(Circulation. 1997;96:727-732.)
© 1997 American Heart Association, Inc.
Articles |
Long-term Angiographic and Clinical Outcome After Percutaneous Transluminal Coronary Angioplasty and Intracoronary Radiation Therapy in Humans
From the Department of Cardiology, Hospital Miguel Perez-Carrefio (J.A.C., O.G., R.E., J.G., B.B., G.V., H.A.), Centro Medico Caracas, Venezuela; Lake Charles, La (S.F.L.); and Department of Radiation Oncology (I.R.C.) and Andreas Gruentzig Cardiovascular Center (R.W., K.B.S.), Emory University Hospital, Atlanta, Ga.
Correspondence to Dr Ron Waksman, Cardiology Research Foundation, Washington Hospital Center, 100 Irving St NW, Suite 4B-1, Washington, DC 20010.
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionReferences |
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Background Ionizing radiation has been shown to reduce neointimal formation after balloon angioplasty in experimental models of restenosis. This study was designed to evaluate the feasibility, safety, and effectiveness of intracoronary radiation therapy (ICRT) after percutaneous transluminal coronary angioplasty (PTCA) for preventing restenosis in human coronary arteries.
Methods and Results Twenty-one patients (22 arteries) with
unstable angina underwent standard balloon angioplasty. ICRT was
performed with the use of an 192Ir source wire that was
hand delivered to the angioplasty site. Angiographic follow-up was
performed at 24 hours, between 30 and 60 days, and at 6 months.
Angioplasty was successful in 19 of 22 lesions, and insertion of the
radioactive source wire was successful at all treated sites.
Angiographic study at 24 hours demonstrated early late loss of the
luminal diameter from 1.92±0.55 to 1.40±0.27 mm. Between 30 and
60 days, repeat angiography demonstrated total occlusion in 2 arteries,
a new pseudoaneurysm in 1 artery, and significant dilatation at
the treatment site in 2 additional vessels. At 
6 months' follow-up,
all remaining arteries (n=20) maintained patent, with a mean lumen
diameter of 1.65±0.8 mm. The calculated late lumen loss was
0.27±0.56 mm, and the late loss index was 0.19. Clinical events
at 1 year included myocardial infarction in 1 patient, repeat
angioplasty to the treated site in 3 patients, and persistent angina in
7 patients.
Conclusions These preliminary results demonstrate that ICRT after coronary intervention is feasible and is associated with an acceptable degree of complications and lower rates of angiographic restenosis indexes.
Key Words: restenosis • angioplasty • radioisotopes • brachytherapy
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Prevention of restenosis after successful PTCA remains the greatest therapeutic challenge in interventional cardiology. Experimental and pathological studies have described restenosis as a healing response to vascular injury that primarily involves formation of a cellular neointima and late vascular remodeling.1 2 3 4 The effective use of endovascular irradiation to prevent intimal proliferation in animal models of balloon arterial injury has been demonstrated in preclinical studies. Use of a high-energy
-emitter
(192Ir) before or after overstretch balloon injury
significantly reduced neointimal formation when measured 2
to 4 weeks after injury. This benefit was seen with doses ranging from
14 to 25 Gy directed to the vessel wall and was maintained at 6
months' follow-up.7 8 9 Results of clinical studies with
endovascular 192Ir radiation in
restenotic stented femoral arteries have indicated low
restenosis rates in 
6 years of
follow-up.10
The purposes of this study were to evaluate the feasibility and safety of a system to deliver ICRT after balloon angioplasty in human subjects and to study the short- and long-term angiographic and clinical results of such therapy.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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All experimental protocols were approved by the ethics and academic review boards of Miguel Perez-Carrefio and Centro Medico Hospitals, Caracas, Venezuela. Informed consent was obtained in each case.
