic material in vitro and in vivo, demonstrating that the photoablative effect of laser light can recanalize even lesions not amenable to conventional PTA.^16–18 First experiences of the use of different laser systems raised high expectations for laser-assisted angioplasty, leading to extensive use of these new devices because the technical success rates, compared with PTA, were equal. The following years were filled with restraints toward laser angioplasty because there was no significant decrease in long-term restenosis rates.^6,19,20

The objective of this chapter is to show the significance of laser-assisted angioplasty in the treatment of peripheral artery disease after 10 years of clinical experience.

Indications

Excimer laser–assisted angioplasty has been proven successful in occlusions as well as long, severe stenosis, where debulking before angioplasty seems advantageous. Perhaps the most important application of the excimer laser is in the treatment of critical limb ischemia, which is associated with multilevel atherosclerotic disease dominated by long occlusions and a large thrombus burden in multiple vascular segments from the iliac artery to the arteries below the knee.

Percutaneous excimer laser–assisted revascularization has been shown to be an effective treatment for patients with claudication or chronic critical limb ischemia presenting in Rutherford stage 2 to 4. Patients with persistent symptoms for more than 6 months, a walking distance between 100 and 300 meters, and markedly reduced quality of life may also benefit from this technique. Single and multiple subtotal stenoses and occlusions in the iliac (Figs. e13-1 to e13-3), femoral (Figs. e13-4 and e13-5), and popliteal arteries can be treated with the laser when there is a suitable connecting vessel segment and sufficient runoff flow. Past experience shows that even long occlusions of more than 20 cm can be recanalized with technical success (see Figs. e13-4 and e13-5).⁸ The indication for excimer laser–assisted revascularization of a lesion should be based on either intraarterial digital subtraction angiography (IA-DSA) or contrast-enhanced magnetic resonance angiography (CE-MRA).

Technique

Anatomy and Approaches

Major target vessels for excimer laser–assisted angioplasty are the iliac and infrainguinal arteries, as well as the arteries below the knee (Fig. e13-6), among other vascular territories. For iliac artery occlusions, access depends on lesion length and location. In general, an occlusion in the external iliac artery should be treated in crossover approach (see Fig. e13-1). The occlusion of the common iliac artery (see Figs. e13-2 and e13-3) or occlusion of both common and external iliac arteries requires a bilateral access. First, these lesions are crossed in antegrade fashion with a guidewire, and then, after snaring the guidewire in the ipsilateral groin, the recanalization procedure is performed in a retrograde approach. Contralateral access with subsequent crossover recanalization of the occlusion can be considered the standard approach for recanalization of long superficial femoral artery occlusions (see Figs. e13-4 and e13-5).