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Abstract
AIMS The presence of subclinical stenosed coronary segments and plaque subtypes has not been compared among those with metabolic syndrome, diabetes, or neither condition in middle-aged individuals. In select, intermediate-risk subjects, it may be reasonable to directly measure atherosclerosis burden by low-dose, multidetector-row computed tomographic coronary angiography. METHODS We performed a cross-sectional analysis of 1024 consecutive, newly self-referred subjects (692 men, 332 women; mean age 53.0±9.7 years) who underwent health evaluation at the China Medical University Hospital. Participants had at least one cardiac risk factor, but no known coronary heart disease. RESULTS Among our 1024 subjects, 135 had diabetes, 334 had metabolic syndrome and 555 had neither condition. The subjects with diabetes and those with metabolic syndrome had a higher prevalence of non-calcified, calcified and mixed-type plaques and stenosed coronary segments than the subjects with neither condition (P<0.05). The odds ratios for diabetes and the presence of any plaque, mixed plaque, calcified plaque and stenosed segment compared with neither metabolic syndrome nor diabetes were 2.893, 3.629, 2.099 and 2.036, respectively, all of which were significant (P<0.05). The odds ratio for metabolic syndrome and the presence of any plaque compared with neither metabolic syndrome nor diabetes was 1.606 (95% CI 1.063-2.426; P<0.05). CONCLUSION In middle-aged subjects, diabetes was related to an increased risk of the presence of mixed plaques, calcified plaques and stenosed coronary segments. However, metabolic syndrome was related to an increased risk of the presence of any coronary plaque, but not related to stenosed coronary segments.
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Affiliation(s)
- T Lin
- Department of Medicine, College of Medicine, China Medical University Hospital, Taichung, Taiwan.
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2
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Waksman R, Pakala R, Okabe T, Hellinga D, Chan R, Tio MO, Wittchow E, Hartwig S, Waldmann KH, Harder C. Efficacy and safety of absorbable metallic stents with adjunct intracoronary beta radiation in porcine coronary arteries. J Interv Cardiol 2007; 20:367-72. [PMID: 17880333 DOI: 10.1111/j.1540-8183.2007.00272.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Absorbable metallic stents (AMS) utilizing Mg alloy carry advantages over permanent metallic stents because of their potential to eliminate stent thrombosis, chronic inflammation, or artifacts with noninvasive imaging. These stents, however, are associated with a modest degree of late recoil and intimal hyperplasia. The aim of the study was to test whether adjunct vascular brachytherapy (VBT) compared to AMS alone can overcome these limitations. METHODS Juvenile domestic pig coronary arteries underwent implantation of either AMS (n = 11) with prior adjunct VBT utilizing Sr/Y-90 beta source seeds, with a dose of 24 Gy at 2 mm from the source, or AMS alone (n = 11). At 28 days following intravascular ultrasound, vessels were harvested and analyzed by histomorphometry. RESULTS Intravascular ultrasound analysis indicated that at follow-up, though statistically not significant, lumen and stent areas in the segments deployed with AMS following radiation were larger than those deployed with AMS alone (3.94 +/- 1.38 and 3.53 +/- 1.75 vs. 2.99 +/- 1.05 and 3.58 +/- 1.48). Extrastent plaque and intrastent plaque areas in the same segments were smaller (2.76 +/- 0.82 and 0.24 +/- 0.47 vs. 3.25 +/- 1.94 and 0.58 +/- 0.81). Morphometric data indicate that vessels in the VBT + AMS group showed characteristics of delayed healing and re-endothelialization. Neointimal area was significantly lower in the VBT + AMS group (0.49 +/- 0.34) compared to AMS (1.3 +/- 0.62, P = 0.001). Lumen area of the VBT + AMS was larger when compared with AMS alone (2.49 +/- 0.82 vs. 1.75 +/- 0.51, P = 0.02). CONCLUSION VBT as an adjunct to AMS further reduces the intimal hyperplasia and improves the lumen area when compared to AMS alone but does not have any impact on late recoil.
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Affiliation(s)
- Ron Waksman
- Cardiovascular Research Institute, Washington Hospital Center, Washington, DC 20010, USA.