Patients and Lesion Characteristics
From July 1994 through January 1995, ICRT after PTCA was
attempted in 17 men and 4 women (22 total arteries; 1 patient had the
procedure in both the left circumflex artery and the RCA). The average
age of the patients was 52 years (range, 34 to 73 years). The majority
of patients had presented with unstable angina (class 2 to 4)
with at least one high-grade stenotic lesion that required
PTCA. The majority of lesions (17 of 22 lesions; 77.3%) were de novo
lesions. Two patients received stents in addition to the planned PTCA
and ICRT: a Gianturco-Roubin stent for acute closure after balloon
angioplasty before ICRT and a stent for severe acute recoil after PTCA
and ICRT. One patient was treated with ICRT for Palmaz-Schatz in-stent
restenosis, and 1 additional patient underwent a rotational
atherectomy ablation before ICRT.
All treated lesions were in native coronary arteries: 11 in the
left anterior descending artery, 7 in the RCA, and 4 in the left
circumflex artery. The majority (19 of 22; 86.4%) of the lesions were
type B according to the American Heart Association/American College of
Cardiology lesion classification. The mean of the
reference vessel diameter was 2.96±0.49 mm (range, 1.8 to
4.0 mm), and the MLD before angioplasty was 0.51±0.26 mm.
The MLD after intervention was 1.92±0.55 mm. Angiographic
follow-up was performed after administration of intracoronary
nitroglycerin at 24 hours in 18 patients and between 30
and 60 days in 12 patients; 19 patients had late angiographic follow-up
at 6 months. Arteriograms were consistently obtained in the
same projections. The quantitative angiographic measurements were
read by independent observers according to a method validated by the
core laboratory at Emory University in Atlanta, Ga.11 We
calculated late loss, defined as Postprocedure MLD-MLD at Follow-up,
and late loss index, defined as Late Loss/Acute Gain, where Acute
Gain=Postprocedure MLD-MLD Before PTCA.
Radiation Details
The radiation system used in this study consisted of a 4F,
noncentered, monorail delivery catheter and a 3-cm 192Ir
line source with either a 0.018 or 0.014 in diameter fixed to a wire of
a similar caliber. After the catheter was placed in position, the
192Ir wire was hand delivered through the catheter to the
treatment site. The treatment time was calculated on the basis of the
activity of the source (range, 529 to 982 mCi), the prescribed dose,
and a distance of 1.5 mm from the center of the source (the
prescription point). The initial activity of the source was determined
with the use of a well chamber calibrated for a 192Ir wire.
The dose rate at different depths was measured with the use of thermal
luminescent dosimeter chips at various distances from the wire. The
mean treatment time was 580±226 seconds (range, 164 to 929 seconds).
The prescribed dose for the first 9 patients (10 arteries ) was 25 Gy
using the 0.0180-in wire; in 11 patients, the prescribed dose was 20
Gy; and in 1 patient, it was 18 Gy using the 0.014-in wire. The
reference lumen diameter was estimated by the operator during the
procedure, and the dose calculations were performed at that time on the
basis of this estimation.
After determination by the core laboratory of the true luminal diameters of the treated vessels, the actual dose delivered to the luminal surface of the vessel was recalculated (assuming the catheter was positioned in the center of the artery) with the use of a standard, commercial treatment-planning system. The mean actual dose at the luminal surface of the treatment site was consistently higher than the prescribed dose and was calculated to be 35.6±11.1 Gy (range, 19.5 to 55 Gy for all arteries), whereas the mean dose at the reference vessel diameter was 23.3±7.5 Gy (range, 11.1 to 42.9 Gy). Because a noncentered system was used in this trial, it is likely that vessels that were treated with 25 Gy received even higher doses of up to a maximum of 92.5 Gy when the catheter was lying against the vessel lumen surface, whereas the contralateral wall of those locations received a minimum dose of 7.2 Gy in larger arteries.
