1
|
Madanat L, Donisan T, Balanescu DV, Jabri A, Al-Abdouh A, Alsabti S, Li S, Kheyrbek M, Mertens A, Hanson I, Dixon S. The contemporary use of intracoronary brachytherapy for instent restenosis: A review. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 51:67-74. [PMID: 36732133 DOI: 10.1016/j.carrev.2023.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/14/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023]
Abstract
In-stent restenosis (ISR) has been a major limitation in interventional cardiology and constitutes nearly 10 % of all percutaneous coronary interventions in the United States. Drug-eluting stent (DES) restenosis proves particularly difficult to manage and poses a high risk of recurrence and repeat intervention. Intra-coronary brachytherapy (IBT) has been traditionally viewed as a potential treatment modality for ISR. However, its use was hindered by procedural complexity, cost, and the advent of newer-generation DES. Recent data suggests promising results regarding IBT for the treatment of resistant DES-ISR. This review addresses the mechanism of action of IBT, procedural details, and associated risks and complications of its use. It will also highlight the available clinical evidence supporting the use of IBT and the future directions of its utilization in the treatment of ISR.
Collapse
Affiliation(s)
- Luai Madanat
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, United States of America.
| | - Teodora Donisan
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN, United States of America
| | - Dinu V Balanescu
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, United States of America
| | - Ahmad Jabri
- Department of Cardiovascular Medicine, Heart and Vascular Center, Metrohealth Medical Center, Cleveland, OH, United States of America
| | - Ahmad Al-Abdouh
- Department of Internal Medicine, University of Kentucky, Lexington, KY, United States of America
| | - Sam Alsabti
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, United States of America
| | - Shuo Li
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, United States of America
| | - Mazhed Kheyrbek
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, United States of America
| | - Amy Mertens
- Department of Cardiovascular Medicine, Beaumont Hospital, Royal Oak, MI, United States of America
| | - Ivan Hanson
- Department of Cardiovascular Medicine, Beaumont Hospital, Royal Oak, MI, United States of America
| | - Simon Dixon
- Department of Internal Medicine, University of Kentucky, Lexington, KY, United States of America
| |
Collapse
|
2
|
DeCunha J, Janicki C, Enger SA. A retrospective analysis of catheter-based sources in intravascular brachytherapy. Brachytherapy 2017; 16:586-596. [PMID: 28190783 DOI: 10.1016/j.brachy.2017.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 01/09/2017] [Accepted: 01/09/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Coronary artery disease involves the deposition of plaque along the walls of a coronary artery leading to narrowed or blocked vessels (stenosis) and is one of the main causes of death in developed countries. Percutaneous transluminal coronary angioplasty (PTCA) is used to reverse stenosis. Restenosis (renarrowing) of the treated vessel is a major complication of PTCA. A metal mesh tube (stent) can be placed inside the vessel to prevent restenosis. Tissue stress incurred during PTCA and stenting can provoke neointimal cell proliferation leading to in-stent restenosis (ISR). Intravascular brachytherapy (IVBT), a form of internal radiotherapy, is used to treat ISR. Renewed interest in IVBT is being expressed as a treatment for patients with ISR in drug-eluting stents. Current treatment planning (TP) of IVBT is extremely limited and assumes human tissue can be approximated by water. The interactions of arterial plaque, guidewires, and the stent have been shown to attenuate radiation significantly but are ignored in TP. Other models have determined the degree of attenuation by each factor in isolation. For the first time, we create a model with several inhomogenities present to determine whether attenuation by multiple inhomogenities combines linearly or if a larger dose reduction than anticipated is realized. We are also able to evaluate a spatial distribution of dose around the source and in arterial walls. METHODS AND MATERIALS A dosimetric analysis of two commercially available IVBT systems was performed in a Monte Carlo-based particle simulation (Geant4). Absorbed dose was calculated using a model of a human coronary artery with a calcified plaque and stent. Dose delivered in water was also calculated to evaluate the accuracy of a water approximation. RESULTS Dose as a function of θ shows significant variation around IVBT sources. For the Guidant Galileo, dose is reduced by 20% behind stent struts and as much as 66% in a region occluded by the guidewire, plaque, and stent. For the Novoste Beta Cath device, delivered dose is reduced by 19% and 58%, respectively, in the same regions. CONCLUSIONS Our findings show that the water approximation used in clinical practice to calculate dose is inaccurate when inhomogeneities are present. Methods proposed for calculating dose perturbations in IVBT may underestimate the magnitude of dose reduction. Increasing source dwell time seems unlikely to resolve dosimetric issues in IVBT. The effectiveness of currently existing β-emitting devices may be reduced in patients with complex lesions at the treatment site. Investigation of new radioisotopes and off-centering devices should be considered to improve dose outcomes.