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Zyciński P, Krzemińska-Pakuła M, Peszyński-Drews C, Kierus A, Trzos E, Rechciński T, Figiel L, Kurpesa M, Plewka M, Chrzanowski L, Drozdz J. Laser biostimulation in end-stage multivessel coronary artery disease--a preliminary observational study. Kardiol Pol 2007; 65:13-21; discussion 22-3. [PMID: 17295156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND Low-energy laser radiation through its direct influence on tissue repair processes without heating effect may have vital importance in the therapy of patients with advanced coronary artery disease (CAD). AIM The introductory assessment of the effects of laser biostimulation applied to patients with advanced multivessel CAD. METHODS 39 patients with advanced CAD were assigned (mean age 64.8+/-9.6, male gender 64%, CCS class 2.5+/-0.5, EF=46+/-11%, 69% with a history of acute myocardial infarction), to undergo two sessions of irradiation of low-energy laser light on skin in the chest area from helium-neon B1 lasers. The time of irradiation was 15 minutes while operations were performed 6 days a week for one month. Before including the patients in the experimental group a full clinical evaluation, basic biochemical tests, ECG, 24h Holter recordings, 6-minute walk test, treadmill test using Bruce protocol and full echocardiographic examination were performed. After the first and second period of laser therapy with a one-month break between them analogical parameters with the initial examination were measured. RESULTS No side effects associated with the laser biostimulation or performed clinical tests were noted. Lower CCS class (2.5+/-0.5 --> 2.2+/-0.4 --> 2.0+/-0.4, p<0.001), higher exercise capacity (5.1+/-2.2 --> 5.8+/-2.2 --> 6.6+/-2.5 [METS], p=0.023), longer exercise time (257+/-126 --> 286+/-127 --> 325+/-156 [s], p=0.06), less frequent angina symptoms during the treadmill test (65% --> 44% --> 38%, p=0.02), longer distance of 6-minute walk test (341+/-93 --> 405+/-113 --> 450+/-109 [m], p <0.001), lower systolic blood pressure values (SP 130+/-14 --> 125+/-12 --> 124+/-14 [mmHg], p=0.05) and trend towards less frequent 1 mm ST depression lasting 1 min during Holter recordings were noted. CONCLUSIONS An improvement of functional capacity and less frequent angina symptoms during exercise tests without a significant change in the left ventricular function were observed. Laser biostimulation in short-term observation was a very safe method. These encouraging results should be confirmed in a larger, placebo-controlled study.
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Affiliation(s)
- Paweł Zyciński
- II Katedra i Klinika Kardiologii Uniwersytetu Medycznego, ul. Kniaziewicza 1/5, Łódź
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4
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Abstract
The problem of restenosis after percutaneous transluminal coronary angioplasty remains the major limiting factor of the procedure. Over the last 10 years, investigators have been studying the use of radiation therapy for preventing restenosis after angioplasty or stent placement. Since radiotherapy has been proven in other cases to be effective in disrupting the cell cycle regulatory proteins and thereby slowing or stopping growth, it was decided to apply the same principle to neointimal hyperplasia. To review the data that have emerged regarding vascular radiation with an emphasis on irradiated stents, 65 articles were reviewed and both preclinical and clinical experiments were included. Overall, studies with gamma and beta radiation show promising results. Endovascular gamma radiation has been shown effective in randomized trials, even at 3-year follow-up. Beta radiation is preferred because of greater safety and localization, and because it has also shown encouraging results in initial clinical trials, as well as in larger randomized studies. Consequently, the Federal Drug Administration has approved the use of both. In both types of endovascular brachytherapy, it seems the greater the dose, the better the initial response. Safety concerns include an increased incidence of late thrombosis and greater restenosis at margins. With irradiated stents, however, the situation is not as clear. At times, animal models have presented confusing results. These have ranged from significant suppression of hyperplasia to outright adverse effects of radiation on the vessel wall. While some clinical trials have been encouraging, others have not. Follow-up of up to 1 year has been disappointing so far. Many issues, such as the "candy wrapper" effect and rebound hyperplasia, must be dealt with before this becomes a viable form of therapy. It has become clear that radiation therapy in this setting, while having potentially great benefits, can cause deleterious effects as well. However, the mixed bag of positive and negative results seen so far, and the attractiveness of stents or percutaneous transluminal coronary angioplasty being "restenosis-proofed," eventually is cause for cautious optimism.
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Affiliation(s)
- Nabeel Hafeez
- Department of Internal Medicine, University Hospital, State University of New York at Stony Brook, USA.
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Voisard R, Höb J, Baur R, Herter T, Hannekum A, Hombach V. Edge restenosis: impact of low dose irradiation on cell proliferation and ICAM-1 expression. BMC Cardiovasc Disord 2006; 6:32. [PMID: 16827927 PMCID: PMC1526455 DOI: 10.1186/1471-2261-6-32] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2006] [Accepted: 07/07/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low dose irradiation (LDI) of uninjured segments is the consequence of the suggestion of many authors to extend the irradiation area in vascular brachytherapy to minimize the edge effect. Atherosclerosis is a general disease and the uninjured segment close to the intervention area is often atherosclerotic as well, consisting of neointimal smooth muscle cells (SMC) and quiescent monocytes (MC). The current study imitates this complex situation in vitro and investigates the effect of LDI on proliferation of SMC and expression of intercellular adhesion molecule-1 (ICAM-1) in MC. METHODS Plaque tissue from advanced primary stenosing lesions of human coronary arteries (9 patients, age: 61 +/- 7 years) was extracted by local or extensive thrombendarterectomy. SMC were isolated and identified by positive reaction with smooth muscle alpha-actin. MC were isolated from buffy coat leukocytes using the MACS cell isolation kit. For identification of MC flow-cytometry analysis of FITC-conjugated CD68 and CD14 (FACScan) was applied. SMC and MC were irradiated using megavoltage photon irradiation (CLINAC2300 C/D, VARIAN, USA) of 6 mV at a focus-surface distance of 100 cm and a dose rate of 6 Gy min-1 with single doses of 1 Gy, 4 Gy, and 10 Gy. The effect on proliferation of SMC was analysed at day 10, 15, and 20. Secondly, total RNA of MC was isolated 1 h, 2 h, 3 h, and 4 h after irradiation and 5 microg of RNA was used in standard Northern blot analysis with ICAM-1 cDNA-probes. RESULTS Both inhibitory and stimulatory effects were detected after irradiation of SMC with a dose of 1 Gy. At day 10 and 15 a significant antiproliferative effect was found; at day 20 after irradiation cell proliferation was significantly stimulated. Irradiation with 4 Gy and 10 Gy caused dose dependent inhibitory effects at day 10, 15, and 20. Expression of ICAM-1 in human MC was neihter inhibited nor stimulated by LDI. CONCLUSION Thus, the stimulatory effect of LDI on SMC proliferation at day 20 days after irradiation may be the in vitro equivalent of a beginning edge effect. Extending the irradiation area in vascular brachytherapy in vivo may therefore merely postpone and not inhibit the edge effect. The data do not indicate that expression of ICAM-1 in quiescent MC is involved in the process.