ICRT Procedure
All procedures were performed with the use of an 8F guiding
catheter system and a conventional balloon angioplasty technique. After
the PTCA balloon was removed, the delivery catheter was inserted to
fully cover the angioplasty site. A dummy (nonradioactive) wire was
advanced within the catheter to the angioplasty site to ensure free
insertion of the radioactive wire. The dummy wire was then removed, and
the radioactive wire was advanced and positioned at the angioplasty
site by both fluoroscopic control and distance measurement. After the
radiation treatment, the radioactive wire was removed and placed in a
shielded container. Intracoronary nitroglycerin
was given, and a final angiogram was taken immediately after the
procedure. In the event of acute recoil, an additional balloon dilation
was performed. All patients were treated with heparin for 24 hours and
discharged 48 to 72 hours after the procedure. After discharge, all
patients were treated with aspirin and warfarin for a period of 3
months to reduce the risk of thrombosis that may occur due to a
possibility of delayed reendothelialization.
Radiation Protection Considerations
Special safety precautions were taken during the procedure. The
sources were transported in a shielded box and were manipulated only
with the use of long forceps. Shielding included leaded glass goggles,
a thyroid shield, and two fluoroscopy aprons. The handling of the
source was shared among three operators. Total handling time of the
radioactive wire was <1 minute per artery, and the calculated exposure
of radiation to a single operator who performed these 22 radiation
procedures was 2 mSv.
Statistical Analysis
All data were recorded on standardized forms, entered into a
computerized database, and expressed as proportions or as mean±SD.
Given the lack of a concurrent group of nonirradiated patients, the
only comparison that was tested was the postprocedural MLD versus the
MLD at 24 hours and at follow-up, for which the paired ttest was used. All tests of significance were two-tailed, and
values of P<.05 were considered to indicate statistical
significance.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Angioplasty was successful (percent residual diameter stenosis <50%) in 19 of 22 sites (86.4%). However, ICRT was successfully delivered to all treated sites. All patients tolerated the radiation therapy, with none of the patients developing ischemia, arrhythmia, or any other major complication during the procedure, and none of the radiation treatments were interrupted. One patient developed coronary spasm after the radiation treatment that was refractory to intracoronary nitroglycerin but resolved after prolonged balloon inflation. The mean MLD after the procedure was 1.92±0.55 mm, and the mean residual percent diameter stenosis after the procedure was 34±13%. All treated arteries undergoing 24-hour angiography were patent except 1 that sustained subacute thrombosis in a bifurcated site (without resulting in acute myocardial infarction or creatine phosphokinase elevation). This patient underwent successful angioplasty to both the thrombosed branch and the radiation-treated site. Early luminal loss was demonstrated in the treated arteries at 24 hours with a reduction of the MLD from 1.92±0.55 to 1.40±0.27 mm, leaving a mean residual percent diameter stenosis of 45±10% (P<.001). All patients were free from in-hospital major cardiac events such as myocardial infarction, bypass surgery, or death. The first 9 patients (10 arteries) who were treated with a higher dose of 25 Gy had a repeat angiogram between 30 and 60 days after the procedure. Two of these patients, although asymptomatic, had total occlusion at the treated site at 30 and 38 days, respectively, without evidence of recent myocardial infarction on their ECG. One of these patients had a total occlusion before the initial angioplasty and radiation treatment. The other patient had severe dissection during the angioplasty procedure before the radiation treatment. One patient developed a small pseudoaneurysm-like appearance at the treatment site immediately after the procedure that was pronounced at 6 months. Another patient (Patient 2 in the Table
)
who underwent uncomplicated PTCA to the proximal left anterior
descending coronary artery developed pseudoaneurysm at
the treatment site at 60 days that was enlarged at 8 months. (Fig 1). This patient remained
asymptomatic and refused bypass surgery. The actual dose
calculated for this patient was 38.5 Gy delivered to a distance of
1.5 mm from the source, and because the radiation was delivered by
a noncentering delivery system, it is likely that the vessel wall at
the treated site received up to 92 Gy. Two other vessels (the RCA and
left circumflex artery) that were treated with 25 Gy (patient 7 in the
Table) showed vessel dilatation and irregular appearance at early
(right coronary artery) and late follow-up (left circumflex
artery) (Fig 2).
