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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.
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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
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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.
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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
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Ohri N, Sharma S, Kini A, Baber U, Aquino M, Roy S, Sheu RD, Buckstein M, Bakst R. Intracoronary brachytherapy for in-stent restenosis of drug-eluting stents. Adv Radiat Oncol 2016; 1:4-9. [PMID: 28799576 PMCID: PMC5506705 DOI: 10.1016/j.adro.2015.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/07/2015] [Accepted: 12/09/2015] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Given the limited salvage options for in-stent restenosis (ISR) of drug-eluting stents (DES), our high-volume cardiac catheterization laboratory has been performing intracoronary brachytherapy (ICBT) in patients with recurrent ISR of DES. This study analyzes their baseline characteristics and assesses the safety/toxicity of ICBT in this high-risk population. METHODS AND MATERIALS A retrospective analysis of patients treated with ICBT between September 2012 and December 2014 was performed. Patients with ISR twice in a single location were eligible. Procedural complications included vessel dissection, perforation, tamponade, slow/absent blood flow, and vessel closure. Postprocedural events included myocardial infarction, coronary artery bypass graft, congestive heart failure, stroke, bleeding, thrombosis, embolism, dissection, dialysis, or death occurring within 72 hours. A control group of patients with 2 episodes of ISR at 1 location who underwent percutaneous coronary intervention without ICBT was identified. Unpaired t tests and χ2 tests were used to compare the groups. RESULTS There were 134 (78%) patients in the ICBT group with 141 treated lesions and 37 (22%) patients in the control group. There was a high prevalence of hyperlipidemia (>95%), hypertension (>95%), and diabetes (>50%) in both groups. The groups were well-balanced with respect to age, sex, and pre-existing medical conditions, with the exception of previous coronary artery bypass graft being more common the ICBT group. Procedural complication rates were low in the control and ICBT groups (0% vs 4.5%, P = .190). Postprocedural event rates were low (<5%) in both groups. Readmission rate at 30 days was 3.7% in the ICBT group and 5.4% in the control group (P = .649). CONCLUSIONS This is the largest recent known series looking at ICBT for recurrent ISR of DES. ICBT is a safe treatment option with similarly low rates (<5%) of procedural and postprocedural complications compared with percutaneous coronary intervention alone. This study establishes the safety of ICBT in a high-risk patient cohort.
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Affiliation(s)
- Nisha Ohri
- Department of Radiation Oncology, Mount Sinai Hospital, New York, New York
| | - Samin Sharma
- Department of Cardiology, Mount Sinai Hospital, New York, New York
| | - Annapoorna Kini
- Department of Cardiology, Mount Sinai Hospital, New York, New York
| | - Usman Baber
- Department of Cardiology, Mount Sinai Hospital, New York, New York
| | - Melissa Aquino
- Department of Cardiology, Mount Sinai Hospital, New York, New York
| | - Swathi Roy
- Department of Cardiology, Mount Sinai Hospital, New York, New York
| | - Ren-Dih Sheu
- Department of Radiation Oncology, Mount Sinai Hospital, New York, New York
| | - Michael Buckstein
- Department of Radiation Oncology, Mount Sinai Hospital, New York, New York
| | - Richard Bakst
- Department of Radiation Oncology, Mount Sinai Hospital, New York, New York
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Maluenda G, Ben-Dor I, Gaglia MA, Wakabayashi K, Mahmoudi M, Sardi G, Laynez-Carnicero A, Torguson R, Xue Z, Margulies AD, Suddath WO, Kent KM, Bernardo NL, Satler LF, Pichard AD, Waksman R. Clinical Outcomes and Treatment After Drug-Eluting Stent Failure. Circ Cardiovasc Interv 2012; 5:12-9. [DOI: 10.1161/circinterventions.111.963215] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The optimal percutaneous treatment of drug-eluting stent (DES) in-stent restenosis (ISR) and the correlates for recurrent DES ISR remain unclear.
Methods and Results—
From 2003 to 2008, 563 patients presenting with recurrent symptoms of ischemia and angiographic ISR after DES implantation were included. Of these, 327 were treated with re-DES (58.1%), 132 underwent vascular brachytherapy (23.4%), and 104 were treated with conventional balloon angioplasty (18.5%). Variables associated with target lesion revascularization at 1 year were explored by individual proportional hazard models. This population presents a high prevalence of comorbidities, including diabetes (43.7%), previous myocardial infarction (MI) (45.8%), coronary bypass graft surgery (39.2%), chronic renal failure (18.8%), and heart failure (17.3%). Baseline clinical characteristics were balanced among the 3 groups; however, patients undergoing vascular brachytherapy presented with more complex lesions and a higher prevalence of prior stent/vascular brachytherapy failure than did the rest of the population. The overall incidence of recurrent DES failure at 1-year follow-up was 12.2%, which was similar among the 3 groups (
P
=0.41). The rate of the composite end point (death, Q-wave-MI and target lesion revascularization) at 1-year follow-up was 14.1% for re-DES, 17.5% for vascular brachytherapy, and 18.0% for conventional balloon angioplasty (
P
=0.57). After univariable analysis tested the traditional known covariates related to ISR, none of them were associated with repeat target lesion revascularization.
Conclusions—
Recurrence of ISR after DES treatment failure is neither infrequent nor benign, and optimal therapy remains unclear and challenging. Given the absence of traditional risk factors for ISR in this population, further research is required to elucidate both the correlates involved in DES ISR and the optimal treatment for this condition.
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Affiliation(s)
- Gabriel Maluenda
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - Itsik Ben-Dor
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - Michael A. Gaglia
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - Kohei Wakabayashi
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - Michael Mahmoudi
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - Gabriel Sardi
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - Ana Laynez-Carnicero
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - Rebecca Torguson
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - Zhenyi Xue
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - Adrian D. Margulies
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - William O. Suddath
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - Kenneth M. Kent
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - Nelson L. Bernardo
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - Lowell F. Satler
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - Augusto D. Pichard
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
| | - Ron Waksman
- From Division of Cardiology, Washington Hospital Center, Washington, DC (G.M., I.B.-D., M.A.G., K.W., M.M., G.S., A.L.-C., R.T., Z.X., A.D.M., W.O.S., K.M.K., N.L.B., L.F.S., A.D.P., R.W.)
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