Radiation for restenosis: the dark side of arteries Robert S Schwartz MD Professor of Medicine Mayo Clinic Rochester, MN.

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Presentation transcript:

Radiation for restenosis: the dark side of arteries Robert S Schwartz MD Professor of Medicine Mayo Clinic Rochester, MN

Stimulation of neointima within an irradiated artery Figure 1

Minimal neointimal neoplasia post stent placement Figure 2

External beam radiation major US center 11 patient pilot study 8 Gy external beam radiation 11/11 restenosis the restenosis rate was 100%

Radiation injury to blood vessels capillary injury is greatest obliteration of capillaries one mechanism of anti-tumor action thrombosis, rupture, fibrosis occasionally lymphocytic vasculitis venous lesions are uncommon

Induction of neointima post external beam radiation Figure 3

Venezuelan study the late loss is too high Figure 4: late loss (millimeters) CondadoLRTMARCATORBENESTENTHELVETICACARPORTMERCATORPARK Condado J, Circulation 1997;96:727

3 questions on radiation Q: Is arterial radiation feasible? A: “Yes” Q: Is it safe? A: “We doubt it” Q: Is it efficacious? A:”We don’t think so” Serruys et al, Circulation 1997;96:

Neointimal hyperplasia at former sites of radiation Figure 5

PREVENT trial Figure 6 Restenosis in the treated segment Raizner et al, PREVENT trial % 22.2% 0.0% 25.0% P 32Control

PREVENT trial Figure 7 Restenosis in the adjacent segment Raizner et al, PREVENT trial % 11.1% 0.0% 25.0% P 32Control

PREVENT trial Figure 8 Restenosis in the treated and adjacent segments Raizner et al, PREVENT trial % 22.2% 0.0% 25.0% P 32Control

BERT trial restenosis rate of 17% 6 patients with an “edge problem” overall restenosis rate of 25%

Beta emitting stents and restenosis Figure 9 Restenosis in the treated and adjacent segments 56.0% (10/18) 39.0% (11/28) 45.0% (5/11) 50.0% (1/2) uCi3-6 uCi 6-12 uCi12-20 uCi

Cellular neointimal hyperplasia of in-stent restenosis Figure 10

Neointimal hyperplasia at former sites of radiation Figure 11

European registry, 150 patients PTCA up to 2 vessels Beta-Cath system, 90-Sr/Y 12,14,16 Gy to 2 mm from source target vessel restenosis 30% late loss index 13% Serruys, 1999 The BRIE trial

Human coronary artery thrombus in situ Figure 12

Multi-layered thrombus in a pig coronary artery Figure 13 Old thrombus New thrombus Absence of neointima

Intracoronary beta radiation Figure 14 Effects of intracoronary beta-radiation after 6 months in stented vessels controltreated Neointimal area (mm 2 ) P=NS

Figure 15 Angiographic restenosis rate 54% 17% controlradiated SCRIPPS trial

Figure 16 The SCRIPPS radiated group, a long term analysis SCRIPPS trial P=NS

Figure 17 GAMMA-I 6 month follow-up GAMMA-I in-stent measures

EVGActin Heat injury Figure 18