Angioscopy-Guided Excimer Laser Atherectomy in Femoropopliteal In-Stent Occlusions.

Background: In-stent occlusions in femoropopliteal lesions (FP-ISOs) remain a significant clinical issue. Excimer laser atherectomy (ELA) can ablate tissue, including thrombi, and may therefore be effective in FP-ISOs, which frequently contain both thrombi and neointimal hyperplasia. Angioscopy can directly visualize the stent lumen, making it useful for distinguishing thrombi from neointimal hyperplasia. Here, we investigated whether angioscopy-guided ELA was useful for FP-ISOs. Methods and Results: We studied 10 consecutive patients with FP-ISO who underwent endovascular therapy (EVT) with ELA between August 2020 and May 2023. Based on preprocedural angioscopy, patients were divided into 2 groups (n=5 in each): M (thrombi <70% of lesion length) and S (thrombi ≥70%). Outcomes, including Thrombolysis in Myocardial Infarction (TIMI) flow grade and major adverse events (MAE; restenosis, amputation, and death) were compared. There were no significant differences between the 2 groups in TIMI grade 3 flow just after EVT or in the ankle-brachial pressure index 1 month after EVT. Clinical outcomes after ELA were similar between the M and S groups (6-month patency: 60% vs. 80%, respectively [P=0.49]; MAE rate: 40% vs. 60%, respectively [P=0.53]). Five patients receiving direct oral anticoagulants (DOACs) had no events. Conclusions: ELA effectively vaporized thrombi in FP-ISOs, achieving comparable outcomes regardless of thrombus burden. Angioscopy-guided ELA, particularly combined with DOAC therapy, may represent a useful strategy for managing FP-ISOs.