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Affiliation(s)
- Rainer Voisard
- Department of Internal Medicine II – Cardiology, University of Ulm, Robert-Koch-Straße 8, D-89081 Ulm, Germany
| | - Jochen Höb
- Department of Internal Medicine II – Cardiology, University of Ulm, Robert-Koch-Straße 8, D-89081 Ulm, Germany
| | - Regine Baur
- Department of Internal Medicine II – Cardiology, University of Ulm, Robert-Koch-Straße 8, D-89081 Ulm, Germany
| | - Tina Herter
- Department of Internal Medicine II – Cardiology, University of Ulm, Robert-Koch-Straße 8, D-89081 Ulm, Germany
| | - Andreas Hannekum
- Department of Cardiac Surgery, University of Ulm, Steinhövelstraße 9, 89070 Ulm, Germany
| | - Vinzenz Hombach
- Department of Internal Medicine II – Cardiology, University of Ulm, Robert-Koch-Straße 8, D-89081 Ulm, Germany
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Tsapaki V, Magginas A, Vano E, Kottou S, Papadakis E, Dafnomili P, Kyrozi E, Kollaros N, Neofotistou V, Cokkinos D. Factors That Influence Radiation Dose in Percutaneous Coronary Intervention. J Interv Cardiol 2006; 19:237-44. [PMID: 16724966 DOI: 10.1111/j.1540-8183.2006.00137.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIM To explore the factors that may influence the radiation dose imparted to the patient in PCI, and investigate whether the use of the latest digital X-ray system based on FP detector technology can have an impact on dose. MATERIALS AND METHOD Demographic and clinical data such as number of lesions treated, number of stents placed, grade of tortuosity, and stage of occlusion, as well as use of double wire and double balloon technique, ostial stenting or bifurcation stenting, and presence of major complications were recorded, together with radiation parameters. RESULTS The factors that increased patient radiation dose were (1) patient gender, as men exhibited higher doses than women; (2) complex lesion; (3) increasing number of stents; (4) position of stent; (5) grade of tortuosity; and (6) stage of occlusion. The FP digital system appeared to be settled in a lower-dose rate for fluoroscopy (a factor of 6) and higher for dose per frame in cine (a factor of 3) in comparison with the image intensifier (II) system. There was a marked reduction of DAP when the FP technology was introduced. CONCLUSION More extensive studies should be performed in the future so as to further investigate the influence of the FP detector in IC.
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Affiliation(s)
- Virginia Tsapaki
- Department of Medical Physics, Konstantopoulio Agia Olga Hospital, Athens, Greece.
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Kuchulakanti P, Torguson R, Canos D, Satler LF, Suddath W, Chan R, White LR, Gevorkian N, Bui A, Wang B, Kent KM, Pichard AD, Waksman R. Optimizing dosimetry with high-dose intracoronary gamma radiation (21 Gy) for patients with diffuse in-stent restenosis. Cardiovascular Revascularization Medicine 2005; 6:108-12. [PMID: 16275606 DOI: 10.1016/j.carrev.2005.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2005] [Accepted: 05/12/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The efficacy of intracoronary gamma radiation (IRT-gamma) in reducing recurrent in-stent restenosis (ISR) is well established using doses of 14-18 Gy. We sought to examine whether an escalation in dose to 21 Gy is safe and confers additional benefit in reducing repeat revascularization and major adverse cardiac events (MACE) in patients with diffuse ISR. METHODS Forty-seven patients with diffuse ISR (lesion length 20-80 mm) in native coronary arteries (n=25) and saphenous vein grafts (n=22) underwent percutaneous transluminal coronary angioplasty and/or additional stents followed by IRT-gamma using the Checkmate system (Cordis) with a dose of 21 Gy. All patients were discharged with clopidogrel for 12 months and aspirin indefinitely. Six-month angiographic and 12-month clinical outcomes of these patients were compared to 120 patients treated with 18 Gy using the same system. RESULTS At baseline, patients in the 21-Gy group had more multivessel, vein graft disease and history of prior myocardial infarctions and coronary artery bypass grafts (P<.001). The use of debulking devices and stents was less in this group (P<.001). Procedural and in-hospital complications were similar. Follow-up at 6 months revealed nonsignificant but lower late loss (in-stent, 0.33+/-0.7 mm; in-lesion, 0.41+/-0.6 mm) in the 21-Gy group compared to the 18-Gy group; follow-up at 12 months revealed a trend toward less overall myocardial infarction, although repeat revascularization and MACE rates were similar. CONCLUSIONS IRT-gamma therapy for diffuse ISR lesions with a 21-Gy dose is clinically safe and feasible with marked reduction in late loss but does not confer additional benefit with regard to repeat revascularization and MACE when compared to a dose of 18 Gy.
