Vascular Brachytherapy and the Strontium90 Vascular Brachytherapy System
Restenosis remains a vexing problem in patients undergoing percutaneous coronary interventions (PCI). This phenomenon is related to a combination of events, including elastic recoil, negative remodeling and fibrointimal tissue proliferation. While stenting (bare metal and drug eluting) has made a dramatic impact in preventing recoil and remodeling, restenosis still occurs. Once restenosis occurs, it presents its own set of challenges due to the excess tissue proliferation. Major predicators of restenosis include diabetes, small stent diameter and long stented lesions. Vascular brachytherapy is the only proven therapy associated with a significant reduction in angiographic restenosis and the need for target vessel revascularization for the treatment of in-stent restenosis.
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Long-Term Outcome of Percutaneous Coronary Interventions Following Failed Beta-Brachytherapy
Brachytherapy was originally administered for in-stent restenosis in 43 patients, and for de novo lesions in 77 patients. Restenotic post-brachytherapy lesions were classified as restenosis within the irradiated segment in 55 patients (56.7%), edge-restenosis in 21 patients (21.6%) and late total occlusion in 21 patients (21.6%). Long-term outcome of patients treated with repeat percutaneous coronary intervention after failure of gamma-brachytherapy for the treatment of in-stent restenosis...
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Late Stent Thrombosis in Brachytherapy: The Role of Long-term Antiplatelet Therapy
Advances in percutaneous coronary intervention (PCI) have emerged in the past decade. Stenting has improved upon the limitations of angioplasty, acute vessel closure and restenosis by providing mechanical vascular support, resulting in sustained clinical and angiographic benefit. This has led to greater utilization of the technique, although it is associated with a significant incidence of in-stent restenosis. Neointimal hyperplasia is the pathophysiologic process that leads to in-stent restenosis. Brachytherapy can be effective in reducing the occurrence of this process. Unfortunately, brachytherapy trials have identified the phenomenon of late stent thrombosis as a potentially serious complication of this procedure. Late stent thrombosis is thrombosis that occurs > 30 days after PCI. The risk of thrombosis is increased in patients receiving a new stent in addition to brachytherapy. It also appears to be increased when adjunctive antiplatelet therapy with ticlopidine or clopidogrel is discontinued early. Strategies to prevent late stent thrombosis include the prolonged use of combination antiplatelet therapy in addition to limited placement of new stents in patients treated with brachytherapy for in-stent restenosis.
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Combination Antiplatelet Therapy Following Brachytherapy with Restenting: ?It Ain?t Over ?til the Fat Lady Sings?
Figure 5 Left anterior oblique selective right coronary angiogram following right coronary artery restenting and brachytherapy. Figure 7 Left anterior oblique selective right coronary angiogram performed 31 months following brachytherapy demonstrates a thrombotic occlusion (arrow) of the proximal dominant right coronary artery in the zone of prior brachytherapy with restenting. In conclusion, we concur with the recommendation of Drs.
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Debulking for In-Stent Restenosis in the Brachytherapy Era: Does it Still Have a Role?
Despite the advent of intracoronary brachytherapy, treatment of in-stent restenosis, particularly diffuse in-stent restenosis, remains problematic. Adjunctive debulking prior to brachytherapy may improve long-term outcomes. We review the literature and report our results of a series of patients treated with excimer laser coronary atherectomy along with balloon angioplasty and brachytherapy for in-stent restenosis. We conclude that adjunctive debulking may improve the long-term clinical outcomes of patients with diffuse in-stent restenosis treated with angioplasty and intracoronary radiation. A randomized controlled trial is warranted.
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Poor Outcome in Patients Treated with Brachytherapy for Diffuse In-Stent Restenosis. The Role of Additional Stenting Despite Prolonged Antiplatelet Therapy
Background. Brachytherapy (IBT) has been the first effective treatment of in-stent restenosis (ISR). However, when IBT is associated with additional stenting, high rates of late thrombosis have been observed. Even though prolongation of a double antiplatelet therapy seems to have overcome this problem, studies analyzing whether additional stenting still remains a negative prognostic factor for restenosis are lacking. Aim. To evaluate outcomes of patients treated for ISR with or without additional stenting and IBT followed by prolonged antiplatelet therapy. Methods. Seventy-seven consecutive patients treated with beta radiation in 89 lesions with ISR were analyzed according to the need for deploying additional stents: 73 lesions were treated without additional stents (Group 1) and 16 lesions with one or more new stents (Group 2) because of suboptimal results or flow-limiting dissections. Double antiplatelet therapy was administered for 12 months. An angiographic follow-up was scheduled after 6 months. P-values < 0.05 were considered significant. Results. Restenosis rates were 31.5% (23/73) and 62.5% (10/16) in Group 1 (G1) and Group 2 (G2), respectively (p = 0.02). The two groups did not differ for late vessel thrombosis (8 in G1 and 2 in G2). In G2, high rates of recurrence were observed in the additional stent (6/16, 37.5%; p = 0.02 versus edge restenosis and in old stent recurrence in both G1 and G2). Conclusions. The association of additional stenting with brachytherapy in treatment of ISR is characterized by poor outcomes, even if a prolonged antiplatelet therapy has been administered. These results are related to high restenosis rates observed in the additional stent.
