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PubMed2001

Percutaneous coronary intervention: current perspective.

More than 20 years have passed since percutaneous transluminal coronary angioplasty (PTCA) was introduced for the treatment of coronary artery disease. During the first decade, PTCA outcome had improved significantly. However, acute occlusive complications and restenosis remained as significant limitations of the procedure. During the second decade, new procedures, such as stents and atherectomy (directional coronary atherectomy, and Rotablator) had been introduced and had a significant impact on the outcome of percutaneous coronary intervention (PCI). In addition to the improvements in the equipment, the use of glycoprotein IIb/IIIa inhibitors to prevent platelet aggregation has reduced procedure-related complications. PCI continues to evolve with new developments such as distal protection devices to prevent distal embolism, brachytherapy and drug-eluting stents to prevent restenosis. These new technologies may play a significant role in expanding the applications of PCI in the future.

Angioplasty, Balloon, Coronary↗
PubMed1999

The value of intravascular ultrasound in interventional cardiology.

Intracoronary ultrasound (ICUS) is a new imaging technique with the unique ability to study vessel wall morphology in vivo, accurately displaying the details of vessel structure. The coronary angiogram represents only a projectional image of the vessel lumen without providing any information concerning vascular wall architecture. Interventional cardiology has developed over the last years with the appearance of new devices and consequently new challenges. The selection of an appropriate device and the assessment of any intervention, as well as the understanding of its mechanisms is essential to perform a better intervention. The use of a tool, such as ICUS, able to identify vessel wall anomalies, complementing coronary angiography, seems to be an appropriate method in the regard. The last years have witnessed an array of studies demonstrating the advantages and disadvantages of ICUS in the setting of interventional cardiology. Despite some contradictions in the literature, the result of a new technology still under scrutiny, it is possible to summarise some of the major achievements: Lesion assessment before coronary interventions for selection of treatment, including calcium detection, plaque eccentricity, diffuse atherosclerotic disease, type of vessel remodelling; ICUS during balloon angioplasty has helped in balloon diameter selection, identification of pseudo successful results and presence/severity of wall dissections, as well as the search of predictors of restenosis; during rotational and directional atherectomy, ICUS can help in the definition of the lesion most suitable for rotational atherectomy, showing if there is a diffuse sub endothelial calcification, excluding unsuitable lesions, selecting cut direction and directly assessing the adequacy of plaque removal; during stent implantation it helps to determine if there was a complete apposition, detect residual narrowing or proximal/distal stenoses or dissections requiring further treatment. Some new concepts have been introduced by ICUS, such as the negative remodelling as one of the mechanisms of restenosis. New developments are under way, including combined devices, looking forward ultrasound, high frequency probes, imaging wires, tissue characterisation and three dimensional technology. Therefore, ICUS has reached enough maturity to be considered an important tool in the catheterization laboratory, complementing the information provided by coronary angiography. However, some more research needs to be done to answer some important questions regarding the whole array of potential applications in an environment of cost containment as the one we live in today.

Angioplasty, Balloon, Coronary↗
PubMed1999

[Curative treatment of restenosis].

It has been clearly demonstrated that post-angioplasty restenosis is the result of the combination of three distinct mechanisms associated to different degrees: constrictive remodelling, neo-intimal hyperplasia and elastic recoil. In contrast, after stent implantation, constrictive remodelling is nil, elastic recoil is very mild and restenosis, when observed, is essentially due to a reaction of intimal hyperplasia. These physiopathological features are important as they affect the therapeutic opportunities. With rates of stent implantation attaining 100% in some centres, intra-stent restenosis is a new pathology which poses serious problems in everyday practice as the best management of this situation has not yet been determined. For a long time, redilatation with a balloon catheter was the only possible solution. Secondarily, ablative techniques were evaluated, such as rotational and laser atherectomy, techniques with the theoretic advantage of eliminating part of the intimal proliferation. Directional atherectomy has also been used by some groups. More recently, other approaches, such as implantation of a second stent inside the first, the cutting balloon and radiotherapy, have been suggested. A surgical option is always possible in cases of repeat and/or diffuse restenosis. Finally, abstention from any local treatment may be justified in asymptomatic patients. These different approaches are discussed in this paper.

Angioplasty, Balloon, Coronary↗
PubMed2002

Fibrinogen and smooth muscle cell detection in atherosclerotic plaques from stable and unstable angina -- an immunohistochemical study.