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The angiographic follow-up in this study ranged between 6 and 14 months
(average, 8±1.9 months) (Table
). Except for the two subacute
occlusions at 30 days, all of the remaining arteries studied were
patent, with a mean luminal diameter at last follow-up of
1.65±0.8 mm and a mean residual stenosis of 41±24%,
similar to the postangioplasty result (P=.2). The calculated late loss
for the entire cohort was 0.44±0.7 mm, whereas the late loss
after excluding the two patients with total occlusions was
0.27±0.56 mm, and the late loss index was 0.19±0.4. An example
of a case with a negative late loss at 14 months with site dilatation
is shown in Fig 2. MLD at late follow-up demonstrated negative late
loss in 10 of the 22 arteries (Table). At 8±1.9 months, angiographic
binary restenosis (>50% diameter stenosis) occurred
in 6 (27.3%) of the 22 treated lesions. At the 12-month clinical
follow-up, the survival rate free of myocardial infarction, bypass
surgery, or revascularization of the target lesion
was 80.9%. Clinical events recorded included a myocardial
infarction in one patient (with a patent artery at the treated site),
repeat angioplasty in three patients (one of these to a new site), and
persistent angina in seven patients. None of the patients or the
medical personnel developed complications or illnesses that could be
related to the effects of the radiation procedure.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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This study describes the first human ICRT trial and is among the first to report clinical and angiographic follow-up of >6 months' duration. The study demonstrated that intracoronary irradiation after standard balloon angioplasty using a catheter-based system is feasible and can be performed with a low and acceptable incidence of procedural or in-hospital adverse events.
Freedom from myocardial infarction, bypass surgery, or
revascularization of the target lesion at 1 year
was 80.9%, similar to the value of 80.5% in the stent group at 6
months in the STRESS trial12 and higher than that reported
in several balloon angioplasty studies.13 14 Radiation as
an adjunct therapy to intracoronary stenting was suggested as
an ideal combination because radiation has been shown to be very
effective at suppressing the neointimal proliferation seen
with stent placement, in which the stent prevents vessel contraction
(unfavorable remodeling).7 16 However, the results seen
here with radiation alone, negative late loss in 10 arteries, and a
late loss index of 0.19 raise the possibility of favorable remodeling
after ICRT and the question of the need for intracoronary
stenting after adequate balloon angioplasty for prevention of late
constriction (Fig 3).
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The lack of a consistent effect after ICRT may be related to the inhomogeneity of dosing due to the lack of centering and inaccurate dose calculations performed in this study. The error in dosing was a result of failure to estimate an accurate vessel size. This can be prevented in the future by using either on-line quantitative coronary angiography or intravascular ultrasound and a centered delivery system.
Another potential concern is the presence of total occlusion at two treated sites at 30 and 38 days' angiographic follow-up. Although one of these patients had a totally occluded artery before ICRT and the other had severe dissection at the time of the angioplasty, this may be a result of delayed reendothelialization. Therefore, ICRT may require a more intense anticoagulation protocol.
Six of the 10 arteries that were treated with higher doses of 25 Gy developed angiographic complications (total occlusions in 2 and pseudoaneurysm and arterial dilatation in 4 vessels). It is possible that some areas of these vessels could have been exposed to two to three times the intended dose due to the noncentered catheter. Although the irregularity and pseudoaneurysm were seen immediately after the procedure in 2 of these patients, it is possible that the radiation at these high doses interferes with the wound-healing process, and this could suggest an upper limit of vessel wall integrity and tolerance to likely toxic doses for this therapy after balloon angioplasty. In contrast, it is possible that the contralateral wall of larger arteries received lower doses than are required for therapy, which may explain the lack of consistency in the effectiveness of the treatment in this cohort.
