Peripheral vascular disease represents the largest obstructive subsegment within the vascular system. Advances in equipment, techniques, biochemical treatments, and the influx of multiple specialties into this arena indicate a coming tidal wave of change to the standard treatment plan for patients with claudication and especially
critical limb ischemia. Initial attempts in the 1980s to utilize the "
laser" to treat
peripheral vascular disease led to a clinical debacle: wavelengths and methods were not optimized; tissue heating was excessive, resulting in restenosis. Since then the "
laser" has fallen from grace for endovascular treatment, although it has an infinite set of potential wavelengths, energy levels, and delivery methods. The
xenon chloride,
excimer laser, a pulsed 308-nm system, has overcome many of these early catastrophes. The long, ongoing success of this method of photoablating
thrombus and plaque represents a true step forward in the endovascular treatment of occlusive disease. Although only a tool, the
excimer laser provides a means to utilize electromagnetic energy instead of shearing mechanical force to resolve occlusions. With its active
element at the tip, the
excimer laser requires much less mechanical translation force to cross total occlusions, find the distal lumen, and thereby cause less plaque destabilization. In addition, removing the firm surface layer of plaque, decapping, and some of the plaque volume, debulking, exposes the softer subsegments of the plaque to balloon angioplasty. Utilizing this method, more complex lesions can be approached safely, with a high likelihood of successful revascularization and a low risk of potentially limb-threatening complication.