64 research outputs found
Radioactive stents delay but do not prevent in-stent neointimal hyperplasia
BACKGROUND: Restenosis after conventional stenting is almost exclusively caused by neointimal hyperplasia. Beta-particle-emitting radioactive stents decrease in-stent neointimal hyperplasia at 6-month follow-up. The purpose of this study was to evaluate the 1-year outcome of (32)P radioactive stents with an initial activity of 6 to 12 microCi using serial quantitative coronary angiography and volumetric ECG-gated 3D intravascular ultrasound (IVUS). METHODS AND RESULTS: Of 40 patients undergoing initial stent implantation, 26 were event-free after the 6-month follow-up period and 22 underwent repeat catheterization and IVUS at 1 year; they comprised half of the study population. Significant luminal deterioration was observed within the stents between 6 months and 1 year, as evidenced by a decrease in the angiographic minimum lumen diameter (-0.43+/-0.56 mm; P:=0.028) and in the mean lumen diameter in the stent (-0.55+/-0. 63 mm; P:=0.001); a significant increase in in-stent neointimal hyperplasia by IVUS (18.16+/-12.59 mm(3) at 6 months to 27.75+/-11. 99 mm(3) at 1 year; P:=0.001) was also observed. Target vessel revascularization was performed in 5 patients (23%). No patient experienced late occlusion, myocardial infarction, or death. By 1 year, 21 of the initial 40 patients (65%) remained event-free. CONCLUSIONS: Neointimal proliferation is delayed rather than prevented by radioactive stent implantation. Clinical outcome 1 year after the implantation of stents with an initial activity of 6 to 12 microCi is not favorable when compared with conventional stenting
Geographic miss: a cause of treatment failure in radio-oncology applied to intracoronary radiation therapy
BACKGROUND: A recognized limitation of endovascular beta-radiation therapy
is the development of new stenosis at the edges of the irradiated area.
The combination of injury and low-dose radiation may be the precursor of
this phenomenon. We translated the radio-oncological concept of
"geographic miss" to define cases in which the radiation source did not
fully cover the injured area. The aims of the study were to determine the
incidence and causes of geographic miss and evaluate the impact of this
inadequate treatment on the outcome of patients treated with intracoronary
beta-radiation. METHODS AND RESULTS: We analyzed 50 consecutive patients
treated with beta-radiation after percutaneous coronary intervention. The
prescribed dose ranged between 12 and 20 Gy at 2 mm from the source axis.
By means of quantitative coronary angiography, the irradiated segment
(IRS) and both edges were studied before and after intervention and at
6-month follow-up. Edges that were injured during the procedure
constituted the geographic miss edges. Twenty-two edges were injured
during the intervention, mainly because of procedural complications that
extended the treatment beyond the margins of the IRS. Late loss was
significantly higher in geographic miss edges than in IRSs and uninjured
edges (0.84+/-0.6 versus 0.15+/-0.4 and 0.09+/-0.4 mm, respectively;
P<0.0001). Similarly, restenosis rate was significantly higher in the
injured edges (10% within IRS, 40.9% in geographic miss edges, and 1.9% in
uninjured edges; P<0.001). CONCLUSIONS: These data support the hypothesis
that the combination of injury and low-dose beta-radiation induces
deleterious outcome
Positive geometric vascular remodeling is seen after catheter-based radiation followed by conventional stent implantation but not after radioactive stent implantation
BACKGROUND: Recent reports demonstrate that intracoronary radiation
affects not only neointimal formation but also vascular remodeling.