The hand-loading delivery system used in this study is limited in effectively shielding 192Ir by standard lead aprons, thus exposing the medical personnel to additional radiation exposure, especially when high activities are used. Additional studies can minimize these problems by using a remote afterloading device to deliver the source and a radiation shield to block exposure to personnel.
The importance of this trial primarily lies in demonstrating that ICRT for prevention of restenosis is feasible and free of any unexpected acute complications. This limited experience without a concurrent nonirradiated group does not allow us to comment definitively on the efficacy of this approach. Preliminarily, it appears that ICRT may inhibit late luminal loss due to either inhibition of neointima formation or by promotion of favorable remodeling. Larger randomized studies are needed to determine whether ICRT will be proven effective in reducing clinical events after PTCA.
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Selected Abbreviations and Acronyms |
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Acknowledgments |
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We thank Jorge Saucedo, MD, Alexandra Lanski, MD, and Jeff Popma, MD, for their consultation in reviewing the angiograms.
Received March 7, 1997; revision received June 16, 1997; accepted June 16, 1997.
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P. K. Coussement, H. de Leon, T. Ueno, M. Y. Salame, S. B. King III, N. A.F. Chronos, and K. A. Robinson Intracoronary {beta}-Radiation Exacerbates Long-Term Neointima Formation in Balloon-Injured Pig Coronary Arteries Circulation, November 13, 2001; 104(20): 2459 - 2464. [Abstract] [Full Text] [PDF]
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W. J. van der Giessen, E. Regar, M. S. Harteveld, V. L.M.A. Coen, R. Bhagwandien, A. Au, P. C. Levendag, J. Ligthart, P. W. Serruys, A. den Boer, et al. "Edge Effect" of 32P Radioactive Stents Is Caused by the Combination of Chronic Stent Injury and Radioactive Dose Falloff Circulation, October 30, 2001; 104(18): 2236 - 2241. [Abstract] [Full Text] [PDF]
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 P. Vermeersch, Z. Nong, E. Stabile, O. Varenne, H. Gillijns, M. Pellens, N. Van Pelt, M. Hoylaerts, I. De Scheerder, D. Collen, et al. L-Arginine Administration Reduces Neointima Formation After Stent Injury in Rats by a Nitric Oxide-Mediated Mechanism Arterioscler Thromb Vasc Biol, October 1, 2001; 21(10): 1604 - 1609. [Abstract] [Full Text] [PDF]
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Z. Chen, K. W. Woodburn, C. Shi, D. C. Adelman, C. Rogers, and D. I. Simon Photodynamic Therapy With Motexafin Lutetium Induces Redox-Sensitive Apoptosis of Vascular Cells Arterioscler Thromb Vasc Biol, May 1, 2001; 21(5): 759 - 764. [Abstract] [Full Text] [PDF]
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M.Y Salame, S Verheye, I.R Crocker, N.A.F Chronos, K.A Robinson, and S.B King III Intracoronary radiation therapy Eur. Heart J., April 2, 2001; 22(8): 629 - 647. [PDF]
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 V. Verin, Y. Popowski, B. de Bruyne, D. Baumgart, W. Sauerwein, M. Lins, G. Kovacs, M. Thomas, F. Calman, C. Disco, et al. Endoluminal Beta-Radiation Therapy for the Prevention of Coronary Restenosis after Balloon Angioplasty N. Engl. J. Med., January 25, 2001; 344(4): 243 - 249. [Abstract] [Full Text] [PDF]