BACKGROUND: This study presents a systematic analysis of atherothrombotic lesions taken by percutaneous atherectomy and post mortem examination from coronary arteries, in order to identify: a) the topographic occurrence of fibrinogen and smooth muscle cells (SMCs), b) their independent expression in stable and unstable plaques, and c) their co-expression, which can provide a better understanding of the involvement of fibrinogen and SMCs in the development and progression of atherosclerotic plaques. MATERIAL/METHODS: 120 specimens from atherosclerotic lesions were collected, using directional coronary atherectomy; 40 additional specimens were collected from postmortem examinations. All specimens were stained by immunohistochemical methods with monoclonal and polyclonal antibodies (DAKO) for fibrinogen and SMCs. RESULTS: Fibrinogen appeared to be a component of all stable and unstable coronary atherosclerotic plaques, with a significant predominance in unstable angina. No significant difference was observed between SMC-stained areas in stable and unstable angina; however, a significant difference exists in co-expression of SMCs and fibrinogen between unstable and stable angina. Interestingly, the total number of SMCs at the first stages of formation of unstable plaques is less than in stable plaques. However, in a number of advanced coronary atherosclerotic plaques associated with unstable angina, we observed an increasingly progressive inflammatory cell activity, in which SMC areas were significantly increased. CONCLUSIONS: This distribution of fibrinogen and SMCs suggests the possibility of a link between SMC migration and proliferation, intensifying the increased fibrinogen concentration in atherosclerotic plaques.

Analog-Digital Conversion↗
PubMed2004

Lesion preparation prior to stenting.

Lesion preparation before stent implantation remains an essential component of the contemporary practice of coronary stent implantation in patients with long lesions, ostial lesions, chronic total occlusions, bifurcations, and calcified or nondilatable lesions. The goal of lesion preparation in these patients is to facilitate stent delivery, reduce plaque shift, and allow optimal stent expansion. Several procedures and second-generation devices have been proposed to achieve this goal, such as directional coronary atherectomy, rotational atherectomy, the cutting balloon, and the FX miniRAIL catheter. Even with the advent of drug-eluting stents, theoretically there are several reasons that aggressive lesion preparation would still be beneficial in selected patient subsets.

Angioplasty, Balloon↗
PubMed2004

Current applications for nicardipine in invasive and interventional cardiology.

Interventional coronary procedures, such as rotational atherectomy and coronary artery bypass graft (CABG) stenting, are associated with a risk of postoperative vasoconstriction, which can lead to sequelae that produce morbidity and even death. Vasodilators, such as calcium channel blockers, sodium nitroprusside and adenosine, are often administered to prevent or reverse these sequelae, and have proven effective for this purpose. The injectable dihydropyridine calcium channel blocker, nicardipine, has several unique properties that make it an effective option for preventing and/or reversing microvascular or conductance vessel vasoconstriction. In this review, we describe the evidence-based uses of nicardipine injection in interventional cardiology and cardiac catheterization procedures. In comparison to other calcium channel blockers, nicardipine injection appears to be potentially safer, easier to administer and capable of producing a more predictable response. This drug has potential advantages in preventing or reversing the no-reflow phenomenon that sometimes occurs after interventions in coronary bypass grafts. Nicardipine may also be effective when administered in a flush solution with other drugs during rotational atherectomy and clot debulking with or without distal protection devices. It also can control the hypertension that occurs after sternotomy and cardiac surgery, and in the cardiac catheterization laboratory. In summary, the dihydropyridine calcium channel blocker, nicardipine, has a wide range of useful applications during cardiovascular interventions.

Atherectomy, Coronary↗
PubMed2005

Coronary artery perforation during percutaneous coronary intervention: incidence and outcomes in the new interventional era.

