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How to deal with thrombus in ACS
"Zap it" - Laser for Thrombus
Suneel Talwar Dorset Heart Centre
Royal Bournemouth Hospital
Conflict of Interest
• Consultant/Advisory Board
– Spectranetics
• Clinical & Research Grant Support
– Boston Scientific Corporation
– Cordis
- Photoablation is the use of light
to vaporize and remove tissue
Excimer Laser
Photochemical
Photothermal
Photomechanical
Breaking molecular
bonds
Producing thermal
energy
Creating
kinetic energy
Mechanism of Action
Three distinct mechanisms of action contribute to Excimer
Laser Photoablation
UV light pulse hits tissue for 125 billionths
of a second
50 microns penetration
Billions of molecular bonds fractured per pulse
0 - 125 billionths of a second
Photochemical Mechanism: Breaking Molecular Bonds
Absorption creates molecular vibration in tissue
Vibration of molecules heats intracellular water
Water vaporizes, rupturing cells
Steam forms expanding vapor bubble
Photothermal Mechanism: Producing thermal energy
Expansion and collapse of vapor bubble breaks
down tissue and clears by-products away from tip
By-products of ablation are water, gas, and small
particles (90%<10 microns = size of red blood cell)
400 millionths of a second
Photomechanical Mechanism: Creating kinetic energy
The Excimer wavelength is very close to what is used in eye surgery,
indicative of its shallow depth of penetration and hence safety
The Wavelength StoryThe Wavelength Story
Excimer (CVX-300Ø)
InfraredUltraviolet
UltravioletUltraviolet vs vs. Infrared. Infrared
Excimer (ophthalmology)
CO2
Ho:YAG
308nm
193nm 2090nm
10600nm
Spectrophotometric Spectrophotometric Scan ofScan of
Fresh ThrombusFresh Thrombus
0
10
20
30
40
50
60
70
0 400 500 600
Wavelenth (nm)
% A
bso
rp
tio
n
Lee et al . Am J Card. 1983: 52; 876-877
Affinity for Photon Absorption
The Excimer
wavelength is
ideally suited
for absorption
by the acute
thrombus
The Antiplatelet Effects of Laser Energy
placebo
60mj
30mj
The Laser inhibits platelet aggregation
acting like a localized IIB IIIa Inhibitor
Am J Cardiol 2004;93:694-701
The data obtained from the participating centres was submitted to independent core laboratories for quantitative coronary analysis and statistical analysis.
High risk patients included
• 30% of the patients had Diabetes
• 24% had previous CABG
• 23% had sustained a previous MI
• 28% had a contraindication to thrombolysis
• 13% presented to the cath lab with cardiogenic
shock.
• The target vessel for revascularisation was an old
saphenous vein graft in 21% of patients.
The greater amount of thrombus the better
the result with the Laser
High flow
rates
post
laser
The CARMEL Study-Complications
Death 6(4%)
Laser Induced Perforation 0
Laser Induced dissection 6(4%)
Acute closure 1(0.6%)
Laser induced no-flow 1(0.6%)
Stent induced no-flow 1(0.6%)
Groin bleeding complications 3 (2%)
Study Summary
Extended FAMILI Flow in Acute Myocardial Infarction
Patients after Laser Intervention -
Extended Pilot Study
Extended FAMILI
Objective: To benchmark microvascular
coronary blood flow in AMI patients after
percutaneous intervention that includes
excimer laser coronary atherectomy
Study Design: Prospective non-randomized study in up to
20 sites, and up to 80 patients.
Principal Investigators:
Jeffrey Moses, MD
Antonio Columbo, MD
EXTENDED FAMILI RESULTS
Laser Success: Defined as TIMI 2-3 with > 20%
reduction in %DS post laser.
Procedure Success: Defined as TIMI 3 flow and <
50% DS on final angiogram without in-hospital
MACE.
- Laser Success: 94%
- Procedure Success: 96%
- 30 Day-MACE: 3%
Low MACE correlated with the high Blush
Scores
EXTENDED FAMILI
Extended FAMILIExtended FAMILI
n=79 n=100 n=101 n=240 n=240 n=252 n=249
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Registry RCT-Device
Arm
RCT-Control Possis
Angiojet
RCT-Control Guardwire Control
Ext FAMILI X-Amine AIMI EMERALD
Blush 0/1
Blush 2
Blush 3
p<0.001
p<0.001
p=0.009
p<0.001
p<0.001
p<0.001
Blush Post-ProcedureBlush Post-Procedure
Svilaas T et al. N Engl J Med 2008;358:557-567
Thrombus Aspiration during Primary PCI: TAPAS study
Extended FAMILI: Conclusions
– Laser appears safe for thrombus ablation in Acute MI: 30
Day MACE 3%
– High Procedural Success Rate of 91%
– Extended FAMILI appears equivalent in TIMI flow rates
compared to other thrombectomy studies.
– Blush scores post-procedure appear to be significantly
better than the other thrombectomy studies.
.
TAAMI: Thrombus Ablation in
Acute Myocardial Infarction
• Randomised controlled study comparing a
Laser-Stent strategy to a Balloon-Stent
strategy
• N= 200
• 5 sites in Poland
TAAMI: Thrombus Ablation in
Acute Myocardial Infarction
• Primary Endpoint - Complete ST resolution and MBG 3 immediately post procedure
• Secondary Endpoint - MACE 30 days
- MBG
- TIMI Flow rates post Laser
- TIMI frame count
- ST reolution at 60 minutes post procedure
Our Approach in AMI
• Turn on the Laser prior to arrival of patient in the Lab to avoid delays
• Laser Catheter: For most total occlusions start with a 0.9/1.4 catheter (both are 6F compatible)
• The laser will work over any 0.014 wire
• The vapor bubble works best in a saline medium (blood and contrast must be flushed prior to lasing)
• Activate the laser a few mm proximal to the start of the lesion
– to maximize the effect of the advancing vapor bubble
– and to avoid cavitation into the plaque
• Use higher energies and rates from the start (60/40)
– to create a larger vapor bubble
– and lead to better inhibition of platelet aggregation
• In order to get the effect of the advancing vapor bubble, the laser catheter must be advanced very slowly (rate of <1mm per second)
Conclusion
• The use of the excimer laser is feasible and safe in the setting of an AMI
• Laser treatment has been shown to result in significant thrombus removal, suggesting direct laser energy absorption and thrombus vaporisation
• The potential clinical benefits of the stunned platelet phenomenon await clinical confirmation
• A prospective randomised multicentre comparing this to convention angioplasty and stenting as well as thrombectomy is necessary to confirm the observations made so far