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Differential Outcome after Intracoronary Radiation Therapy Is Related to a Simple Classification Based on Lesion Length and Reference Diameter
Objective. We sought to develop a prognostic lesion classification based on simple angiographic parameters, lesion length and reference diameter that predicts differential outcome in patients undergoing intracoronary radiation. Methods and Results. Three types of lesions were identified: Type A characterized by lesion length <= 30 mm, reference diameter > 2.5 mm to <= 4.0 mm (short lesion: ?normal? diameter), Type B by lesion length <= 30 mm, reference diameter <= 2.5 mm or > 4 mm (short lesion: ?extreme? diameter), and Type C by lesion length > 30 mm (long lesion). A total of 1,151 lesions (77.7% in-stent restenosis) in 1,098 consecutive patients undergoing brachytherapy were classified into these 3 lesion types. Overall, 79.9%, 10.3 % and 9.8 % patients met the criteria for Type A, B and C lesions. While the in-hospital major adverse cardiac event (MACE) rate was 1.4%, 3.6% and 3.8% (p = 0.026), the 6-month MACE rate was 16.1%, 22.5% and 32.1% (p < 0.001), the angiographic restenosis rate was 21.3%, 32.4% and 42.4% (p < 0.001), and the late thrombosis rate was 4.1%, 9.0% and 11.3%, (p < 0.001) in Type A, B and C lesions, respectively. Consequently, with increasing lesion severity, 3 risk groups with low, medium and high risk were defined. Multivariate analysis showed that Type B and C lesions were independent predictors of 6-month MACE (OR, 1.5 and 1.9, respectively). Conclusion. The proposed novel and easily applicable lesion classification effectively predicts early and medium term outcome, and may be used for appropriate therapeutic decision making in patients undergoing brachytherapy.
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CME Offering: Vascular Brachytherapy: A New Approach to Renal Artery In-Stent Restenosis
CME Offering: Vascular Brachytherapy: A New Approach to Renal Artery In-Stent Restenosis Feature: CME Offering: Vascular Brachytherapy: A New Approach to Renal Artery In-Stent Restenosis - Christopher D. Jahraus, MD and Ali S. Meigooni, PhD Learning objectives. 228 Key words: angioplasty, vascular brachytherapy, endovascular, radiotherapy, renal artery stenosis, stent Introduction Since the time of its introduction in 1978, percutaneous transluminal renal angioplasty (PTRA) has evolved into ...
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Results of Intracoronary b-Brachytherapy Administered by 60 mm Transfer Device/Radiation Source Train: A Subgroup Analysis from the RENO Registry
Objective. To investigate the safety and efficacy of a 60 mm transfer device, delivering 60 mm radiation source train, in the treatment of coronary lesions by b-brachytherapy employing the BetaCath? system (Novoste, Norcross, Georgia). Methods and Results. As part of the REgistry NOvoste (RENO), the first large-scale registry of intracoronary b-radiation applied in routine clinical practice, forty-six centers registered 1,098 consecutive patients undergoing brachytherapy with the BetaCath system. Of these, 49 patients with 56 lesions were treated with a 60 mm transfer device/radiation source train (TD/RST) in at least 1 vessel, constituting the study population. With 75.4% in-stent restenosis (ISR), 3.6% graft lesions, long lesions (30.9 ± 14.7 mm) and 19% diabetes, the cohort had a high-risk for recurrence. The in-hospital major adverse cardiac event (MACE) rate was 4.1%. The 6-month follow-up revealed 2.0% death, 4.1% myocardial infarction, 8.2% target vessel revascularization, 12.2% MACE, 82.6% improved angina, 16.7% binary restenosis and 4.1% late thrombosis. The results were comparable to all other patients in the registry treated with standard source lengths of 30 mm and 40 mm, although much longer lesions were treated by the 60 mm device (18.4 ± 11.3 mm versus 30.9 ± 14.7 mm; p < 0.0001). In the ISR subgroup (mean lesion length, 32.03 ± 14.99 mm), the 6-month MACE rate was 12.8%, while the angiographic restenosis rate was 16.0% and the late thrombosis rate was 2.6%. Conclusion. b-brachytherapy with 60 mm TD/RST was safe, feasible and effective in this broad population of high-risk patients presenting in day-to-day practice. Its efficacy in long-segment ISR, where conventional interventional strategies have poor outcome rates, is particularly noteworthy.