BACKGROUND: Coronary artery perforation (CP) is a serious complication of percutaneous coronary intervention (PCI). We sought to define the incidence and outcome of CP given the advance in interventional techniques, devices and use of glycoprotein inhibitors (GP IIb/IIIa). METHODS: We retrospectively reviewed the records of patients who underwent PCI at our institution over a four-year period. The incidence of CP was derived from patient records and then confirmed by reviewing the angiogram. Perforations were classified as Type 1, 2, or 3, as previously defined. RESULTS: A total of 4,886 patients underwent PCI. Atherectomy devices were used in 329 patients and GP IIb/IIIa in 2,200 patients. Twenty-five CP were identified (0.5% incidence). Six were Type 1 (24%), 10 were Type 2 (40%), and 9 were Type 3 (36%). 13/25 (52%) of the CP were Type C Lesions, and 12/25 (48%) occurred in calcified vessels. All Type 1 perforations were caused by coronary wires and 4/6 CP occurred with the use of hydrophilic and extra stiff wires. Type 2 perforations were caused by coronary wires in 8/10 CP, and by stent deployment in 2/10. Two patients with Type 2 CP sustained a non-ST-elevation myocardial infarction. Type 3 perforations were caused by stent placement in 4/9 CP, 2/9 by atherectomy devices, and 3/9 by coronary wires. Four patients with Type 3 CP underwent pericardial drainage, 5 patients had a myocardial infarction and 2 patients died. CONCLUSION: Type 1 and 2 perforations are predominately caused by hydrophilic and stiff wires and do not require pericardial drainage or surgical intervention. Type 3 perforations are more often associated with stent and device use. A majority of Type 3 perforations can be initially managed by percutaneous methods.

Abciximab↗
PubMed2006

Endothelin-converting enzyme expression in the neointima after percutaneous coronary intervention.

Smooth muscle cells (SMCs) are the major cellular component of neointimal tissues after percutaneous coronary intervension (PCI). Endothelin-1 (ET-1) is a powerful vasoconstrictor and has a mitogenic effect on SMCs. Endothelin-converting enzyme (ECE) is a key enzyme in the process of ET-1 generation. However, the expression of ECE in association with post-PCI repair processes has not been reported. Thirteen coronary sites after PCI obtained at autopsy and 6 atherectomy specimens obtained from restenotic sites were investigated. Frozen sections were stained with antibodies against ECE, SMCs, macrophages, and endothelial cells. The immunoreactivity of ECE was quantified using computer-aided planimetry. At the early stage after PCI, most neointimal SMCs expressed ECE. The ECE-positive cell area was significantly (p<0.005) larger in the sites within 3 months after PCI than in the sites from 6 months onward. In atherectomy specimens, neointimal SMCs showed distinct ECE positivity. These findings suggest that ECE is upregulated in the neointima at early stages after PCI injury. ECE may be one of the mediators in the repair processes after PCI in humans.

Aged↗
PubMed1995

[Pseudo-stenosis caused by vessel wall invagination during interventional treatment of 2 coronary vessels in a patient].

We report on a 59-year-old man who underwent a combined procedure of directional coronary atherectomy (DCA) and PTCA of significant lesions of the right coronary artery (RCA) and the left circumflex artery (LCX). Already after positioning of a standard guide wire in the right coronary artery a new excentric "pseudo-stenosis" was observed in the proximal part of the right coronary artery. Since the patient remained symptom free, a 7F DCA catheter was introduced to the stenotic area in the mid RCA, which led to an extension of the narrowing, involving the total segment proximal to the DCA catheter. Directional coronary atherectomy was performed without complications. Removal of the catheter, after successful DCA, and administration of intracoronary nitroglycerin did not relieve the proximal narrowing, which disappeared spontaneously after the guide wire was pulled out. During PTCA of the left circumflex using a standard guide wire and a 3.0 mm Monorail balloon catheter, a similar tight narrowing of the origin of the LCX was observed, which could also not be influenced by vasodilator drugs, but relieved after wire removal. Until now, this phenomenon has only been described for the right coronary artery. The reason underlying intimal folding is a shifting of the intimal layer against the medial layer of the vessel wall. Our observation firstly describes this phenomenon of "pseudo narrowing" in two different vessels in one patient. We, like other authors before, recommend that interventional therapy of these pseudo-lesions should be avoided.

Angioplasty, Balloon, Coronary↗
PubMed1993

[New trends in limb salvage. Endovascular techniques applied to leg arteries].

