Excimer laser angioplasty for acute coronary occlusion: a stratified meta-analysis of efficacy against aspiration thrombectomy and conventional PCI

Primary percutaneous coronary intervention (PCI) achieves epicardial reperfusion in most STEMI patients, yet microvascular obstruction persists in up to 60% of patients. Excimer laser coronary angioplasty (ELCA) vaporizes thrombus in situ and may reduce distal embolization, but the evidence base has not been systematically synthesized. This systematic review and meta-analysis (PROSPERO CRD420261422463) included comparative studies of adjunctive ELCA versus aspiration thrombectomy (Stratum A) or PCI alone (Stratum B) in acute coronary occlusion. Primary outcomes were final TIMI-3 flow and myocardial blush grade (MBG) 3; secondary outcomes were short-term mortality, MACCE, and slow-flow/no-reflow. A random-effects model with Hartung-Knapp-Sidik-Jonkman confidence intervals was applied to all outcomes. Certainty was assessed with GRADE. Ten studies (1 RCT, 9 observational) were included, from a total enrolled population exceeding 3,500. In Stratum A, no outcome reached significance: MBG-3 (OR 3.57, 95% CI 0.07–185.10), mortality (OR 0.31, 0.02–4.04), MACCE (OR 0.22, 0.04–1.26), TIMI-3 flow (OR 1.58, 0.67–3.75) and slow-flow/no-reflow (OR 0.78, 0.22–2.78). In Stratum B, using each study’s propensity-matched data, no outcome differed significantly (TIMI-3 OR 0.88, 0.38–2.03; MBG-3 OR 1.06, 0.13–8.43; slow-flow/no-reflow OR 0.93, 0.29–3.02; mortality OR 0.44, 0.05–3.80). Composite endpoints were not pooled across incompatible follow-up horizons, and all outcomes were of very low certainty. Adjunctive ELCA-containing strategies during primary PCI were not associated with improved angiographic or short-term clinical outcomes against either comparator. Multicenter randomized trials are required before recommending clinical adoption. Clinical Rationale, Methodological Framework, and Outcomes of Adjunctive Excimer Laser Coronary Angioplasty (ELCA) in Acute Coronary Occlusion. This graphical abstract summarizes the clinical unmet need, intervention methodology, and pooled quantitative evidence evaluating the efficacy of adjunctive ELCA during primary percutaneous coronary intervention (PCI). The synthesis encompasses 10 comparative studies (1 RCT, 9 observational) comprising over 3,500 patients, pre-specified into two comparator strata (mechanical aspiration thrombectomy vs. PCI alone using matched data). CI: confidence interval; ELCA: excimer laser coronary angioplasty; GLMM: generalized linear mixed model; GRADE: Grading of Recommendations Assessment, Development and Evaluation; HK-SJ: Hartung-Knapp-Sidik-Jonkman; MACCE: major adverse cardiovascular and cerebrovascular events; MBG: myocardial blush grade; MVO: microvascular obstruction; NS: not significant; OR: odds ratio; PCI: percutaneous coronary intervention; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PROSPERO: International Prospective Register of Systematic Reviews; RCT: randomized controlled trial; STEMI: ST-elevation myocardial infarction; TIMI: Thrombolysis in Myocardial Infarction.