Collapse
Affiliation(s)
- J DeCunha
- Department of Physics, Medical Physics Unit, McGill University, Montreal, Quebec, Canada.
| | - C Janicki
- Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
| | - S A Enger
- Medical Physics Unit, Department of Oncology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada; Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
3
|
Benjo A, Cardoso RN, Collins T, Garcia D, Macedo FY, El-Hayek G, Nadkarni G, Aziz E, Jenkins JS. Vascular brachytherapy versus drug-eluting stents in the treatment of in-stent restenosis: A meta-analysis of long-term outcomes. Catheter Cardiovasc Interv 2016; 87:200-8. [PMID: 25963829 DOI: 10.1002/ccd.25998] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 02/12/2015] [Accepted: 04/04/2015] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Clinical trials have shown a short-term benefit of drug-eluting stents (DES) compared to vascular brachytherapy (VBT) for treatment of in-stent restenosis (ISR). The long-term benefits of DES vs. VBT are conflicting in the literature. This study aimed to do a meta-analysis of long-term outcomes of DES compared to VBT for treatment of ISR. METHODS PubMed, EMBASE, Cochrane Central and unpublished data were searched for cohort studies and randomized controlled trials (RCTs) that directly compared VBT to DES for the treatment of ISR. We evaluated the following outcomes at 2-5 years of follow-up: target lesion revascularization (TLR), target vessel revascularization (TVR), myocardial infarction (MI), stent thrombosis, cardiovascular (CV) mortality, and overall mortality. Heterogeneity was defined as I(2) values > 25%. Review Manager 5.1 was used for statistical analysis. RESULTS We included 1,375 patients from five studies, of which three were RCTs. VBT was used to treat ISR in 685 (49.8%) patients. After a 2-5 year follow-up, no significant differences were found between treatment groups regarding MI (P = 0.49), stent thrombosis (P = 0.86), CV mortality (P = 0.35), and overall mortality (P = 0.71). TLR (OR 2.37; CI 1.55-3.63; P < 0.001) and TVR (OR 2.23; CI 1.01-4.94; P = 0.05) were significantly increased in patients who received VBT. CONCLUSION This study suggests that DES are associated with decreased long-term revascularization procedures when compared to VBT for the treatment of ISR. This benefit does not appear to be associated with a significant reduction in mortality or myocardial infarction.
Collapse
Affiliation(s)
- Alexandre Benjo
- Department of Cardiology, Ochsner Medical Center, New Orleans, Louisiana
| | | | - Tyrone Collins
- Department of Cardiology, Ochsner Medical Center, New Orleans, Louisiana
| | - Daniel Garcia
- Department of Medicine, University of Miami, Miami, Florida
| | | | - Georges El-Hayek
- Department of Medicine, St. Luke's Roosevelt Hospital Center, New York, New York
| | - Girish Nadkarni
- Department of Nephrology, Ichan Mount Sinai School of Medicine, New York, New York
| | - Emad Aziz
- Department of Medicine, St. Luke's Roosevelt Hospital Center, New York, New York
| | - J Stephen Jenkins
- Department of Cardiology, Ochsner Medical Center, New Orleans, Louisiana
| |
Collapse
|
4
|
Alfonso F, Rivero F. Network meta-analyses on in-stent restenosis treatment: dealing with complexity to clarify efficacy and safety. J Thorac Dis 2015; 7:1678-83. [PMID: 26623081 PMCID: PMC4635300 DOI: 10.3978/j.issn.2072-1439.2015.10.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
5
|
Wang ZW, Wu HB, Mao ZF, Hu XP, Zhang H, Hu ZP, Ren ZL. In vitro selection and identification of ssDNA aptamers recognizing the Ras protein. Mol Med Rep 2014; 10:1481-8. [PMID: 24938205 DOI: 10.3892/mmr.2014.2337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 03/04/2014] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to develop high-affinity single-stranded DNA (ssDNA) aptamers that can selectively recognize the protein Ras and can be used as preventive and therapeutic agents for restenosis occurring after coronary surgery or angioplasty. For this purpose, we used the systematic evolution of ligands by exponential enrichment (SELEX) technique, also known as in vitro selection. Using this technique, ssDNA aptamers recognizing the Ras protein were obtained from a synthesized random ssDNA library in vitro. The binding rate and affinity of each aptamer pool, isolated in successive rounds of selection, were measured using ELISA, and the finally selected aptamer pool was cloned and sequenced. The