UNLABELLED: Femoro-distal bypasses are not always feasible in patients presenting with "critical" chronic ischemia. The results of endovascular therapies carried out over a 2-year period were analyzed. PATIENTS--METHODS: 23 patients with critical ischemia (rest pain 13%, gangrene 87%) had 25 procedures on 29 leg arteries; percutaneous transluminal angioplasty in 17 arteries, rotational atherectomy in 10 arteries, laser recanalization (1 artery), directional atherectomy (1 artery). RESULTS: The hospital mortality rate was 4.3%. The cumulative patency and limb salvage rates are respectively 51% and 77% at 6 months, 34% and 71% at 12 months. DISCUSSION: Candidates for tibial-peroneal endovascular techniques should have a threatened limb, as long as the consequences of failed procedures on patients presenting with claudication can be disastrous, and as long as mid-term patency rates reported in the literature are not fair enough. In localized stenoses or short occlusions with adequate runoff, endovascular techniques are a good alternative to femorotibial bypasses for limb salvage. In diffuse lesions with no possibility of bypass, endovascular techniques can facilitate limb salvage, even if the mid-term patency rate is poor. When conventional therapies cannot face critical ischemia, endovascular therapies can provide a fair limb salvage rate.

Aged↗
PubMed1994

[Distal arteritis of the legs: endovascular treatment].

Femoro-tibial bypasses are not always feasible in patients presenting with "critical" chronic ischemia. The results of endovascular therapies carried out over a 2-year period are analyzed. Twenty-three patients with critical ischemia (rest pain 13%, gangrene 87%) had 25 procedures on 29 leg arteries: percutaneous transluminal angioplasty in 17 arteries, rotational atherectomy in 10 arteries, laser recanalization (1 artery), directional atherectomy (1 artery). The hospital mortality rate was 4.3%. The cumulative patency and limb salvage rates were respectively 51% and 77% at 6 months, 34% and 71% at 12 months. Candidates for tibial-peroneal endovascular techniques should have a threatened limb, as long as the consequences of failed procedures on patients presenting with claudication can be disastrous, and as long as mid-term patency rates reported in the literature are not fair enough. In localized stenosis or short occlusions with adequate runoff, endovascular techniques are a good alternative to femorotibial bypasses for limb salvage. In diffuse lesions with no possibility of bypass, endovascular techniques can facilitate limb salvage, even if the mid-term arterial patency rate is poor. When conventional therapies cannot face critical ischemia, endovascular therapies can provide a fair limb salvage rate.

Aged↗
PubMed1995

[15 years of coronary angioplasty: focus on the different techniques].

The growth of transcutaneous coronary angioplasty in the 1980s and early 1990s was particularly rapid, as about 42,000 procedures were performed in France in 1994. This treatment for coronary atherosclerosis now constitutes a valid alternative to surgical or medical treatment. New treatment modalities for coronary atherosclerosis have been added to the original balloon technique. Two types of coronary angioplasty can now be performed depending either by flattening and crushing the atheroma against the arterial wall (balloon, stent) or by destroying and fragmenting it (Rotablator, Laser, directional atherectomy). Among these new instruments, vascular stents have reduced the incidence of restenosis and have improved the safety of interventional cardiology, while others, such as Rotablator and Laser, allow the treatment of lesions inaccessible to the balloon. Directional atherectomy, by allowing specific excision, will occupy an important place in future developments of interventional cardiology, which is still a relatively young specialty.

Angioplasty, Balloon, Coronary↗
PubMed1996

[Applications and value of intravascular ultrasound imaging in coronary interventions].

Intravascular ultrasound (IVUS) is a twodimensional imaging technique that provides crossections of the coronary artery with a high spatial resolution and therefore became the new gold standard for quantifying complex lesions. The detailed information about vessel and lumen dimensions before and particularly after angioplasty is of high clinical value, because the acute luminal gain is an important predictor of restenosis. At the moment IVUS is the only way of analyzing the plaque composition in vivo. This allows plaque-specific interventional therapy of coronary lesions with balloon or modern alternative angioplasty techniques like directional atherectomy, rotational atherectomy, stenting or a combination of these. IVUS can also quantify the plaque burden in angiographically normal reference segments during balloon angioplasty and stenting. This often leads to the use of larger balloon diameters than those chosen by angiographic measurement of the reference segments. For stenting the prognostic significance of this additional luminal gain could be shown, for other interventional procedures this is currently being investigated in controlled studies.

Angioplasty, Balloon, Coronary↗
PubMed1996

[Usefulness of percutaneous transluminal angioplasty of lesions in saphenous vein graft].

