Use of intracoronary radiation to prevent restenosis
- Bruce D Klugherz, MD
Bruce D Klugherz, MD
- Medical Director, Cardiac Catheterization Laboratory
- Abington Memorial Hospital, Abington, PA
- Daniel M Kolansky, MD
Daniel M Kolansky, MD
- Associate Professor of Medicine
- University of Pennsylvania School of Medicine
Restenosis has been the principal limitation to the long-term success of percutaneous coronary revascularization. The rate of angiographic restenosis following balloon angioplasty alone (defined as 50 percent or greater reduction in luminal diameter at follow-up angiography) is 40 to 50 percent . About half of the patients with angiographic restenosis manifest clinical restenosis with recurrent ischemia that leads to repeat revascularization of the targeted vessel .
Intracoronary stents, by virtue of their ability to prevent elastic recoil and constrictive remodeling, initially reduced the frequency of angiographic restenosis to approximately 20 percent and the need for repeat revascularization to approximately 10 to 12 percent (figure 1) [3,4]. Even better results have been obtained with drug-eluting stents, which are the stents of choice for most coronary interventions currently (figure 2). (See "Drug-eluting intracoronary stents: General principles".)
Prior to the availability of drug-eluting stents, one major focus of investigation to treat restenosis was the use of intracoronary radiation. Based upon the data presented below, the United States Food and Drug Administration (FDA) has approved both gamma and beta intracoronary radiation for use in the treatment of in-stent restenosis . This technique is applied immediately after mechanical treatment (usually balloon dilatation) of the stent restenosis. However, the increased efficacy of drug-eluting stents for in-stent restenosis has markedly limited the role of intracoronary radiation for this indication.
Data do not support the use of intracoronary radiation for the prevention of restenosis after treating de novo lesions with balloon angioplasty alone, and the FDA has not approved this technique for this indication. (See 'Comparison to drug-eluting stents' below.)
Another radiation approach, insertion of radioactive stents, has been demonstrated to cause an increase in restenosis at the edges of the stent and may delay rather than prevent restenosis within the stent itself. The development of these stents has been discontinued.
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- GENERAL PRINCIPLES
- Radiation dose
- Scattering after stenting
- Use for in-stent restenosis
- - Comparison to drug-eluting stents
- - Saphenous vein grafts
- De novo stenting
- Use for restenosis after PTCA
- Use after angioplasty alone
- Effect on normal coronary segments
- Late thrombosis
- Prolonged dual antiplatelet therapy
- Edge stenosis
- Delayed healing of dissections
- Coronary artery spasm