Laser Revascularization for Critical Limb Ischemia

  • Gagan D. Singh
  • Ehrin J. Armstrong
  • John R. Laird


Critical limb ischemia is associated with progressive multi-level lower extremity atherosclerosis and poor long term amputation and mortality rates. In additional to medical therapy, adjunctive endovascular intervention remains an important modality to maintain arterial patency to allow for adequate tissue healing leading to limb salvage and improving overall mortality. Laser atherectomy holds particular primes for challenging femoropopliteal and infrapopliteal lesions – for both de novo and in-stent restenosis. The current chapter delineates the technical aspects of laser atherectomy for treatment of complex lower extremity lesions and to review the clinical literature supporting the use of laser atherectomy in the treatment of critical limb ischemia.


Laser Atherectomy Critical Limb Ischemia Limb Salvage De Novo lesions Femoropopliteal In-Stent Restenosis 


  1. 1.
    Ouriel K. Peripheral arterial disease. Lancet. 2001;358(9289):1257–64.CrossRefPubMedGoogle Scholar
  2. 2.
    Norgren L, Hiatt WR, Dormandy MR, Nehler KA, Fowkes FGR. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45(1):S5A–67.CrossRefGoogle Scholar
  3. 3.
    Dormandy JA, Rutherford RB. Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC). J Vasc Surg. 2000;31(1 Pt 2):S1–296.PubMedGoogle Scholar
  4. 4.
    Matsi PJ, Manninen HI, Suhonen MT, Pirinen AE, Soimakallio S. Chronic critical lower-limb ischemia: prospective trial of angioplasty with 1–36 months follow-up. Radiology. 1993;188(2):381–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Parsons RE, Suggs WD, Lee JJ, Sanchez LA, Lyon RT, Veith FJ. Percutaneous transluminal angioplasty for the treatment of limb threatening ischemia: do the results justify an attempt before bypass grafting? J Vasc Surg. 1998;28(6):1066–71.CrossRefPubMedGoogle Scholar
  6. 6.
    Rogers JH, Laird JR. Overview of new technologies for lower extremity revascularization. Circulation. 2007;116(18):2072–85.CrossRefPubMedGoogle Scholar
  7. 7.
    Wollenek G, Laufer G. Comparative study of different laser systems with special regard to angioplasty. Thorac Cardiovasc Surg. 1988;36 Suppl 2:126–32.CrossRefPubMedGoogle Scholar
  8. 8.
    Scheinert D, Laird Jr JR, Schroder M, Steinkamp H, Balzer JO, Biamino G. Excimer laser-assisted recanalization of long, chronic superficial femoral artery occlusions. J Endovasc Ther. 2001;8(2):156–66.CrossRefPubMedGoogle Scholar
  9. 9.
    Laird Jr JR, Reiser C, Biamino G, Zeller T. Excimer laser assisted angioplasty for the treatment of critical limb ischemia. J Cardiovasc Surg (Torino). 2004;45(3):239–48.Google Scholar
  10. 10.
    Laird JR. Peripheral excimer laser angioplasty (PELA) trial results. Presented at late breaking clinical trials. Transcatheter cardiovascular therapeutics (TCT) annual meeting, 24–28 Sept 2002, Washington, DC.Google Scholar
  11. 11.
    Siracuse JJ, Giles KA, Pomposelli FB, Hamdan AD, Wyers MC, Chaikof EL, Nedeau AE, Schermerhorn ML. Results for primary bypass versus primary angioplasty/stent for intermittent claudication due to superficial femoral artery occlusive disease. J Vasc Surg. 2012;55(4):1001–7.PubMedCentralCrossRefPubMedGoogle Scholar
  12. 12.
    Gray BH, Laird JR, Ansel GM, Shuck JW. Complex endovascular treatment for critical limb ischemia in poor surgical candidates: a pilot study. J Endovasc Ther. 2002;9(5):599–604.CrossRefPubMedGoogle Scholar
  13. 13.
    Laird JR, Zeller T, Gray BH, Scheinert D, Vranic M, Reiser C, Biamino G, Investigators L. Limb salvage following laser-assisted angioplasty for critical limb ischemia: results of the LACI multicenter trial. J Endovasc Ther. 2006;13(1):1–11.CrossRefPubMedGoogle Scholar
  14. 14.
    Bosiers M, Peeters P, Elst FV, Vermassen F, Maleux G, Fourneau I, Massin H. Excimer laser assisted angioplasty for critical limb ischemia: results of the LACI Belgium Study. Eur J Vasc Endovasc Surg. 2005;29(6):613–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Stoner MC, De Freitas DJ, Phade SV, Parker FM, Bogey WM, Powell S. Mid-term results with laser atherectomy in the treatment of infrainguinal occlusive disease. J Vasc Surg. 2007;46(2):289–95.CrossRefPubMedGoogle Scholar
  16. 16.
