Intracoronary Brachytherapy for Treatment of In-Stent Restenosis

Saphenous vein graft failure after coronary artery bypass surgery: pathophysiology, management, and future directions

OBJECTIVE

To review our current understanding of the epidemiology and pathogenesis of vein graft failure (VGF), give an overview of current preventive and interventional measures, and explore strategies that may improve vein graft patency.

BACKGROUND

VGF and progression of native coronary artery disease limit the long-term efficacy of coronary artery bypass graft surgery.

METHODS

We reviewed the published literature on the pathophysiology, prevention, and/or treatment of VGF by searching the MEDLINE (January 1, 1966-January 1, 2012), EMBASE (January 1, 1980-January 1, 2012), and Cochrane (January 1, 1995-January 1, 2012) databases. In addition, we reviewed references from the selected articles for studies not identified in the initial search. Basic science and clinical studies were included; non-English language publications were excluded.

RESULTS

Acute thrombosis, neointimal hyperplasia, and accelerated atherosclerosis are the 3 mechanisms that lead to VGF. Preventive measures include matching and quality assessment of conduit and target vessel, lipid-lowering drugs, antithrombotic therapy, and cessation of smoking. Treatment of VGF includes medical therapy, percutaneous intervention, and redo coronary artery bypass graft surgery. In patients undergoing graft intervention, the use of drug-eluting stents, antiplatelet agents, and embolic protection devices may improve clinical outcomes.

CONCLUSIONS

Despite advances in management, VGF remains one of the leading causes of poor in-hospital and long-term outcomes after coronary artery bypass graft surgery. New developments in VGF prevention such as gene therapy, external graft support, fully tissue-engineered grafts, hybrid grafts, and synthetic conduits are promising but unproven. Future efforts to reduce VGF require a multidisciplinary approach with a primary focus on prevention.

Upregulation of tissue factor expression and thrombogenic activity in human aortic smooth muscle cells by irradiation, rapamycin and paclitaxel

BACKGROUND

Intracoronary brachytherapy as well as rapamycin or paclitaxel coated stents reduce restenosis rates after stenting, but are associated with an increased risk of late stent thrombosis. Tissue factor (TF) may contribute to late thrombosis. This study examined the impact of rapamycin and paclitaxel on TF expression and compares the TF activity induction of both drugs and irradiation in SMCs.

METHODS

SMCs were stimulated with rapamycin, paclitaxel or irradiation. Real-time PCR, a chromogenic TF activity assay and Western blotting were done.

RESULTS

Rapamycin or paclitaxel increased the TF mRNA expression 5-fold and the TF activity 4- to 6-fold with a maximum at 5 h. Irradiation induced TF activity 2- to 4-fold with a maximum at 7 days.

CONCLUSION

The fast increase of TF expression in SMCs post rapamycin and paclitaxel treatment may explain acute stent thrombosis when anti-thrombotic therapies are withdrawn, whereas the irradiation induced long term increase of cellular thrombogenicity may contribute to late thrombosis post intracoronary brachytherapy. Therapies counteracting these side effects may reduce the risk of thrombotic complications after the coronary application of anti-proliferative therapies.

Ionizing radiation induces upregulation of cellular procoagulability and tissue factor expression in human peripheral blood mononuclear cells

INTRODUCTION

The therapeutic application of ionizing radiation is associated with thrombotic events, but the exact underlying molecular mechanisms are still unclear. Tissue factor (TF), the primary initiator of blood coagulation, is essentially involved in the pathophysiology of thrombosis. Circulating monocytes have been identified to upregulate TF under inflammatory conditions and, thereby, enhance blood thrombogenicity. The study examines the effect of irradiation on the cellular procoagulability and TF protein expression of human peripheral blood mononuclear cells (PBMNCs) in a time period of 7 days.

MATERIALS AND METHODS

Human PBMNCs were irradiated with 20 Gy. Procoagulability of PBMNCs, released microparticles and microparticle-free cell supernatant was analyzed by a chromogenic assay and TF protein expression quantified by TF ELISA. To determine whether irradiated PBMNCs and shed microparticles initiate plasma clotting, a one stage clotting assay was performed.

RESULTS

We found a significant increase of PBMNC-associated procoagulant activity over a time period of 7 days post irradiation. Moreover, 3 days post irradiation PBMNCs initiated the plasma clotting faster than non-irradiated cells. An enhanced cellular TF protein concentration was persistently observed throughout the investigated time up to 7 days post irradiation. Microparticle-associated TF activity significantly increased 3 days post irradiation compared with the non-irradiated controls. PBMNC-derived microparticles post irradiation also initiated the plasma clotting faster than microparticles derived from controls.

CONCLUSIONS

The results show irradiation to induce TF expression and to increase procoagulability of PBMNCs and cell-derived microparticles. This could be a possible mechanism by which ionizing radiation enhances blood thrombogenicity.

Clinical outcome of patients undergoing low aggressive angioplasty combined with brachytherapy and short-term dual antiplatelet therapy for in-stent restenosis

OBJECTIVE

The impact of vessel injury on the outcome of patients undergoing percutaneous coronary intervention combined with brachytherapy for in-stent restenosis is under investigation. We report our clinical experience adopting a low aggressive balloon angioplasty technique, to limit vessel trauma, associated with brachytherapy and short-term dual antiplatelet therapy.

METHODS

Forty-nine consecutive patients, undergoing percutaneous coronary intervention with brachytherapy for symptomatic in-stent restenosis, were prospectively observed for a median time of 21 + or - 8 months. Clinical follow-up included anginal status, death, myocardial infarction and repeat revascularization; only patients with evidence of ischaemia repeated coronary angiography. Low aggressive angioplasty consisted in the use of a conventional balloon with a balloon to artery ratio < or = 1, avoiding high inflation pressures and the use of other devices. Dual antiplatelet therapy was continued for 3-6 months.

RESULTS

Early angiographic result was good and the need for additional stent implantation was low (3.9%). At follow-up, we did not observe death, acute myocardial infarction or stent thrombosis, but 10 patients repeated coronary angiography for recurrence of ischaemia: disease progression was present in two cases (4.1%). Restenosis emerged in the remaining eight patients (16.3%): two cases showed restenosis within the target lesion segment, one case within the injured segment, one case within the radiated segment, and four cases at the edges. The consequent new revascularization was surgical in three patients and percutaneous in seven patients.

CONCLUSIONS

Our data suggest that low aggressive angioplasty followed by brachytherapy and short-term dual antiplatelet therapy for in-stent restenosis is related to a good outcome, with a low restenosis rate and without stent thrombosis.