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Since the early demonstration of the laser to ablate or vaporize coronary atherosclerotic plaque obstruction,' several clinical studies have been performed with different lasers both in diseased peripheral and coronary arteries.2-7 In addition , a variety of fiber-optic catheters delivering laser energy to the obstruction have been tried, See p 787 usually under fluoroscopic imaging. Clinical experiences with argon energy transmitted through bare optical fiber2 or sapphire lens3 or delivered to heat a thick capped fiber4 have resulted, not infrequently, in mechanical and laser perforation or dissection of the vascular wall. This is not surprising because tissue studies have shown that the pathway of recanaliza-tion by either the bare fiber8 or the laser-heated metal cap9 may facilitate the creation of a false intraluminal channel. Angioscopy may provide another method of guiding laser delivery with some precision onto the arterial plaque obstruction.10-12 However, angioscopy cannot determine the intraluminal thickness of the atherosclerotic plaque, and momentary cessation of blood flow or displacement of blood by constant flushing of saline are necessary for visualization of the target site. Indeed, despite angioscopic guidance, clinical studies have been disappointing, with a high frequency of wall perforation in peripheral athero-sclerotic arteries.13 Current angioscopic catheters are still relatively large with limited flexibility and lack angulation at the tip. Stiffer angioscopic catheters may result in intraluminal wall injury in small or tortuous arteries.14 The use of a leading soft wire to guide the fiber-optic laser catheter under radiographic imaging has helped reduce the perforation rate. However, it does not guarantee that the wire will not partially deviate into a false channel. Moreover, even when the wire is passed into the true lumen of an eccentric plaque obstruction, it may not prevent laser injury to the thin The opinions expressed in this editorial comment are not necessarily those of the editors or of the American Heart Association. vessel wall opposite the thick mass of the plaque. In clinical studies using the free beam excimer laser, despite the use of an over-the-wire circumferentially oriented multifiber catheter system, a high frequency of coronary dissections has been observed5'6 apparently related, in part, to dead space between peripheral fiber optics and the control guide wire. The recent introduction of the soft hydrophilic-coated guide wire followed by balloon angioplasty alone has greatly improved the successful recanaliza-tion of long obstructions and occlusions. In some patients with coronary occlusion in which difficulty was encountered while passing …

Laser angioplasty: a plea for modesty in the search for a real beginning.