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Vasil'ev AP, Sekisova MA, Strel'tsova NN, Senatorov IN. [Laser correction of microcirculation disorders in patients having CHD with hypercholesterinemia]. Klin Med (Mosk) 2005; 83:33-7. [PMID: 15803829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The study demonstrates that hypercholesterinemia in patients with coronary heart disease (CHD) is associated with functional depression of microcirculation, increase in total peripheral vascular resistance, reduction in the functional efficiency of heart and decrease in activity tolerance. After receiving a course of low-intensity infrared laser radiation treatment the patients displayed positive changes in blood lipid spectrum, which was associated with improvement in microcirculation, decrease in afterload, increase in economization of heart functioning and activity tolerance. The obtained results demonstrate that the hypolipidemic effect of laser radiation is a substantial factor in the regression of CHD manifestations.
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Ribichini F, Ferrero V, Piessens M, Heyndrickx GR, de Bruyne B, Verbeke L, Matullo G, Büchi M, Piazza A, Guarrera S, Lüscher TF, Wijns W. Intracoronary β-irradiation prevents excessive in-stent neointimal proliferation in de novo lesions of patients with high plasma ACE levels. The BetAce randomized trial. Cardiovascular Revascularization Medicine 2005; 6:7-13. [PMID: 16263350 DOI: 10.1016/j.carrev.2005.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2005] [Accepted: 02/22/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND This study evaluated vascular brachytherapy (VBT) as a potent antiproliferative treatment to prevent in-stent restenosis (ISR) after coronary angioplasty of de novo lesions in patients carrying the D allele of the I/D polymorphism of the ACE gene and high ACE plasma levels (>34 U/l). METHODS AND MATERIALS A prospective randomized trial was designed to detect a 30% improvement in the minimal lumen diameter (MLD) of the stenotic artery, as measured by quantitative coronary analysis (QCA), 6 months following VBT at the time of stented angioplasty. All patients were carriers of the D allele of the ACE gene, with plasma ACE levels >34 U/l. RESULTS Thirty-one patients (33 stenoses) were allocated to stent implantation (control group) and 30 patients (31 stenoses) to VBT and stented angioplasty. After angioplasty, in-stent MLD was similar in the two groups. At 6 months in the control group, in-stent MLD had decreased to 1.74+/-0.8 versus 2.25+/-1.05 mm in the VBT group (P=.04). The mean in-stent diameter was 2.3+/-0.8 mm in the control group versus 2.9+/-1.05 mm after VBT (P=.02), and the restenosis rate was 37.5% versus 17.9%, respectively (P=.08). At 6 months, a higher need for target vessel revascularization (TVR) was observed in the control group: 35.5% versus 13.3% (P=.04). CONCLUSIONS This randomized study confirms that patients with high plasma ACE concentrations are exposed to an increased risk for ISR after coronary stenting. The preventive use of VBT in these patients reduced neointimal formation by 65% such that the MLD at follow-up was increased by 29% compared with the control group.
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Affiliation(s)
- Flavio Ribichini
- Division of Cardiology, Università del Piemonte Orientale, Ospedale Maggiore della Carita', Novara, Italy.
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Task Force on CART, American Society for Therapeutic Radiology and Oncology. Roles and responsibilities of specialists involved in coronary artery radiation therapy (CART) and the CART procedure. Int J Radiat Oncol Biol Phys 2003; 57:6-8. [PMID: 12953687 DOI: 10.1016/s0360-3016(03)00760-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Cox JD. History, protocols, and the team. Int J Radiat Oncol Biol Phys 2003; 57:1-2. [PMID: 12909205 DOI: 10.1016/s0360-3016(03)00758-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Höher M, Wöhrle J, Wohlfrom M, Kamenz J, Nusser T, Grebe OC, Hanke H, Kochs M, Reske SN, Hombach V, Kotzerke J. Intracoronary beta-irradiation with a rhenium-188-filled balloon catheter: a randomized trial in patients with de novo and restenotic lesions. Circulation 2003; 107:3022-7. [PMID: 12796137 DOI: 10.1161/01.cir.0000074203.66371.29] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Restenosis requiring reintervention is the main limitation of coronary angioplasty. Intracoronary irradiation reduces neointimal proliferation. We studied the efficacy of a self-centering liquid rhenium-188-filled balloon catheter for coronary beta-brachytherapy. METHODS AND RESULTS After successful coronary angioplasty with or without stenting, 225 patients (71% de novo lesions) were randomly assigned to receive 22.5 Gy intravascular beta-irradiation in 0.5-mm tissue depth (n=113) or to receive no additional intervention (n=112). Clinical and procedural data did not differ between the groups except a higher rate of stenting in the control group (63%) compared with the rhenium-188 group (45%, P<0.02). After 6 months of follow-up, late loss was significantly lower in the irradiated group compared with the control group, both of the target lesion (0.11+/-0.54 versus 0.69+/-0.81 mm, P<0.0001) and of the total segment (0.22+/-0.67 versus 0.70+/-0.82 mm, P<0.0001). This was also evident in the subgroup of patients with de novo lesions and independent from stenting. Binary restenosis rates were significantly lower at the target lesion (6.3% versus 27.5%, P<0.0001) and of the total segment (12.6% versus 28.6%, P<0.007) after rhenium-188 brachytherapy compared with the control group. Target vessel revascularization rate was significantly lower in the rhenium-188 (6.3%) compared with the control group (19.8%, P=0.006). CONCLUSIONS Intracoronary beta-brachytherapy with a rhenium-188 liquid-filled balloon is safe and efficiently reduces restenosis and revascularization rates after coronary angioplasty.
