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Abstract
Percutaneous coronary intervention of chronic total occlusions (CTO) is associated with a significantly higher incidence of reocclusion and restenosis compared with non‐total occlusions. Randomized and observational trials have demonstrated the effectiveness of intracoronary brachytherapy (ICBT) for the prevention of recurrent in‐stent restenosis. However, limited data are available on the effectiveness of ICBT in patients with totally occluded in‐stent restenosis. The authors assessed the long‐term outcome of patients treated with intracoronary gamma radiation for totally occluded in‐stent restenotic lesions.
Percutaneous coronary intervention and subsequent catheter‐based irradiation with iridium‐192 was performed in 100 patients (103 vessels) with diffuse in‐stent restenosis. At baseline, CTO of the target vessel at the site of the stent was present in 15 vessels (14.5%). Follow‐up data were collected during follow‐up visits and from telephone interviews. Repeat coronary angiography was performed in symptomatic patients with clinical restenosis. Clinical and angiographic characteristics were similar between the two groups, although there was a trend towards more unstable angina at the index procedure in CTO patients (66.7% versus 41.4%; p = 0.12) compared with patients without non‐total occlusions. A higher percentage of patients (53.3%) with CTO required longer radiation sources (14 seeds, covering a length of 55 mm), compared with 23.9% of patients with non‐total occlusion (p = 0.04). With a mean follow‐up period of 47.5 ± 24.0 months, major adverse cardiac events (MACE) were observed in 10 of 15 patients (66.7%) with CTO compared with 25 out of 88 patients (28.4%) without CTO (p = 0.009). According to multivariate analysis, total occlusion of the target vessel at baseline was the single independent predictor of MACE at one‐year follow‐up (relative risk 16.2, 95% confidence interval 4.2–62.9; p < 0.0001).
This study shows that the use of gamma radiation for the prevention of recurrence of in‐stent restenosis in patients with CTO does not seem to be as effective as in patients with non‐total occlusions. Furthermore, CTO was an independent predictor of worse outcome at long‐term follow‐up in this study. (Int J Cardiovasc Intervent 2004; 1: 33–38)