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M. B. Leon, P. S. Teirstein, J. W. Moses, P. Tripuraneni, A. J. Lansky, S. Jani, S. C. Wong, D. Fish, S. Ellis, D. R. Holmes, et al. Localized Intracoronary Gamma-Radiation Therapy to Inhibit the Recurrence of Restenosis after Stenting N. Engl. J. Med., January 25, 2001; 344(4): 250 - 256. [Abstract] [Full Text] [PDF]
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R. Sheppard and M. J. Eisenberg Intracoronary Radiotherapy for Restenosis N. Engl. J. Med., January 25, 2001; 344(4): 295 - 297. [Full Text] [PDF]
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M. Wohlfrom, J. Kotzerke, J. Kamenz, M. Eble, B. Hess, J. Wohrle, S. N Reske, V. Hombach, H. Hanke, and M. Hoher Endovascular irradiation with the liquid {beta}-emitter Rhenium-188 to reduce restenosis after experimental wall injury Cardiovasc Res, January 1, 2001; 49(1): 169 - 176. [Abstract] [Full Text] [PDF]
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C Hehrlein, A Kovacs, G.K Wolf, N Yue, and R Nath A novel balloon angioplasty catheter impregnated with beta-particle emitting radioisotopes for vascular brachytherapy to prevent restenosis. First in vivo results Eur. Heart J., December 2, 2000; 21(24): 2056 - 2062. [Abstract] [PDF]
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K Kozuma, M.A Costa, M Sabate, C.J Slager, E Boersma, I.P Kay, J.P.A Marijnissen, S.G Carlier, J.J Wentzel, A Thury, et al. Relationship between tensile stress and plaque growth after balloon angioplasty treated with and without intracoronary beta-brachytherapy Eur. Heart J., December 2, 2000; 21(24): 2063 - 2070. [Abstract] [PDF]
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M. Sabate, M. A. Costa, K. Kozuma, I. P. Kay, C. J. van der Wiel, V. Verin, W. Wijns, P. W. Serruys, and on behalf of the Dose Finding Study Group Methodological and clinical implications of the relocation of the minimal luminal diameter after intracoronary radiation therapy J. Am. Coll. Cardiol., November 1, 2000; 36(5): 1536 - 1541. [Abstract] [Full Text] [PDF]
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I. P. Kay, M. Sabate, M. A. Costa, K. Kozuma, M. Albertal, W. J. van der Giessen, A. J. Wardeh, J. M. R. Ligthart, V. M. A. Coen, P. C. Levendag, et al. Positive Geometric Vascular Remodeling Is Seen After Catheter-Based Radiation Followed by Conventional Stent Implantation but Not After Radioactive Stent Implantation Circulation, September 19, 2000; 102(12): 1434 - 1439. [Abstract] [Full Text] [PDF]
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D. Meerkin, J.-C. Tardif, O. F. Bertrand, J. Vincent, F. Harel, and R. Bonan The effects of intracoronary brachytherapy on the natural history of postangioplasty dissections J. Am. Coll. Cardiol., July 1, 2000; 36(1): 59 - 64. [Abstract] [Full Text] [PDF]
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R. Waksman, B. Bhargava, G. S. Mintz, R. Mehran, A. J. Lansky, L. F. Satler, A. D. Pichard, K. M. Kent, and M. B. Leon Late total occlusion after intracoronary brachytherapy for patients with in-stent restenosis J. Am. Coll. Cardiol., July 1, 2000; 36(1): 65 - 68. [Abstract] [Full Text] [PDF]
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M. Hoher, J. Wohrle, M. Wohlfrom, H. Hanke, R. Voisard, H. H. Osterhues, M. Kochs, S. N. Reske, V. Hombach, and J. Kotzerke Intracoronary {beta}-Irradiation With a Liquid 188Re-Filled Balloon : Six-Month Results From a Clinical Safety and Feasibility Study Circulation, May 23, 2000; 101(20): 2355 - 2360. [Abstract] [Full Text] [PDF]
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J. M. Ahmed, G. S. Mintz, R. Waksman, N. J. Weissman, R. Mehran, A. D. Pichard, L. F. Satler, K. M. Kent, and M. B. Leon Safety of Intracoronary {gamma}-Radiation on Uninjured Reference Segments During the First 6 Months After Treatment of In-Stent Restenosis : A Serial Intravascular Ultrasound Study Circulation, May 16, 2000; 101(19): 2227 - 2230. [Abstract] [Full Text] [PDF]
