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Aims Excimer laser coronary atherectomy (ELCA) is increasingly used for complex percutaneous coronary intervention (PCI), including severe coronary artery calcification, in-stent restenosis (ISR), chronic total occlusions (CTO), and large thrombus burden. Contemporary real-world long-term outcome data from high-volume tertiary centres remain limited. In this study, we aim to evaluate the procedural characteristics, short- and long-term outcomes following ELCA-assisted PCI in a tertiary referral cardiac centre ( figure 1).Methodology A retrospective observational study of 62 consecutive patients undergoing ELCA-assisted PCI from 2015 to 2020 was undertaken. Baseline demographics, lesion complexity, laser parameters, adjunctive modalities (intravascular (IV) imaging, rotational atherectomy, intravascular lithotripsy, glycoprotein IIb/IIIa inhibitors and circulatory support), procedural outcomes, and clinical events at long-term follow-up were analysed. The primary outcome included a composite endpoint of major adverse cardiac events (MACE), including target vessel revascularisation, non-fatal myocardial infarction (MI), and all-cause mortality.Results The median patient age was 70 years [IQR, 58-76 years], with 17 patients (27.4%) being females. Previous PCI was present in 64.5% and coronary artery bypass graft (CABG) in 20.8%. The main presentation was acute coronary syndrome (53.2%), followed by stable angina (38.7%). Indications of ELCA included heavily calcific plaques (33.9%), ISR (30.6%), CTO (19.4%), and heavy thrombus burden (16.1%). The right coronary artery was the most frequent target vessel (43.5%), followed by the left anterior descending artery (24.2%), with 4.5% involving the left main bifurcation. ELCA was combined with intracoronary imaging in 46.8% of cases and rotational atherectomy in 20.8%. The most used catheter size was 0.9 mm (43.5%), with fluence of 80 mJ/mm2 in 46.8%, and a median pulse of 7,434 ( table 1).Procedural success was achieved in 91.9% of cases, with only one pre-planned Impella support. The overall complication rate was 14.5%. The most frequent complications were slow-flow/no-reflow (8.1%), procedure-related cardiogenic shock (6.5%), of which two patients required Impella support, Ellis class III coronary perforation in two cases (3.2%) (successfully managed with covered stent), and side-branch occlusion (3.2%). Procedural failure (8.1%) clustered in cases with severe calcification, left main/multivessel disease, absence of intravascular imaging, and no adjunctive calcium modification, with in-hospital mortality of 6.45%.After a median follow-up duration of 49 months [IQR, 8-101 months], the total incidence of MACE was 41.3%. Event-free survival was 93.1% at 30 days, 81% at 1 year, and 74.2% at 2 years. Diabetes mellitus (DM), prior CABG, history of MI, and ISR lesion characteristics were associated with a higher risk of MACE. On multivariate analysis, DM (HR: 3.76; 95%CI: 1.52-9.32, p=0.004), prior CABG (HR: 9.64; 95%CI: 3.43-27.10, p<0.001), and ISR (HR: 4.20; 95%CI: 1.48-12.19, p = 0.007) were independent predictors of MACE (figure 2), (table 2).Conclusions In a high-volume tertiary setting, ELCA-assisted PCI demonstrates high procedural success and acceptable short-term outcomes despite its application in highly complex clinical scenarios. While event-free survival remains high at 30 days, the significant incidence of MACE at longer follow-up reflects the high-risk nature of this cohort, specifically those with DM, prior CABG, and ISR. These findings underscore the utility of ELCA as a versatile tool for complex lesion preparation and suggest that a multi-modality approach is essential for optimising long-term durability in complex coronary interventions.Abstract 70 Table 1Procedural dataVariableTotal patients (n = 62)Arterial Access, n (%)Radial arteryFemoral arteryRadio-femoral dual access32 (51.6)17 (27.4)13 (21)Laser indication, n (%)1. Heavily calcified native lesion2. In-stent restenosis3. Chronic total occlusion4. Heavy thrombus burden21 (33.9)19 (30.6)12 (19.4)10 (16.1)Target vessel, n (%)LM/LM bifurcationLADLCxRCAGraft9 (14.5)15 (24.2)9 (14.5)27 (43.5)3 (4.8)Laser catheter size, n (%)0.9 mm1.4 mm1.7 mm2.0 mm27 (43.5)5 (8.1)3 (4.8)5 (8.1)Fluence, n (%)80 mJ/mm240-80 mJ/mm220-40 mJ/mm229 (46.8)16 (20.8)2 (3.2)Pulses, median [IQR]7,434 [0-10,000]Adjuvant intravascular imaging, n (%)IVUSOCT29 (46.8)21 (33.9)8 (12.9)Adjuvant rotational atherectomy, n (%)16 (20.8)Adjuvant shockwave balloon, n (%)3 (4.8)Aspiration catheter, n (%)5 (8.1)Embolic protection device, n (%)4 (6.5)Mechanical circulatory support, n (%)4 (6.5)Inotropes, n (%)6 (9.7)Glycoprotein IIb/IIIa inhibitors, n (%)9 (14.5)Abstract 70 Table 2Multivariate analysis for prediction of MACEVariableP-valueHR95% CIDiabetes mellitus0.0043.76(1.52-9.32)Previous MI0.510.69(0.22-2.13)Previous CABG<0.0019.64(3.43-27.10)Heavily calcified native lesion 0.600.72(0.20-2.52)In-stent restenosis0.0074.20(1.48-12.19)Abstract 70 Figure 1Excimer laser atherectomy: 10-year single-centre experienceAbstract 70 Figure 2Kaplan–meier cumulative hazard curves for longterm MACE by lesion, procedural, and clinical characteristics