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Brachytherapy for Rental Artery In-Stent Restenosis
ABSTRACT: Percutaneous transluminal angioplasty with stenting is now an established modality for treatment of atherosclerotic renal artery stenosis. However, the rate of restenosis can be as high as 20%. While intravascular brachytherapy has proven efficacy in coronary artery in-stent stenosis, its role in the treatment of renal artery in-stent stenosis is not well understood. We report a case of recurrent in-stent renal artery stenosis treated successfully by brachytherapy with excellent follow up results at 22 months.
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 Electrophysiologic Perspective on the BIPOLAR RF EPICARDIAL ABLATION Procedure for Atrial Fibrillation
Complimentary Accredited Breakfast Symposium
Click Here for More Info.
Location: The St. Regis San Francisco
125 3rd Street
San Francisco, CA 94103
3rd and Mission Streets
Gallery Ballroom, 2nd floor
This activity is supported by an educational grant from AtriCure, Inc.
This program is not part of the Heart Rhythm 2008 Official Scientific Sessions as planned by the Heart Rhythm Society Scientific Sessions Committee. This event is neither sponsored nor endorsed by the Heart Rhythm Society.
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 Newest Perspectives on Drug-Eluting Stents
Complimentary CME Accredited Dinner Meetings Click Here for More Info.
Miami, FL - Date: Friday, April 4, 2008 6:00pm EST -8:00 pm EST
Birmingham, AL - Date: Friday, May 9, 2008 6:00pm EST -8:00 pm EST
This activity is supported by an educational grant from Abbott Vascular.
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 CLINICAL EXPERIENCE WITH A NEW HYBRID CORONARY WIRE
On Demand Web Archive
Non-Accredited
This activity is supported by an educational grant from Terumo Medical Corporation.
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 Pharmacoinvasive Management of Acute Coronary Syndrome: Incorporating the 2007 ACC/AHA Guidelines
Complimentary Accredited CME Program
This activity is supported by an educational grant from Sanofi-Aventis.
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 Varicose Veins: Causes, Symptoms, Diagnosis and Treatment of Chronic Venous Insufficiency
A Complimentary Accredited ON-DEMAND Webcast
This activity is supported by an educational grant from Diomed, Inc.
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 Create a Successful Vena Cava Filter Practice
Accredited CD
This activity is supported by an educational grant from Cook Incorporated and has been designed for Interventional Cardiologists, Vascular Surgeons, Fellows and Interventional Cardiovascular Nurses and Technologists.
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Webcast and Web Archives |
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 Achieving Optimal Outcomes in Carotid Stenting: Lessons Learned from Recent Clinical Trials
Complimentary Accredited ON DEMAND Webcast
Topics
1. EVA-3S & Space-Bumps in the road
2. CAPTURE 3500-Lesion morphology & Predictors for Stroke
3. CAPTURE II vs. EXACT 1500-Does open or Closed Cell Stent design really matter?
This activity has been developed for Interventional Cardiologists, Vascular Surgeons, Interventional Radiologists, Neurologists, Interventional Nurses and Technologists with an interest in the diagnosis and treatment of peripheral artery disease. |
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 Anticoagulation Techniques for Peripheral Vascular Interventions
Complimentary Accredited ON DEMAND Webcast
This activity has been developed for Interventional Cardiologists, Vascular Surgeons, Interventional Radiologists, Podiatric Physicians, Endovascular Allied Professionals, Endocrinologists, Wound Care Specialists, Directors of the Wound Care Clinic, and Primary Care Physicians, Pharmacists, Nurses and Technologists.
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 New Treatment Strategies for the Endovascular Approach to Critical Limb Ischemia: ADVANCEMENTS IN LIMB SALVAGE MEDICINE
Complimentary Accredited ON DEMAND Webcast
This activity has been developed for Interventional Cardiologists, Vascular Surgeons, Interventional Radiologists, Podiatric Physicians, Endovascular Allied Professionals, Endocrinologists, Wound Care Specialists, Directors of the Wound Care Clinic, and Primary Care Physicians, Pharmacists, Nurses and Technologists.
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 Reducing the Incidence of CIN during Cardiac Catheterization and PCI
Complimentary Accredited ON DEMAND
Educational Web Archive
This activity has been developed for nurses and technologists. |
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March 2007 Supplement
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On-Demand Webcast
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Archived Webcast
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Release Date: December 8, 2006