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Wallner K, Kearney KE, Tiwana J, Pristera N, Kim EY, Sandison G, Lombardi WL, Phillips ML, Don C, Azzalini L, Kim M. Extreme coronary radiation doses from intravascular brachytherapy. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 59:29-34. [PMID: 37684192 DOI: 10.1016/j.carrev.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/21/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023]
Abstract
PURPOSE To evaluate coronary artery integrity after very high radiation doses from intravascular brachytherapy (IVBT) in the setting of source asymmetry. METHODS Ten patients treated for right coronary artery (RCA) in-stent restenosis (ISR) between 2017 and 2021 and for whom follow-up angiograms were available were identified from departmental records. Procedural angiograms, taken to document source position, were used to estimate vascular wall doses. The 2.5 mm proximal source marker was used to estimate the distance from source center to the media and adventitia. Distances were converted to dose (Gy) using the manufacturers' dose fall-off table, measured in water. Follow-up films were scrutinized for any sign of late vascular damage. RESULTS The average minimal distance from catheter center to the adjacent media and the adventitia was 0.9 mm (±0.2) mm and 1.4 mm (±0.2), respectively. The average maximum media and adventitial doses adjacent to the source were 75 Gy (±26) and 39 Gy (±14), respectively. Follow-up angiograms were available from 0.6 years to 3.9 years following IVBT (median: 1.6 years). No IVBT-treated vascular segment showed signs of degeneration, dissection or aneurysm. CONCLUSION IVBT vascular wall doses are frequently far higher than prescribed. The lack of complications in this unselected group of patients gives a modicum of reassurance that raising the prescription dose is unlikely to lead to a sudden appearance of complications.
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Affiliation(s)
- Kent Wallner
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States of America.
| | - Kathleen E Kearney
- Department of Cardiology, University of Washington, Seattle, WA, United States of America
| | - Jasleen Tiwana
- Department of Cardiology, University of Washington, Seattle, WA, United States of America
| | - Nicole Pristera
- Department of Cardiology, University of Washington, Seattle, WA, United States of America
| | - Edward Y Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States of America
| | - George Sandison
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States of America
| | - William L Lombardi
- Department of Cardiology, University of Washington, Seattle, WA, United States of America
| | - Mark L Phillips
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States of America
| | - Creighton Don
- Department of Cardiology, University of Washington, Seattle, WA, United States of America
| | - Lorenzo Azzalini
- Department of Cardiology, University of Washington, Seattle, WA, United States of America
| | - Minsun Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States of America
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Salihu A, Roguelov C, Fournier S, Coucke P, Eeckhout E. Intracoronary Brachytherapy for Restenosis: 20 Years of Follow-Up. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 54:1-4. [PMID: 37087307 DOI: 10.1016/j.carrev.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND/PURPOSE Intracoronary brachytherapy (ICB) has mainly been used to treat in-stent restenosis following percutaneous coronary intervention and was virtually abandoned about 20 years ago. However, patients treated with this strategy are still alive and some teams continue to perform this therapy. We aimed to investigate the very long-term clinical outcome of patients treated with ICB. METHODS/MATERIALS A total of 173 consecutive patients who had been treated with ICB at a large tertiary referral centre between 1998 and 2003 were included. The primary endpoint of the study was all-cause mortality. The secondary endpoints were as follows: occurrence of major adverse cardiac events (MACE, defined as all-cause death, non-fatal myocardial infarction, or target vessel revascularization), cardiac death, and presence of angina at the end of follow-up. RESULTS Patients' mean age at the time of ICB was 64 ± 10 years and 77 % were male. Restenosis (bare metal stent vs. balloon angioplasty) was the only indication for ICB. Unstable angina was present in 34 % of the patients. Follow-up was available for 166 patients. After a mean follow-up of 20 ± 1.3 years, 66 % of the patients had died (including 74 patients (67 %) with cardiac death). Cumulative MACE rate at 20 years was 96 %. CONCLUSIONS Very long-term follow-up of patients with in-stent restenosis treated with ICB confirmed a high all-cause mortality rate mainly due to cardiac causes and MACEs.
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Affiliation(s)
- Adil Salihu
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - Christan Roguelov
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Stephane Fournier
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | - Eric Eeckhout
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Fischell TA. Editorial: Intracoronary Brachytherapy for In-Stent Restenosis: Not Bad in the Sprint, But Fails in the Marathon. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 54:5-6. [PMID: 37271595 DOI: 10.1016/j.carrev.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 06/06/2023]
Affiliation(s)
- Tim A Fischell
- Michigan State University, United States of America; Western Michigan University, United States of America; Borgess Heart Institute, 1521 Gull Road, Kalamazoo, MI 49008, United States of America.