    Serino F, Cao Y, Renzi C, Mascellari L, Toscanella F, Raskovic D, Tempesta P, Bandiera G, Santini A. Excimer laser ablation in the treatment of total chronic obstructions in critical limb ischaemia in diabetic patients. Sustained efficacy of plaque recanalisation in mid-term results. Eur J Vasc Endovasc Surg. 2010;39(2):234–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Laird Jr JR, Yeo KK, Rocha-Singh K, Das T, Joye J, Dippel E, Reddy B, Botti C, Jaff MR. Excimer laser with adjunctive balloon angioplasty and heparin-coated self-expanding stent grafts for the treatment of femoropopliteal artery in-stent restenosis: twelve-month results from the SALVAGE study. Catheter Cardiovasc Interv. 2012;80(5):852–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Sultan S, Tawfick W, Hynes N. Cool excimer laser-assisted angioplasty (CELA) and tibial balloon angioplasty (TBA) in management of infragenicular arterial occlusion in critical lower limb ischemia (CLI). Vasc Endovascular Surg. 2013;47(3):179–91.CrossRefPubMedGoogle Scholar
  19. 19.
    Armstrong EJ, Singh S, Singh GD, Yeo KK, Ludder S, Westin G, Anderson D, Dawson DL, Pevec WC, Laird JR. Angiographic characteristics of femoropopliteal in-stent restenosis: association with long-term outcomes after endovascular intervention. Catheter Cardiovasc Interv. 2013;82(7):1168–74.CrossRefPubMedGoogle Scholar
  20. 20.
    Schmidt A, Zeller T, Sievert H, Krankenberg H, Torsello G, Stark MA, Scheinert D. Photoablation using the turbo-booster and excimer laser for in-stent restenosis treatment: twelve-month results from the PATENT study. J Endovasc Ther. 2014;21:52–60.CrossRefPubMedGoogle Scholar
  21. 21.
    Tosaka A, Soga Y, Iida O, Ishihara T, Hirano K, Suzuki K, Yokoi H, Nanto S, Nobuyoshi M. Classification and clinical impact of restenosis after femoropopliteal stenting. J Am Coll Cardiol. 2012;59(1):16–23.CrossRefPubMedGoogle Scholar
  22. 22.
    Dippel EJ, Makam P, Kovach R, George JC, Patlola R, Metzger DC, Mena-Hurtado C, Beasley R, Soukas P, Colon-Hernandez PJ, et al. Randomized controlled study of excimer laser atherectomy for treatment of femoropopliteal in-stent restenosis: initial results from the EXCITE ISR trial (EXCImer Laser Randomized Controlled Study for Treatment of FemoropopliTEal In-Stent Restenosis). JACC Cardiovasc Interv. 2015;8(1 Pt A):92–101.CrossRefPubMedGoogle Scholar
  23. 23.
    Schillinger M, Sabeti S, Loewe C, Dick P, Amighi J, Mlekusch W, Schlager O, Cejna M, Lammer J, Minar E. Balloon angioplasty versus implantation of nitinol stents in the superficial femoral artery. N Engl J Med. 2006;354(18):1879–88.CrossRefPubMedGoogle Scholar
  24. 24.
    Scheinert D, Scheinert S, Sax J, Piorkowski C, Braunlich S, Ulrich M, Biamino G, Schmidt A. Prevalence and clinical impact of stent fractures after femoropopliteal stenting. J Am Coll Cardiol. 2005;45(2):312–5.CrossRefPubMedGoogle Scholar
  25. 25.
    Tepe G, Zeller T, Albrecht T, Heller S, Schwarzwalder U, Beregi JP, Claussen CD, Oldenburg A, Scheller B, Speck U. Local delivery of paclitaxel to inhibit restenosis during angioplasty of the leg. N Engl J Med. 2008;358(7):689–99.CrossRefPubMedGoogle Scholar
  26. 26.
    Van Den Berg JC, Pedrotti M, Canevascini R, Chimchila Chevili S, Giovannacci L, Rosso R. Endovascular treatment of in-stent restenosis using excimer laser angioplasty and drug eluting balloons. J Cardiovasc Surg (Torino). 2012;53(2):215–22.Google Scholar
  27. 27.
    van den Berg JC. Commentary: laser debulking and drug-eluting balloons for in-stent restenosis: a light at the end of the tunnel? J Endovasc Ther. 2013;20(6):815–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Gandini R, Del Giudice C, Merolla S, Morosetti D, Pampana E, Simonetti G. Treatment of chronic SFA in-stent occlusion with combined laser atherectomy and drug-eluting balloon angioplasty in patients with critical limb ischemia: a single-center, prospective, randomized study. J Endovasc Ther. 2013;20(6):805–14.CrossRefPubMedGoogle Scholar
  29. 29.
    Photoablative atherectomy followed by a paclitaxel-coated balloon to inhibit restenosis in instent femoro-popliteal obstructions (PHOTOPAC). Retrieved 30 Dec 2013 from

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  • Gagan D. Singh
    • 1
  • Ehrin J. Armstrong
    • 2
    • 3
  • John R. Laird
    • 4
  1. 1.Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of California Davis Medical CenterSacramentoUSA
  2. 2.Division of Cardiovascular Medicine, Department of Internal MedicineVA Eastern Colorado Healthcare SystemDenverUSA
  3. 3.Division of CardiologyUniversity of Colorado School of MedicineDenverUSA
  4. 4.Division of Cardiovascular MedicineUC Davis Vascular CenterSacramentoUSA

Personalised recommendations