Primary percutaneous coronary intervention (PCI) restores epicardial coronary flow in most patients with ST-segment elevation myocardial infarction (STEMI), but microvascular obstruction persists in a substantial proportion of patients. Excimer laser coronary angioplasty (ELCA) is an adjunctive technique that vaporizes thrombus in situ and has been proposed to reduce distal embolization and improve microvascular reperfusion. Prior evidence had not been systematically synthesized to clarify whether ELCA confers angiographic or clinical advantages over aspiration thrombectomy or conventional PCI alone in the setting of acute coronary occlusion.
This systematic review and meta-analysis was registered on PROSPERO (CRD420261422463). The authors included comparative studies that evaluated adjunctive ELCA strategies during primary PCI against two comparators: aspiration thrombectomy (Stratum A) and PCI alone (Stratum B). Both randomized and observational comparative studies were eligible; effect estimates were pooled using a random-effects model with Hartung-Knapp-Sidik-Jonkman confidence intervals. Certainty of evidence was assessed using the GRADE framework.
Ten studies met inclusion criteria: one randomized controlled trial and nine observational studies. The combined enrolled population exceeded 3,500 patients. Where available, propensity-matched data from included observational studies were used for pooled analyses comparing ELCA-containing strategies with PCI alone.
Primary angiographic outcomes were final TIMI-3 flow and myocardial blush grade (MBG) 3. Secondary endpoints included short-term mortality, major adverse cardiovascular and cerebrovascular events (MACCE), and slow-flow or no-reflow. The investigators applied a random-effects approach with Hartung-Knapp-Sidik-Jonkman intervals for all pooled estimates. Composite endpoints were not pooled when follow-up horizons across studies were incompatible. The GRADE system was used to appraise certainty of evidence for each outcome.
In the comparison of adjunctive ELCA versus aspiration thrombectomy, none of the prespecified outcomes reached statistical significance. Reported pooled odds ratios (OR) and confidence intervals included:
These estimates indicate wide confidence intervals and no clear statistical benefit for ELCA over aspiration thrombectomy across the measured angiographic and short-term clinical outcomes.
Using each study’s propensity-matched data where available, pooled analyses comparing ELCA-containing strategies against PCI alone similarly showed no significant differences in the evaluated outcomes:
Again, confidence intervals were broad and crossed unity for all pooled estimates, indicating no demonstrable advantage of ELCA strategies over PCI alone for the outcomes reported.
All outcomes in the pooled analyses were judged to be of very low certainty by GRADE. Limitations affecting certainty included the predominance of observational study designs (9 of 10 included studies), heterogeneity in follow-up horizons that precluded pooling of some composite endpoints, and imprecision evidenced by wide confidence intervals. The single available randomized trial did not change the overall pattern of findings. The authors expressly noted that composite endpoints were not pooled when follow-up periods were incompatible across studies, preserving the integrity of comparisons but limiting synthesis of longer-term composite outcomes.
This stratified meta-analysis found that adjunctive excimer laser coronary angioplasty (ELCA) during primary PCI for acute coronary occlusion was not associated with improved angiographic outcomes (final TIMI-3 flow or MBG-3) or with better short-term clinical outcomes (mortality, MACCE, slow-flow/no-reflow) compared with either aspiration thrombectomy or conventional PCI alone. Given that all pooled outcomes were of very low certainty, the authors conclude that current evidence does not support routine clinical adoption of ELCA as an adjunctive strategy in this context.
They recommend that well-designed multicenter randomized trials are required to definitively determine whether ELCA offers meaningful benefit over aspiration thrombectomy or standard PCI in patients with acute coronary occlusion before recommending broader clinical use.