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Affiliation(s)
- Martin Höher
- Department of Internal Medicine II, University of Ulm, Robert-Koch-Strasse-8, 89081 Ulm, Germany.
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Guerra P, Bonan R. New research in vascular brachytherapy applications beyond coronary artery disease. J Invasive Cardiol 2003; 15 Suppl A:31A-32A. [PMID: 12668840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Affiliation(s)
- Peter Guerra
- Department of Cardiology, Montreal Heart Institute, Quebec, Canada H1T 1C8
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Affiliation(s)
- Philip M Devlin
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Tsyb AF, Kaplan MA, Tkachenko NP, Popovkina OE. [Possibilities of the low-intensity infrared laser therapy in atherosclerotic lesions of the cardiovascular system]. Vestn Ross Akad Med Nauk 2003:45-52. [PMID: 14724973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
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Basavaraju SR, Easterly CE. Pathophysiological effects of radiation on atherosclerosis development and progression, and the incidence of cardiovascular complications. Med Phys 2002; 29:2391-403. [PMID: 12408314 DOI: 10.1118/1.1509442] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Radiation therapy while important in the management of several diseases, is implicated in the causation of atherosclerosis and other cardiovascular complications. Cancer and atherosclerosis go through the same stages of initiation, promotion, and complication, beginning with a mutation in a single cell. Clinical observations before the 1960s lead to the belief that the heart is relatively resistant to the doses of radiation used in radiotherapy. Subsequently, it was discovered that the heart is sensitive to radiation and many cardiac structures may be damaged by radiation exposure. A significantly higher risk of death due to ischemic heart disease has been reported for patients treated with radiation for Hodgkin's disease and breast cancer. Certain cytokines and growth factors, such as TGF-beta1 and IL-1 beta, may stimulate radiation-induced endothelial proliferation, fibroblast proliferation, collagen deposition, and fibrosis leading to advanced lesions of atherosclerosis. The treatment for radiation-induced ischemic heart disease includes conventional pharmacological therapy, balloon angioplasty, and bypass surgery. Endovascular irradiation has been shown to be effective in reducing restenosis-like response to balloon-catheter injury in animal models. Caution must be exercised when radiation therapy is combined with doxorubicin because there appears to be a synergistic toxic effect on the myocardium. Damage to endothelial cells is a central event in the pathogenesis of damage to the coronary arteries. Certain growth factors that interfere with the apoptotic pathway may provide new therapeutic strategies for reducing the risk of radiation-induced damage to the heart. Exposure to low level occupational or environmental radiation appears to pose no undue risk of atherosclerosis development or cardiovascular mortality. But, other radiation-induced processes such as the bystander effects, abscopal effects, hormesis, and individual variations in radiosensitivity may be important in certain circumstances.
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Serruys PW, Sianos G, van der Giessen W, Bonnier HJRM, Urban P, Wijns W, Benit E, Vandormael M, Dörr R, Disco C, Debbas N, Silber S. Intracoronary beta-radiation to reduce restenosis after balloon angioplasty and stenting; the Beta Radiation In Europe (BRIE) study. Eur Heart J 2002; 23:1351-9. [PMID: 12191746 DOI: 10.1053/euhj.2001.3153] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIMS The BRIE trial is a registry evaluating the safety and performance of (90)Sr delivered locally (Beta-Cath TM system of Novoste) to de-novo and restenotic lesions in patients with up to two discrete lesions in different vessels. METHODS AND RESULTS In total, 149 patients (175 lesions) were enrolled; 62 treated with balloons and 113 with stents. The restenosis rate, the minimal luminal diameter and the late loss were determined in three regions of interest: (a) in a subsegment of 5mm containing the original minimal luminal diameter pre-intervention termed target segment; (b) the irradiated segment, 28 mm in length, and (c) the entire analysed segment, 42 mm in length, termed the vessel segment. Binary restenosis was 9.9% for the target segment, 28.9% for the irradiated segment, and 33.6% for the vessel segment. These angiographic results include 5.3% total occlusions. Excluding total occlusions binary restenosis was 4.9%, 25% and 29.9%, respectively. At 1 year the incidence of major adverse cardiac events placed in a hierarchical ranking were: death 2%, myocardial infarction 10.1%, CABG 2%, and target vessel revascularization 20.1%. The event-free survival rate was 65.8%. Non-appropriate coverage of the injured segment by the radioactive source termed geographical miss affected 67.9% of the vessels, and increased edge restenosis significantly (16.3% vs 4.3%, P=0.004). It accounted for 40% of the treatment failures. CONCLUSION The results of this registry reflect the learning process of the practitioner. The full therapeutic potential of this new technology is reflected by the restenosis rate at the site of the target segment. It can only be unravelled once the incidence of late vessel occlusion and geographical miss has been eliminated by the prolonged use of thienopyridine, the appropriate training of the operator applying this new treatment for restenosis prevention, and the use of longer sources.
