Long-Term Outcome of Percutaneous Coronary Interventions
Long-Term Outcome of Percutaneous Coronary Interventions
Background: Recurrent restenosis following vascular brachytherapy (VBT) has been reported in up to one-third of the patients enrolled in clinical trials. The long-term outcome of repeat percutaneous intervention (PCI) after failed beta-brachytherapy is currently unknown.
Methods: We retrospectively analyzed 97 consecutive patients undergoing percutaneous coronary reintervention after failed beta-brachytherapy at our institution (80.8% of all brachytherapy failures). Long-term incidence of major adverse cardiac events (MACE; death, myocardial infarction, target lesion revascularization) was assessed.
Results: The procedure was successful in 90 patients (92.8%). A new stent was implanted in 72% of the procedures (sirolimus-eluting stent in 16.5%). After 3 years, survival was 94.3%, survival-free from myocardial infarction was 86.7% and MACE-free survival was 66.1%. No difference was observed in MACE-free survival between patients originally treated with brachytherapy for recurrent in-stent restenosis and patients receiving irradiation for de novo lesions (68.2% de novo group versus 61.2% ISR group; p = 0.6 by log rank test). Overall, a second target lesion revascularization was performed in 27 patients (27.8%) after an average of 11.2 ± 11.2 months; 21 patients (21.6%) had restenosis, and 6 (6.2%) developed late total vessel occlusion (related to acute myocardial infarction in 2 cases).
Conclusion: Repeat PCI is the most common choice after failed brachytherapy. This strategy appears to be a reasonable therapeutic option for this complex iterative pathology.
Ionizing radiation has been shown to reduce neointimal formation after balloon angioplasty through the reduction of vascular smooth muscle cell proliferation and positive vessel remodeling. Although coronary vascular brachytherapy (VBT) for prevention of restenosis in de novo lesions is controversial, it represents the gold standard treatment for diffuse in-stent restenosis (ISR). However, in clinical trials, brachytherapy failure (angiographic restenosis and target lesion revascularization) has been reported in a consistent number of patients, with a slow but progressive increase over long-term follow-up. Although in this clinical setting bypass surgery may represent a more definitive choice of treatment, repeat percutaneous coronary intervention (PCI) remains an appealing strategy.
Recently, two studies reported the outcome of repeat PCI in patients after failure of gamma-brachytherapy in the GAMMA and the WRIST trials. They showed that the pattern of recurrent restenosis was predominantly focal. In these studies, percutaneous reintervention was accomplished safely, but in up to one-third of the patients a repeat reintervention was necessary during follow-up.
Beta-radiation, in contrast with gamma, has limited penetration and does not require modifications to the standard shielding used in the catheterization laboratory. As a result, beta-sources became the most widely used type of vascular brachytherapy. Nevertheless, there is no specific information in the literature regarding the outcome of patients who failed beta-brachytherapy. The process of restenosis after coronary irradiation is still not entirely understood, and a possible different vascular response to percutaneous treatment following beta- and gamma-radiation cannot be ruled out a priori.
The aim of this study was therefore to assess the long-term clinical outcome of patients who underwent percutaneous revascularization for restenosis following intracoronary beta-brachytherapy with catheter-based techniques.
Background: Recurrent restenosis following vascular brachytherapy (VBT) has been reported in up to one-third of the patients enrolled in clinical trials. The long-term outcome of repeat percutaneous intervention (PCI) after failed beta-brachytherapy is currently unknown.
Methods: We retrospectively analyzed 97 consecutive patients undergoing percutaneous coronary reintervention after failed beta-brachytherapy at our institution (80.8% of all brachytherapy failures). Long-term incidence of major adverse cardiac events (MACE; death, myocardial infarction, target lesion revascularization) was assessed.
Results: The procedure was successful in 90 patients (92.8%). A new stent was implanted in 72% of the procedures (sirolimus-eluting stent in 16.5%). After 3 years, survival was 94.3%, survival-free from myocardial infarction was 86.7% and MACE-free survival was 66.1%. No difference was observed in MACE-free survival between patients originally treated with brachytherapy for recurrent in-stent restenosis and patients receiving irradiation for de novo lesions (68.2% de novo group versus 61.2% ISR group; p = 0.6 by log rank test). Overall, a second target lesion revascularization was performed in 27 patients (27.8%) after an average of 11.2 ± 11.2 months; 21 patients (21.6%) had restenosis, and 6 (6.2%) developed late total vessel occlusion (related to acute myocardial infarction in 2 cases).
Conclusion: Repeat PCI is the most common choice after failed brachytherapy. This strategy appears to be a reasonable therapeutic option for this complex iterative pathology.
Ionizing radiation has been shown to reduce neointimal formation after balloon angioplasty through the reduction of vascular smooth muscle cell proliferation and positive vessel remodeling. Although coronary vascular brachytherapy (VBT) for prevention of restenosis in de novo lesions is controversial, it represents the gold standard treatment for diffuse in-stent restenosis (ISR). However, in clinical trials, brachytherapy failure (angiographic restenosis and target lesion revascularization) has been reported in a consistent number of patients, with a slow but progressive increase over long-term follow-up. Although in this clinical setting bypass surgery may represent a more definitive choice of treatment, repeat percutaneous coronary intervention (PCI) remains an appealing strategy.
Recently, two studies reported the outcome of repeat PCI in patients after failure of gamma-brachytherapy in the GAMMA and the WRIST trials. They showed that the pattern of recurrent restenosis was predominantly focal. In these studies, percutaneous reintervention was accomplished safely, but in up to one-third of the patients a repeat reintervention was necessary during follow-up.
Beta-radiation, in contrast with gamma, has limited penetration and does not require modifications to the standard shielding used in the catheterization laboratory. As a result, beta-sources became the most widely used type of vascular brachytherapy. Nevertheless, there is no specific information in the literature regarding the outcome of patients who failed beta-brachytherapy. The process of restenosis after coronary irradiation is still not entirely understood, and a possible different vascular response to percutaneous treatment following beta- and gamma-radiation cannot be ruled out a priori.
The aim of this study was therefore to assess the long-term clinical outcome of patients who underwent percutaneous revascularization for restenosis following intracoronary beta-brachytherapy with catheter-based techniques.
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