Subintimal excimer laser coronary atherectomy (S-ELCA) as a bail-out for device-uncrossable chronic total occlusion: case report.

Background: Chronic total occlusion (CTO) that cannot be crossed with balloons or microcatheters despite successful guidewire passage represent one of the most challenging scenarios in percutaneous coronary intervention (PCI). Excimer laser coronary angioplasty (ELCA) is an established adjunct for device-uncrossable lesions; however, the safety of its application within the subintimal space remains limited. Case summary: A 67-year-old male with a complex cardiac history, including prior recurrent interventions and coronary artery bypass grafting, was referred for staged PCI of a right coronary artery CTO because of refractory angina (Canadian Cardiovascular Society class III). Following successful antegrade subintimal wire tracking and re-entry using a Stingray balloon, multiple ultra-low-profile balloons and dedicated microcatheters failed to traverse the subintimal-to-true-lumen transition. A 0.9-mm ELCA catheter at 80 mJ/mm Discussion: This case demonstrates the potential safety and feasibility of subintimal ELCA (SELCA) as a bail-out for device-uncrossable lesions during antegrade dissection re-entry of CTO-PCI, with the first reported evidence of vascular healing at the subintimal laser site at two-year follow-up.