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Affiliation(s)
- P W Serruys
- Department of Interventional Cardiology, Thoraxcenter, Heartcenter, Erasmus Medical Center, Academisch Ziekenhuis Dijkzigt Rotterdam, The Netherlands
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21
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Marshall PR. Preparing for the introduction of new technologies: who is going to pay for them? J Cardiovasc Manag 2002; 13:14-20. [PMID: 11828780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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22
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Patel NS, Chiu-Tsao ST, Tsao HS, Harrison LB. A new treatment planning formalism for catheter-based beta sources used in intravascular brachytherapy. Cardiovasc Radiat Med 2001; 2:157-64. [PMID: 11786322 DOI: 10.1016/s1522-1865(01)00083-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Intravascular brachytherapy (IVBT) is an emerging modality for the treatment of atherosclerotic lesions in the artery. As part of the refinement in this rapidly evolving modality of treatment, the current simplistic dosimetry approach based on a fixed-point prescription must be challenged by future rigorous dosimetry method employing image-based three-dimensional (3D) treatment planning. The goals of 3D IVBT treatment planning calculations include (1) achieving high accuracy in a slim cylindrical region of interest, (2) accounting for the edge effect around the source ends, and (3) supporting multiple dwell positions. The formalism recommended by Task Group 60 (TG-60) of the American Association of Physicists in Medicine (AAPM) is applicable for gamma sources, as well as short beta sources with lengths less than twice the beta particle range. However, for the elongated beta sources and/or seed trains with lengths greater than twice the beta range, a new formalism is required to handle their distinctly different dose characteristics. Specifically, these characteristics consist of (a) flat isodose curves in the central region, (b) steep dose gradient at the source ends, and (c) exponential dose fall-off in the radial direction. In this paper, we present a novel formalism that evolved from TG-60 in maintaining the dose rate as a product of four key quantities. We propose to employ cylindrical coordinates (R, Z, phi), which are more natural and suitable to the slim cylindrical shape of the volume of interest, as opposed to the spherical coordinate system (r, theta, phi) used in the TG-60 formalism. The four quantities used in this formalism include (1) the distribution factor, H(R, Z), (2) the modulation function, M(R, Z), (3) the transverse dose function, h(R), and (4) the reference dose rate at 2 mm along the perpendicular bisector, D(R0=2 mm, Z0=0). The first three are counterparts of the geometry factor, the anisotropy function and the radial dose function in the TG-60 formalism, respectively. The reference dose rate is identical to that recommended by TG-60. The distribution factor is intended to resemble the dose profile due to the spatial distribution of activity in the elongated beta source, and it is a modified Fermi-Dirac function in mathematical form. The utility of this formalism also includes the slow-varying nature of the modulation function, allowing for more accurate treatment planning calculations based on interpolation. The transverse dose function describes the exponential fall-off of the dose in the radial direction, and an exponential or a polynomial can fit it. Simultaneously, the decoupling nature of these dose-related quantities facilitates image-based 3D treatment planning calculations for long beta sources used in IVBT. The new formalism also supports the dosimetry involving multiple dwell positions required for lesions longer than the source length. An example of the utilization of this formalism is illustrated for a 90Y coil source in a carbon dioxide-filled balloon. The pertinent dosimetric parameters were generated and tabulated for future use.
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Affiliation(s)
- N S Patel
- Department of Radiation Oncology, Beth Israel Medical Center and St. Luke's-Roosevelt Hospital Center, 10 Union Square East, New York, NY 10003, USA
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Mitka M. Stent + radiation no sure cure for stenosis. JAMA 2001; 285:2069. [PMID: 11311078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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24
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Kozuma K, Costa MA, Sabaté M, Slager CJ, Boersma E, Kay IP, Marijnissen JP, Carlier SG, Wentzel JJ, Thury A, Ligthart JM, Coen VL, Levendag PC, Serruys PW. Relationship between tensile stress and plaque growth after balloon angioplasty treated with and without intracoronary beta-brachytherapy. Eur Heart J 2000; 21:2063-70. [PMID: 11102257 DOI: 10.1053/euhj.2000.2465] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIMS We investigated the influence of tensile stress on plaque growth after balloon angioplasty with and without beta-radiation therapy. METHODS AND RESULTS Thirty-one consecutive patients successfully treated with balloon angioplasty were analysed qualitatively and quantitatively by means of an ECG-gated three-dimensional intravascular ultrasound post-procedure and at follow-up. Eighteen patients were irradiated with catheter-based beta-radiation ((90)Sr/(90)Y source) and 13 were not (control). Studied segments were divided into 2 mm subsegments. Thus 184 irradiated and 111 non-irradiated subsegments were included. Tensile stress was calculated according to Laplace's law. The radiation dose was calculated by means of dose-volume histograms. Plaque growth was positively correlated to tensile stress in both the radiation and control groups (r=0.374, P=0.0001 and r=0.305, P=0.001). Low-dose subsegments (<6 Gy) had a significant correlation (r=0.410, P=0.0001) whereas no correlation was observed in the effective-dose subsegments (> or = 6 Gy). Multivariate analysis identified tensile stress as the only independent predictor of plaque increase in non-irradiated subsegments, whereas actual dose and plaque morphology were stronger predictors in irradiated subsegments. CONCLUSION The results of this study suggest that plaque growth is related to tensile stress after balloon angioplasty. Intracoronary brachytherapy may alter the biophysical process on plaque growth when the prescribed dose is effectively delivered.