binding affinities of each aptamer in this pool were measured. Their primary and secondary structures were analyzed using the DNAMAN 5.29 software, and the relationship between these structures and corresponding binding affinities was analyzed. The rate of aptamer pool binding to the Ras protein gradually increased from 2.4 to 34.5% along the selection process. Optical density (OD) and equilibrium dissociation constant (Kd) measurements showed that OD gradually increased from 0.220 to 1.080 and Kd decreased from 51.5 to 18.3 nM. The 11th pool of aptamers was selected based on these analyses, and cloning and sequencing of individual aptamers was performed. Secondary structure analysis revealed different conformations, but of a single type: stem‑loop. The aptamer Ra1 showed the highest affinity, with a measured OD of 1.213 and an estimated Kd of 15.3 nM. The binding affinity of the aptamer Ra1 to Ras was dose-dependent. In conclusion, high‑affinity ssDNA aptamers recognizing the Ras protein have been successfully selected. These aptamers may serve in the future as preventive and/or therapeutic agents for restenosis occurring after coronary surgery or angioplasty.
Collapse
Affiliation(s)
- Zhi-Wei Wang
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Hong-Bing Wu
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Zhi-Fu Mao
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Xiao-Ping Hu
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Hao Zhang
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Zhi-Peng Hu
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Zong-Li Ren
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| |
Collapse
|
6
|
Richardt G, Leschke M, Abdel-Wahab M, Toelg R, El-Mawardy M, Serruys PW, Silber S, Windecker S, Belardi JA, Neumann FJ, Widimsky P. Clinical Outcomes of the Resolute Zotarolimus-Eluting Stent in Patients With In-Stent Restenosis. JACC Cardiovasc Interv 2013; 6:905-13. [DOI: 10.1016/j.jcin.2013.04.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 04/12/2013] [Accepted: 04/19/2013] [Indexed: 01/06/2023]
|
7
|
Comparative Efficacy and Safety of Drug-Eluting Stent and Conventional Therapies in Coronary Heart Disease Patients with In-Stent Restenosis: A Meta-Analysis. Cell Biochem Biophys 2013; 68:211-29. [DOI: 10.1007/s12013-013-9692-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
8
|
Minar E. Commentary: resuscitation of endovascular brachytherapy owing to improved logistics. J Endovasc Ther 2013; 19:476-9. [PMID: 22891825 DOI: 10.1583/12-3832c.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
9
|
Goyal SN, Bharti S, Krishnamurthy B, Agrawal Y, Ojha SK, Arya DS. Impact of metabolic syndrome on re-stenosis development: role of drug-eluting stents. Diab Vasc Dis Res 2012; 9:177-88. [PMID: 22219135 DOI: 10.1177/1479164111430336] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Metabolic syndrome (MetS) is defined as a cluster of numerous cardiovascular risk factors, which encompasses obesity, dyslipidaemia, insulin resistance and hypertension. Patients with MetS are more prone to developing cardiovascular events than other patients. To date, several approaches such as physical exercise, dietary control and invasive and non-invasive therapeutic interventions for dyslipidaemia, hypertension and insulin resistance have been used to manage MetS. However, there is a progressive elevation in the incidence of fatal and non-fatal cardiovascular events due to the increased prevalence of obesity and diabetes. Percutaneous coronary intervention has emerged over the last few years as an effective revascularisation strategy for those with coronary artery disease, in parallel with the development of effective anti-platelet medications and newer drug-eluting stents. In recent years, considerable research efforts have been undertaken to elucidate the pathophysiology of re-stenosis and develop strategies to prevent re-stenosis following percutaneous transluminal coronary angioplasty and stent implantation. Although the rate of stent re-stenosis and target-lesion revascularisation has been reduced, there is little information in the literature on the outcome of MetS in the pathophysiology of re-stenosis. In this review article, we summarise the recent development and progress on re-stenosis and the role of drug-eluting stents, particularly in MetS.
Collapse
Affiliation(s)
- S N Goyal
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | | | | |
Collapse
|