Radioactive stents and catheter-based techniques deliver radiation in
different ways, suggesting that different patterns of remodeling after
each technique may be expected. METHODS AND RESULTS: We analyzed
remodeling in 18 patients after conventional stent implantation, 16
patients after low-activity radioactive stent implantation, 16 patients
after higher activity radioactive stent implantation, and, finally, 17
patients who underwent catheter-based radiation followed by conventional
stent implantation. Intravascular ultrasound with 3D reconstruction was
used after stent implantation and at the 6-month follow-up to assess
remodeling within the stent margins and at its edges. Preprocedural
characteristics were similar between groups. In-stent neointimal
hyperplasia (NIH) was inhibited by high-activity radioactive stent
implantation (NIH 9.0 mm(3)) and by catheter-based radiation followed by
conventional stent implantation (NIH 6.9 mm(3)) compared with low-activity
radioactive stent implantation (NIH 21.2 mm(3)) and conventional stent
implantation (NIH 20.8 mm(3)) (P:=0.008). No difference in plaque or total
vessel volume was seen behind the stent in the conventional, low-activity,
or high-activity stent implantation groups. However, significant increases
in plaque behind the stent (15%) and in total vessel volume (8%) were seen
in the group that underwent catheter-based radiation followed by
conventional stent implantation. All 4 groups demonstrated significant
late lumen loss at the stent edges; however, edge restenosis was seen only
in the group subjected to high-activity stent implantation and appeared to
be due to an increase in plaque and, to a lesser degree, to negative
remodeling. CONCLUSIONS: Distinct differences in the patterns of
remodeling exist between conventional, radioactive, and catheter-based
radiotherapy with stenting
Sustained suppression of neointimal proliferation by sirolimus-eluting stents: one-year angiographic and intravascular ultrasound follow-up
BACKGROUND: We have previously reported a virtual absence of neointimal hyperplasia 4 months after implantation of sirolimus-eluting stents. The aim of the present investigation was to determine whether these results are sustained over a period of 1 year. METHODS AND RESULTS: Forty-five patients with de novo coronary disease were successfully treated with the implantation of a single sirolimus-eluting Bx VELOCITY stent in Sao Paulo, Brazil (n=30, 15 fast release [group I, GI] and 15 slow release [GII]) and Rotterdam, The Netherlands (15 slow release, GIII). Angiographic and volumetric intravascular ultrasound (IVUS) follow-up was obtained at 4 and 12 months (GI and GII) and 6 months (GIII). In-stent minimal lumen diameter and percent diameter stenosis remained essentially unchanged in all groups (at 12 months, GI and GII; at 6 months, GIII). Follow-up in-lesion minimal lumen diameter was 2.28 mm (GIII), 2.32 mm (GI), and 2.48 mm (GII). No patient approached the >/=50% diameter stenosis at 1 year by angiography or IVUS assessment, and no edge restenosis was observed. Neointimal hyperplasia, as detected by IVUS, was virtually absent at 6 months (2+/-5% obstruction volume, GIII) and at 12 months (GI=2+/-5% and GII=2+/-3%). CONCLUSIONS: This study demonstrates a sustained suppression of neointimal proliferation by sirolimus-eluting Bx VELOCITY stents 1 year after implantation
Three dimensional intravascular ultrasonic assessment of the local mechanism of restenosis after balloon angioplasty
OBJECTIVE: To assess the mechanism of restenosis after balloon angioplasty. DESIGN: Prospective study. PATIENTS: 13 patients treated with balloon angioplasty. INTERVENTIONS: 111 coronary subsegments (2 mm each) were analysed after balloon angioplasty and at a six month follow up using three dimensional intravascular ultrasound (IVUS). MAIN OUTCOME MEASURES: Qualitative and quantitative IVUS analysis. Total vessel (external elastic membrane), plaque, and lumen volume were measured in each 2 mm subsegment. Delta values were calculated (follow up - postprocedure). Remodelling was defined as any (positive or negative) change in total vessel volume. RESULTS: Positive remodelling was observed in 52 subsegments while negative remodelling occurred in 44. Remodelling, plaque type, and dissection were heterogeneously distributed along the coronary segments. Plaque composition was not associated with changes in IVUS indices, whereas dissected subsegments had a greater increase in total vessel volume than those without dissection (1.7 mm(3) v -0.33 mm(3), p = 0.04). Change in total vessel volume was correlated with changes in lumen (p < 0.05, r = 0.56) and plaque volumes (p < 0.05, r = 0.64). The site with maximum lumen loss was not the same site as the minimum lumen area at follow up in the majority (n = 10) of the vessels. In the multivariate model, residual plaque burden had an influence on negative remodelling (p = 0.001, 95% confidence interval (CI) -0.391 to -0.108), whereas dissection had an effect on total vessel increase (p = 0.002, 95% CI 1.168 to 4.969). CONCLUSIONS: The mechanism of lumen renarrowing after balloon angioplasty appears to be determined by unfavourable remodelling. However, different patterns of remodelling may occur in individual injured coronary segments, which highlights the complexity and influence of local factors in the restenotic process
Randomized Comparison Between Everolimus-Eluting Bioresorbable Scaffold and Metallic Stent: Multimodality Imaging Through 3 Years
Objectives: The aim of this study was to investigate the vascular responses and fates of the scaffold after bioresorbable vascular scaffold (BVS) implantation using multimodality imaging. Background: Serial comprehen
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