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Affiliation(s)
- K Kozuma
- Department of Interventional Cardiology, Thoraxcenter, University Hospital Dijkzigt Rotterdam and Erasmus University, The Netherlands
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25
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Nath R, Amols H, Coffey C, Duggan D, Jani S, Li Z, Schell M, Soares C, Whiting J, Cole PE, Crocker I, Schwartz R. Intravascular brachytherapy physics: report of the AAPM Radiation Therapy Committee Task Group no. 60. American Association of Physicists in Medicine. Med Phys 1999; 26:119-52. [PMID: 10076966 DOI: 10.1118/1.598496] [Citation(s) in RCA: 238] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Recent preclinical and clinical studies indicate that irradiation using ionizing radiation in the dose range of 15 to 30 Gy may reduce the occurrence of restenosis in patients who have undergone an angioplasty. Several delivery systems of intravascular brachytherapy have been developed to deliver radiation doses in this range with minimal normal tissue toxicity. In late 1995 the American Association of Physicists in Medicine (AAPM) formed a task group to investigate these issues and to report the current state of the art of intravascular brachytherapy physics. The report of this task group is presented here.
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Affiliation(s)
- R Nath
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut 06510, USA.
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Carlier SG, Marijnissen JP, Coen VL, van der Giessen WJ, Sabate M, Ligthart J, den Boer A, Céspedes IE, Li W, van der Steen AF, Levendag PC, Serruys PW. Guidance of intracoronary radiation therapy based on dose-volume histograms derived from quantitative intravascular ultrasound. IEEE Trans Med Imaging 1998; 17:772-778. [PMID: 9874301 DOI: 10.1109/42.736033] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Application of ionizing radiation to prevent restenosis in atherosclerotic vessels treated by balloon angioplasty is a new treatment under investigation in interventional cardiology and radiology. There is variability in dose prescription, and both gamma- and beta-emitters are used, leading to a wide range of dose distribution over the arterial vessel wall. We present a new modality of dosimetry based on a method that three-dimensional (3-D) image reconstruction of electrocardiogram (ECG)-gated intravascular ultrasound (IVUS) images. Dose volume histograms (DVH) are used to describe the cumulative distribution of dose over two specific volumes: i) at the level of the luminal surface, defined with a thickness of 0.1 mm from the automatically detected contour of the highly echogenic blood-vessel interface, and ii) the adventitia volume is computed considering a 0.5-mm thickness from the echogenic media-adventitia interface. DVH provide a tool for reporting the actual delivered dose at the site believed to be the target: the adventitia, and to detect excessive radiation which could lead to vascular complications. Simulation of a gamma-emitter or of a radioactive source train in the center of the lumen are possible. The data obtained from the first ten patients included in the beta-irradiation trial (BERT 1.5) conducted in our institution are presented, supporting the use of DVH based on quantitative IVUS measurements for optimal dose prescription in vascular interventional radiation therapy.
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Affiliation(s)
- S G Carlier
- Department of Intervention Cardiology, Thoraxcentre, Erasmus University Rotterdam, The Netherlands.
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27
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Noël G, Feuvret L, Bourhis J, Pousset F, Gerbaulet A, Popowski Y, Mazeron JJ. [Role of intravascular brachytherapy in the prevention of vascular restenosis after angioplasty]. Cancer Radiother 1998; 2:325-37. [PMID: 9755746 DOI: 10.1016/s1278-3218(98)80344-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
About 30% of patients who underwent percutaneous transluminal coronary angioplasty show evidence of restenosis, which appears to be independent of the angioplasty method used. The restenosis is due of two factors, firstly migration of smooth vascular muscle cells of the vascular media to the intima and multiplication which lead to the formation of a neo-intima. Irradiation limits the proliferation by acting of the cells in the mitotic stage. The vascular target volume is not very thick and is difficult to define it, that why brachytherapy seems to be the best procedure to prevent restenosis. However, the development of this treatment present many difficulties. Different irradiation techniques have been studied. Such techniques include catheter containing radioactive sealed source, radioactive stent, or balloon containing radioactive liquid inside. Each of these methods have their own advantages, inconveniences, problems and risks. Radioisotope may be either beta or gamma emitters. Gamma emitter presents problems for radioprotection but the satisfactory dose distribution may be difficult to obtain using beta emitter. Choice of dose, dose rate and delay between the end of angioplasty and the beginning of brachytherapy is subject to some discuss. Animal experiments using radioisotope have shown reduction in cell proliferation. Human trials showed feasibility, safety of the method and real impact on restenosis prevention. However, long-term efficacy has not been proved because the follow-up of the patients is too short. A randomized trial of 192Ir brachytherapy for prevention of restenosis has recently shown the efficacy in short and median term. However, long term efficiency and secondary effects have not yet been established as the follow up time of this study is still too short. That is why, collaboration between cardiologists and radiotherapists and physicists is indispensable to enable the development of an optimal technique.
