CASE REPORTS

Complex Transradial Three Vessel Brachytherapy in a Single Session

Olivier F. Bertrand, MD, PhD, Robert De Larochellière, MD, *Michel Tessier, MD, MSc
Olivier F. Bertrand, MD, PhD, Robert De Larochellière, MD, *Michel Tessier, MD, MSc
Treatment of in-stent restenosis using catheter-based brachytherapy is an effective treatment modality. Several international randomized trials have established the safety and efficacy of different systems and isotopes.1–3 Although patients with relatively short lesions have been initially recruited in these trials, the treatment of long and very long in-stent restenosis with brachytherapy has already been reported.4 We have already described our initial experience using the Novoste Beta-Rail™ system and a transradial approach.5 In this report, we discuss the case of a patient who presented with severe in-stent restenosis in 3 different vessels and was treated by transradial vascular brachytherapy during a single session. Case Report. A 43-year-old woman was initially treated for post-myocardial infarction angina by multivessel stenting, which was performed by a right transradial approach. At that time, she received three stents (NIR stents, Boston Scientific/Scimed, Maple Grove, Minnesota, 2.5 x 31 mm, 3.0 x 25 mm and 3.5 x 12 mm) in the left anterior descending artery (LAD): one stent in the 2d marginal branch (BX Velocity, Cordis Corporation, Miami Lakes, Florida, 2.25 x 18 mm), one stent in distal circumflex artery (BX Velocity, Cordis Johnson & Johnson 2.25 x 18 mm) and one stent (BX Velocity, Cordis Corporation, 2.25 x 18 mm) in the proximal right coronary artery (RCA). Angiographic success was obtained in all four vessels after high-pressure stent deployment. About 4 months later, she noticed a recurrence of her symptoms which rapidly progressed to rest angina. Repeat catheterization was scheduled. Control angiography showed subtotal occlusion of the stents implanted in the LAD with severe diffuse in-stent restenosis in the 2d Mg branch and in the distal Cx artery (Figures 1A and 2A). In addition, a new lesion was present on the origin of the 2d Mg branch (Figure 2A). No in-stent restenosis was noted in the proximal RCA, and left ventricular function was normal with mild anterolateral hypokinesia. She was initially referred for bypass surgery, but the cardiac surgeons refused to operate due to the impossibility of grafting the distal LAD. Since no other option could be offered, she was accepted for multivessel brachytherapy and signed the required informed consent. Following our standard procedure, a 7 French (Fr) sheath was inserted in the left radial artery and the left main stem was cannulated using an EBU 3.5 7 Fr guiding catheter (Zuma II, Medtronic, Minneapolis, Minnesota). A bolus of Abciximab (Reopro, Eli-Lilly, Indianapolis, Indiana) was given intracoronary and a perfusion was started. Using a Choice-PT (Boston Scientific/Scimed) guidewire, we crossed the subtotal lesion of the LAD. Intravascular ultrasound (IVUS) examination (Atlantis 40 MHz, Boston Scientific) revealed diffuse neointimal formation with a minimal stent area (MSA) of 2.4 mm2 for the distal stent. Distally, the lumen was Discussion. Catheter-based brachytherapy is now frequently used as a therapeutic option for treatment of in-stent restenosis. Following positive results of multiple randomized trials, regulatory authorities, throughout the world, have authorized systems using g and b isotopes. The majority of clinical trials have included short lesions, although more recently, effectiveness has also been demonstrated with longer lesions.4,6 Given the incidence of multivessel stenting during the same procedure, it is likely that some patients will present with in-stent restenosis in separate vessels. If we consider the costs associated with vascular brachytherapy, it is more cost-effective to treat such patients in a single session. Indeed, in this case report, we used the same delivery catheter for the 3 vessels. It should be emphasized, though, that the procedure time was prolonged and required prolonged fluoroscopy time as well as high-contrast volume. This implies that not all patients could undergo such complex procedures at the same time. This case also illustrates some specific problem that a cardiac surgeon might face when a patient has received multiple stents to entirely reconstruct a coronary artery, especially the LAD.7 Certainly, the long-term follow-up of such multi-vessel brachytherapy is required to definitively establish the maintained efficacy and safety of that catheter-based therapeutic option. In conclusion, a patient presenting with multivessel in-stent restenosis underwent successful transradial brachytherapy during a single session. Follow-up angiography showed persistence of the initial results.
References
1. Leon MB, Teirstein PS, Moses JW, et al. Localized intracoronary gamma-radiation therapy to inhibit the recurrence of restenosis after stenting. N Engl J Med 2001;344:250–256. 2. Popma JJ, Suntharaligam M, Lansky AJ, et al. Randomized trial of 90 Sr/90 Y beta-radiation versus placebo control for treatment of in-stent restenosis. Circulation 2002;106:1090–1096. 3. Waksman R, Ajani AE, White RL, et al. Two-year follow-up after beta and gamma intracoronary radiation therapy for patients with diffuse in-stent restenosis. Am J Cardiol 2001;88:425–428. 4. Ahmed JM, Mintz GS, Waksman R, et al. Serial intravascular ultrasound analysis of the impact of lesion length on the efficacy of intracoronary gamma-irradiation for preventing recurrent in-stent restenosis. Circulation 2001;103:188–191. 5. Bertrand OF, De Larochellière R, Gleeton O, et al. Trans-radial coronary brachytherapy using the Novoste Beta-Rail system. Cathet Cardiovasc Intervent 2002;55:362–366. 6. Ahmed JM, Mintz GS, Waksman R, et al. Serial intravascular ultrasound assessment of the efficacy of intracoronary gamma-radiation therapy for preventing recurrence in very long, diffuse, in-stent restenosis lesions. Circulation 2001;104:856–859. 7. Pfister AJP. Coronary artery endarterectomy for extensive in-stent restenosis. http://www.ctsnet.org\section/videogallery