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Radhoe SP, Schuurman AS, Ligthart JM, Witberg K, de Jaegere PPT, van Domburg RT, Regar E. Two decades after coronary radiation therapy: A single center longitudinal clinical study. Catheter Cardiovasc Interv 2020; 96:E204-E212. [PMID: 31789481 PMCID: PMC7540400 DOI: 10.1002/ccd.28637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/21/2019] [Accepted: 11/21/2019] [Indexed: 11/26/2022]
Abstract
Objectives The aim of this study was to evaluate the very long‐term clinical outcome after radioactive stent (RS) implantation and intracoronary β radiation brachytherapy (IRBT). Background Radioactive stents (RS) and intracoronary β radiation brachytherapy (IRBT) were introduced to prevent restenosis after percutaneous coronary intervention (PCI). Both techniques were associated with a higher incidence of major adverse cardiac events (MACE) in the short and intermediate‐term follow up as compared to conventional PCI. Methods One hundred and thirty‐three patients received radioactive stents (32P) and 301 patients were treated with IRBT adjunctive to PCI. These groups were propensity matched to respectively 266 and 602 control patients who were treated with routine PCI during the same inclusion period. Endpoints were all‐cause mortality and MACE, defined as all‐cause death, any myocardial infarction or any revascularization. Results Median follow‐up duration was 17 years. All‐cause mortality rates were similar in all groups. Adjusted hazard ratios for MACE and mortality in the RS cohort were 1.55 (95% CI 1.20–2.00) and 0.92 (95% CI 0.63–1.34), respectively. Adjusted hazard ratios for MACE and all‐cause mortality in the IRBT cohort were 1.41 (95% CI 1.18–1.67) and 0.95 (95% CI 0.74–1.21), respectively. The difference in MACE rates was predominantly driven by coronary revascularizations in both groups, with a higher MI rate in the IRBT group as well. Conclusions Coronary radiation therapy was associated with early increased MACE rates, but the difference in MACE rates decreased beyond 2 years, resulting in a comparable long‐term clinical outcome. Importantly, no excess in mortality was observed.
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Affiliation(s)
- Sumant P Radhoe
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Anne-Sophie Schuurman
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jurgen M Ligthart
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Karen Witberg
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Peter P T de Jaegere
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ron T van Domburg
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Evelyn Regar
- University Heart Center, University Hospital Zürich, Zürich, Switzerland
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Liang JJ, Sio TT, Slusser JP, Lennon RJ, Miller RC, Sandhu G, Prasad A. Outcomes after percutaneous coronary intervention with stents in patients treated with thoracic external beam radiation for cancer. JACC Cardiovasc Interv 2014; 7:1412-20. [PMID: 25459527 DOI: 10.1016/j.jcin.2014.05.035] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/10/2014] [Accepted: 05/22/2014] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The aim of this study was to assess outcomes after percutaneous coronary intervention (PCI) with stents in patients treated with thoracic external beam radiation therapy (EBRT). BACKGROUND Thoracic EBRT for cancer is associated with long-term cardiotoxic sequelae. The impact of EBRT on patients requiring coronary stents is unclear. METHODS We analyzed outcomes after PCI in cancer survivors treated with curative thoracic EBRT before and after stenting between 1998 and 2012. Reference groups were propensity-matched cohorts with stenting but no EBRT. Primary endpoint was target lesion revascularization (TLR), a clinical surrogate for restenosis. Secondary endpoints included myocardial infarction (MI) and cardiac and overall mortality. RESULTS We identified 115 patients treated with EBRT a median 3.6 years after stenting (group A) and 45 patients treated with EBRT a median 2.2 years before stenting (group B). Long-term mean TLR rates in group A (3.2 vs. 6.6%; hazard ratio: 0.6; 95% confidence interval: 0.2 to 1.6; p = 0.31) and group B (9.2 vs. 9.7%; hazard ratio: 1.2; 95% confidence interval: 0.4 to 3.4; p = 0.79) were similar to rates in corresponding control patients (group A: 1,390 control patients; group B: 439 control patients). Three years post-PCI, group A had higher overall mortality (48.6% vs. 13.9%; p < 0.001) but not MI (4.8% vs. 4.3%; p = 0.93) or cardiac mortality (2.3% vs. 3.6%; p = 0.66) rates versus control patients. There were no significant differences in MI, cardiac, or overall mortality rates in group B. CONCLUSIONS Thoracic EBRT is not associated with increased stent failure rates when used before or after PCI. A history of PCI should not preclude the use of curative thoracic EBRT in cancer patients or vice versa. Optimal treatment of cancer should be the goal.