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Affiliation(s)
- G Noël
- Centre des tumeurs, hôpital de la Pitié-Salpêtrière, Paris, France
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28
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Bertrand OF, Mongrain R, Lehnert S, Bilodeau L, Tanguay JF, Laurier J, Côté G, Bourassa MG. Intravascular radiation therapy in atherosclerotic disease: promises and premises. Eur Heart J 1997; 18:1385-95. [PMID: 9458443 DOI: 10.1093/oxfordjournals.eurheartj.a015463] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- O F Bertrand
- Interventional Cardiology Laboratories, Montreal Heart Institute, Quebec, Canada
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29
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Weinberger J, Simon AD. Intracoronary irradiation for the prevention of restenosis. Curr Opin Cardiol 1997; 12:468-74. [PMID: 9352174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Restenosis after coronary angioplasty is a major limitation of an otherwise highly effective and safe procedure for the treatment of atherosclerotic coronary artery disease. Although the advent of coronary stenting has reduced restenosis rates for selected patients, an overall restenosis rate of 20% to 25% remains. Despite numerous trials, no effective pharmacologic therapy has been found. Intracoronary irradiation is a new technique proposed to prevent restenosis after angioplasty. In animal models of restenosis after balloon injury, there is marked reduction of neointimal proliferation when the injured vessel is irradiated, using a variety of radiation sources and delivery systems. Early human trials have underscored the importance of careful source calibration and dosimetry. A small, randomized, double-blind, placebo-controlled study of intracoronary irradiation to prevent recurrent restenosis recently reported striking reductions in angiographic restenosis as well as clinical event rates. A number of important issues remain unresolved, such as defining which component of the arterial wall serves as the target tissue for radiation, the minimal effective dose, the maximum tolerable dose, and user-friendly radiation delivery systems. Further studies are needed to define the safety, efficacy and the ultimate usefulness of intracoronary irradiation as an adjunct to current procedures in interventional cardiology.
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Affiliation(s)
- J Weinberger
- Interventional Cardiology Center, Columbia-Presbyterian Medical Center, New York, NY 10032, USA
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30
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Popowski Y, Verin V, Papirov I, Nouet P, Rouzaud M, Grob E, Schwager M, Urban P, Rutishauser W, Kurtz JM. High dose rate brachytherapy for prevention of restenosis after percutaneous transluminal coronary angioplasty: preliminary dosimetric tests of a new source presentation. Int J Radiat Oncol Biol Phys 1995; 33:211-5. [PMID: 7642421 DOI: 10.1016/0360-3016(95)00107-a] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE Balloon dilatation of coronary artery stenosis has become a standard treatment of atherosclerotic heart disease. Restenosis due to excessive intimal cell proliferation, which subsequently occurs in 20-50% of patients, represents one of the major clinical problems in contemporary cardiology, and no satisfactory method for its prevention has thus far been found. Because modest doses of radiation have proved effective in preventing certain types of abnormal cellular proliferation resulting from surgical trauma, and brachytherapy has already been used successfully after dilation of peripheral arteries, development of a radioactive source suitable for coronary artery applications would be of great interest. METHODS AND MATERIALS Nonradioactive flexible yttrium-89 wires (diameter of 0.15 and 0.26 mm) were activated within the thermal neutron flux of an experimental reactor. Standard angioplasty balloons (2 cm long, 2.5 mm in diameter when inflated) were inserted for dosimetry into a specially manufactured tissue equivalent phantom. Four wells, drilled perpendicular to the axis of the balloon, allowed for the insertion of thermal luminescent dosimeters (TLDs; 2 mm of diameter) and spacers. The angioplasty balloon was inflated with air or with contrast media. Radioactive yttrium-90 wires were left in the central lumen of the balloon for 2 min. Doses at the surface of the balloon, and at 1, 2, and 3 mm were determined from TLD readings. RESULTS Doses obtained at the surface of the balloon, for a 2-min exposure for the 0.26 mm wire (balloon inflated with air) and the 0.15 mm wire (air or contrast), were 56.5 Gy, 17.8 Gy, 5.4 Gy, respectively. As expected for a beta emitter, the fall-off in dose as a function of depth was rapid. External irradiation from the beta source was negligible. CONCLUSIONS Our experiments indicate that the dose rates attainable at the surface of the angioplasty balloon using this technique allow the doses necessary for the inhibition of intimal cell proliferation to be reached within a relatively short period of time. The thin yttrium-90 wires are very easy to handle, and their mechanical and radioactive properties are well suited to the requirements of the catheterization procedure.
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Affiliation(s)
- Y Popowski
- Radiation Oncology Division, University Hospital, Geneva, Switzerland
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31
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Korochkin IM, Kartelishev AV, Leshakov SI, Kapustina GM, Vernekina NS. [Clinico-pathochemical substantiation of the exacerbation phenomenon in patients with ischemic heart disease during treatment with the helium-neon laser]. Kardiologiia 1988; 28:72-5. [PMID: 3199659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Some pathochemical mechanisms of coronary disease aggravation in the course of laser therapy were assessed by means of the measurement of erythrocyte membrane lipids and phospholipids as well as plasma alpha-tocopherol and diene conjugate levels. The aggravation was associated with an activation of metabolic processes aiming to produce regeneration of membrane structures. The regeneration takes place in the presence of chronic deficiency of total phospholipids and inadequate antioxidant protection of biomembranes, therefore complete stabilization and normalization of their composition and activity is impossible.
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Opolski G, Kasprzak J, Słomka K. [Effect of laser irradiation on arteriosclerotic changes in coronary arteries. Preliminary report]. Pol Arch Med Wewn 1987; 77:83-6. [PMID: 3275393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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