The purpose of this study is to evaluate the potential efficacy of saphenous vein graft (SVG) angioplasty. Angioplasty of 64 lesions in SVG was performed in 32 patients. (balloon angioplasty for 59 lesions and directional atherectomy for 5 lesions). The angioplasty site involved the proximal vein graft including aortic anastomosis in 9 lesions, the midportion of the graft in 32 lesions, and the distal anastomotic site in 17 lesions. Six grafts were totally occluded. The overall initial success rate was 89%, and restenosis rate was 57%. The initial success rate was lower in occluded grafts (75%) than in proximal (89%), midportion (94%), or distal lesions (88%). There were similar trend for restenosis (proximal 67%, midportion 50%, distal 56%, occluded 75%). The initial success rate was higher in vein graft < 1 year old compared with graft 1 to 5 years or > 5 years after operation (100% versus 87%, 82% respectively). The restenosis rate did not depend on graft age (< 1 year 53%, 1 to 5 years 75%, > 5 years 50%). There was no procedural death or emergent operation. Distal embolization occurred in two cases, both of which underwent directional atherectomy. Angioplasty of a non occlusive obstruction in saphenous vein graft had an initial success rate of approximately 90% and is a safe procedure. Angioplasty of chronic total occlusion was associated with poor acute result. Although the induced high restenosis rate remains a significant problem, angioplasty of saphenous vein graft is a reasonable alternative to revasculization.

Aged↗
PubMed1998

Application of solid-state pulsed-wave, mid-infrared laser for percutaneous revascularization in heart transplant recipients.

BACKGROUND: Severe allograft coronary artery disease is a significant cause of death in heart transplant recipients. Percutaneous revascularization has thus far been attempted with balloon angioplasty and, to a lesser extent, with directional atherectomy. The new, investigational, solid-state pulsed-wave mid-infrared laser (holmium:YAG) can vaporize and remove atheromatous and thrombotic plaques. This mechanism of plaque ablation may be useful for allograft coronary artery disease associated with focal stenoses deemed unsuitable for standard balloon angioplasty, especially thrombus-containing lesions. METHODS: Five adult heart transplant recipients with severe focal stenoses related to allograft coronary artery disease underwent six laser angioplasty procedures. Laser catheters (2.1 microm, 250 to 600 mJ, 5 Hz) varying from 1.2 mm to 2.0 mm delivered 45 +/- 7.4 pulses (mean +/- SD). Five laser procedures were completed with adjunct balloon angioplasty and one with directional atherectomy. RESULTS: Laser success (defined as stenosis reduction > 20%, no cardiac catheterization laboratory or in-hospital major complication) was achieved in six of seven lesions (85%), and the overall (laser and adjunct balloon) procedural success rate was 100%. No major complications occurred. Laser-assisted angioplasty reduced mean stenosis from 90% +/- 3% to 9% +/- 11%. All five patients recovered and were discharged. Angiographic follow-up demonstrated a 50% restenosis rate. CONCLUSIONS: In selected heart transplant recipients laser-assisted angioplasty can provide safe and successful acute revascularization. Focal lesions considered "nonideal" for balloon angioplasty and, in particular, thrombotic lesions can benefit from application of this device; however, long-term reduction of restenosis rates is not expected from this modality.

Adult↗
PubMed1991

New technologies for the treatment of obstructive arterial disease.