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Affiliation(s)
- Jackson J Liang
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Joshua P Slusser
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Ryan J Lennon
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Robert C Miller
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Gurpreet Sandhu
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Abhiram Prasad
- Cardiovascular Sciences, St. George's, University of London, London, United Kingdom.
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Seabra Gomes R, de Araújo Gonçalves P, Campante Teles R, de Sousa Almeida M. Late results (>10 years) of intracoronary beta brachytherapy for diffuse in-stent restenosis. Rev Port Cardiol 2014; 33:609-16. [PMID: 25304770 DOI: 10.1016/j.repc.2014.02.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 01/28/2014] [Accepted: 02/02/2014] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Until the development of drug-eluting stents (DES), diffuse in-stent restenosis (ISR) was the main limitation of bare-metal stents in percutaneous coronary intervention (PCI). Among the different treatments available, intracoronary brachytherapy (BT) emerged as one of the most promising, although it was almost abandoned with the increasing use of DES. OBJECTIVE To assess the Portuguese experience with 90Sr/90Y beta brachytherapy for the treatment of diffuse ISR regarding long-term (>10 years) major adverse cardiac events (MACE) and angiographic restenosis. METHODS This single-center, retrospective, observational study included 12 consecutive patients treated between January and June 2001, mean age 58.6±9.9 years (range 43-77 years), 11 male. All had chronic stable angina, 75% had dyslipidemia, 58% had hypertension, 50% had peripheral arterial disease, 42% had diabetes and 50% had multivessel disease. Recurrent ISR was present in half of the patients and 11 had normal left ventricular function. After balloon dilatation, BT was performed using an Sr90/Y90 (Novoste Beta-CathTM) beta radiation source. All patients remained under dual antiplatelet therapy until scheduled nine-month follow-up angiography. Patients were followed for the occurrence of death (all-cause and cardiovascular), non-fatal myocardial infarction (MI), revascularization, stent thrombosis and angiographic restenosis. MACE were defined as the combined incidence of cardiac death, MI and urgent target vessel revascularization. RESULTS In all cases there was both clinical and angiographic success. In a mean follow-up of 10.9±2.5 years, 19 events occurred in seven patients: death in three (25%), only one cardiac (8.3%); ST-elevation MI in one (related to a non-target vessel) (8.3%); and 15 revascularizations in five (42%), of which nine were of the target vessel (mainly in the first two years). There was only one case of probable stent thrombosis. Angiographic restenosis at nine months was 27% (three out of 11 patients), of which two were total occlusions. Ten-year MACE-free survival was 42% (5 patients). CONCLUSIONS Intracoronary beta brachytherapy for the treatment of diffuse ISR in this small cohort of patients proved to be safe and efficacious, with no late adverse events related to intracoronary radiation.
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Affiliation(s)
- Ricardo Seabra Gomes
- Unidade de Intervenção Cardiovascular (UNICARV), Serviço de Cardiologia, Hospital de Santa Cruz - CHLO, Lisboa, Portugal
| | - Pedro de Araújo Gonçalves
- Unidade de Intervenção Cardiovascular (UNICARV), Serviço de Cardiologia, Hospital de Santa Cruz - CHLO, Lisboa, Portugal; Faculdade de Ciências Médicas da Universidade Nova de Lisboa, Lisboa, Portugal.
| | - Rui Campante Teles
- Unidade de Intervenção Cardiovascular (UNICARV), Serviço de Cardiologia, Hospital de Santa Cruz - CHLO, Lisboa, Portugal
| | - Manuel de Sousa Almeida
- Unidade de Intervenção Cardiovascular (UNICARV), Serviço de Cardiologia, Hospital de Santa Cruz - CHLO, Lisboa, Portugal
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Seabra Gomes R, de Araújo Gonçalves P, Campante Teles R, de Sousa Almeida M. Late results (>10 years) of intracoronary beta brachytherapy for diffuse in-stent restenosis. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.repce.2014.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Waksman R, Barbash IM, Chan R, Randolph P, Makuria AT, Virmani R. Beta radiation for renal nerve denervation: initial feasibility and safety. EUROINTERVENTION 2013; 9:738-44. [DOI: 10.4244/eijv9i6a118] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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