The well-known limitations of balloon angioplasty include unpredictable abrupt closure, chronic total occlusion, diffuse disease, and restenosis, among other factors. These limitations have prompted the development of new technologic approaches to angioplasty including laser applications for plaque ablation, mechanical device applications for plaque removal/debridement, and stent devices for structural maintenance of vascular lumen patency. Devices which directly apply laser energy for ablation of plaque material include a balloon-centered laser angioplasty system, excimer laser ablation catheter systems, and a fluorescence-guided spectral feedback laser system. Experience with these devices indicates that plaque can be successfully ablated by using laser energy. Vessel perforation and dissection are complications reported with these devices and the effects of laser angioplasty on restenosis remain unclear. Indirect application of laser energy has been tested by using a "hot tip" catheter and a laser balloon angioplasty system. Although the hot tip device has received FDA approval for use in peripheral arteries, it appears to have very limited applications in the coronary arteries. Laser balloon angioplasty appears to be beneficial in the setting of threatened acute closure; the device continues to be evaluated for potential beneficial impact on restenosis. Mechanical atherectomy catheters are designed to remove atherosclerotic plaque from the arterial system and include the AtheroCath, the Transluminal Extraction Catheter (TEC), and the Pullback Atherectomy Catheter (PAC). The Rotablator is an atheroablation device which debrides the obstructing plaque material with distal embolization of the particulate debris. Successful removal/debridement of atherosclerotic plaque has been demonstrated with the AtheroCath, Rotablator, and the TEC device. Pre-clinical studies demonstrate successful removal of plaque material with the PAC device. Despite the theoretic advantage of removing plaque material when performing angioplasty with these devices, there has been little or no reduction in restenosis rates based on a significant experience with the AtheroCath and the Rotablator. Intravascular stent devices including one self-expanding device design and two balloon-expandable device designs have been employed successfully in the elective setting to treat recurrent restenosis lesions. Two of the devices have been successfully tested in the setting of threatened acute closure. Early follow-up studies suggest some improvement in restenosis rates in certain clinical settings following intravascular stenting. Acute and subacute thrombosis remain substantial problems for stent devices and very aggressive anticoagulation regimens are necessary to minimize the adverse events. In summary, a number of a new technologic approaches for treatment of atherosclerotic lesions have been developed and are undergoing significant clinical evaluation.(ABSTRACT TRUNCATED AT 400 WORDS)

Angioplasty, Laser↗
PubMed1995

In-hospital outcome of percutaneous transluminal coronary angioplasty for long lesions and diffuse coronary artery disease.

We performed coronary angioplasty on 151 long or diffuse lesions (120 long and 31 diffuse) in 141 patients (86% male, mean age 50 +/- 9 years). Long lesions were defined as lesions 11-20 mm in length and diffuse lesions as lesions longer than 20 mm, or three or more lesions in the same vessel. One or more adverse morphologic features were present in 131 (93%) lesions. Long balloons were used in 44%, significantly more often for diffuse disease (long lesions 39% and diffuse disease 64%; P = 0.004). Newer devices including the rotational atherectomy device (9 lesions), stents and perfusion balloons were employed in 18 (12%) lesions, more often for diffuse lesions (long lesions 8% vs. diffuse lesions 26%; P = 0.017). Lesion severity was comparable in the two groups (long lesions: 88 +/- 7%; diffuse lesions: 88 +/- 8%), but diffuse lesions were associated with significantly higher residual stenosis (long lesions: 6 +/- 8%; diffuse lesions: 12 +/- 13%, P = 0.01). Major complications occurred in five (3.5%) patients, including one death (0.7% mortality). The angiographic and clinical success rates for all patients were 99% and 96%, respectively, and were comparable for long and diffuse lesions. Judicious case selection and the use of long balloons and newer interventional devices permit coronary angioplasty for long lesions and diffuse disease with excellent success and a low risk of complications. Diffuse lesions are associated with more frequent use of long balloons and newer devices, especially rotational atherectomy and slightly higher residual stenosis as compared to long lesions.

Adult↗
PubMed1991

Diffuse embolization following percutaneous transluminal coronary angioplasty of occluded vein grafts: the blush phenomenon.

Percutaneous transluminal coronary angioplasty (PTCA) was performed on 146 saphenous vein grafts in 116 patients. In 29 patients, 31 grafts were totally occluded. Myocardial staining lasting over 5 minutes--"the blush phenomenon"--followed the opening of the occluded grafts in 9 of these patients. In 5 of these 9, enzyme release suggested infarction. A sixth patient died within a few hours of PTCA, with suspected infarction. Autopsy demonstrated diffuse and extensive distal coronary arterial embolization of grumous material, including cholesterol crystals, platelets, and fibrin. The blush phenomenon was not seen following PTCA in the remaining 20 patients with total occlusions, nor in any of the 87 patients with stenosed grafts. We have not observed the blush phenomenon following PTCA of more than 3300 coronary arteries. Of the 9 patients demonstrating the blush phenomenon, 6 had a recent history of myocardial infarction or unstable angina pectoris, compared with 4 of the remaining 20 patients with occluded grafts. We now approach occluded grafts with injection of intragraft thrombolytic agents or with atherectomy prior to PTCA. Future approaches may include atherectomy or laser angioplasty.

Adult↗