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R. E. Kuntz and D. S. Baim Prevention of Coronary Restenosis : The Evolving Evidence Base for Radiation Therapy Circulation, May 9, 2000; 101(18): 2130 - 2133. [Full Text] [PDF]
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R. Waksman, R. L. White, R. C. Chan, B. G. Bass, L. Geirlach, G. S. Mintz, L. F. Satler, R. Mehran, P. W. Serruys, A. J. Lansky, et al. Intracoronary {gamma}-Radiation Therapy After Angioplasty Inhibits Recurrence in Patients With In-Stent Restenosis Circulation, May 9, 2000; 101(18): 2165 - 2171. [Abstract] [Full Text] [PDF]
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P. WEXBERG and M. GOTTSAUNER-WOLF Intravascular radiotherapy: restenosis and more? Heart, May 1, 2000; 83(5): 497 - 498. [Full Text]
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E. Thorin, D. Meerkin, O. F. Bertrand, P. Paiement, M. Joyal, and R. Bonan Influence of Postangioplasty {beta}-Irradiation on Endothelial Function in Porcine Coronary Arteries Circulation, March 28, 2000; 101(12): 1430 - 1435. [Abstract] [Full Text] [PDF]
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M. Y. Salame, S. Verheye, S. P. Mulkey, N. A. F. Chronos, S. B. King III, I. R. Crocker, and K. A. Robinson The Effect of Endovascular Irradiation on Platelet Recruitment at Sites of Balloon Angioplasty in Pig Coronary Arteries Circulation, March 14, 2000; 101(10): 1087 - 1090. [Abstract] [Full Text] [PDF]
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I P Kay, M Sabate, G Van Langenhove, M A Costa, A J Wardeh, A L Gijzel, N V Deshpande, S G Carlier, V L M A Coen, P C Levendag, et al. Outcome from balloon induced coronary artery dissection after intracoronary beta radiation Heart, March 1, 2000; 83(3): 332 - 337. [Abstract] [Full Text]
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D. O. Williams and B. L. Sharaf Intracoronary Radiation : It Keeps on Glowing Circulation, February 1, 2000; 101(4): 350 - 351. [Full Text] [PDF]
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P. S. Teirstein, V. Massullo, S. Jani, J. J. Popma, R. J. Russo, R. A. Schatz, E. M. Guarneri, S. Steuterman, K. Sirkin, D. A. Cloutier, et al. Three-Year Clinical and Angiographic Follow-Up After Intracoronary Radiation : Results of a Randomized Clinical Trial Circulation, February 1, 2000; 101(4): 360 - 365. [Abstract] [Full Text] [PDF]
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Y. Vodovotz, R. Waksman, W.-H. Kim, B. Bhargava, R. C. Chan, and M. Leon Effects of Intracoronary Radiation on Thrombosis After Balloon Overstretch Injury in the Porcine Model Circulation, December 21, 1999; 100(25): 2527 - 2533. [Abstract] [Full Text] [PDF]
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 R. A. Hall, D. J. Fordyce, M. E. Lee, B. Eisenberg, R. F. Lee, J. H. Holmes IV, and W. G. Campbell Brain SPECT imaging and neuropsychological testing in coronary artery bypass patients Ann. Thorac. Surg., December 1, 1999; 68(6): 2082 - 2088. [Abstract] [Full Text] [PDF]
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O F Bertrand, S Lehnert, R Mongrain, and M G Bourassa Early and late effects of radiation treatment for prevention of coronary restenosis: a critical appraisal Heart, December 1, 1999; 82(6): 658 - 662. [Full Text]
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 D. P Lee, S. Lo, K. Forster, A. C Yeung, and S. N Oesterle Clinical applications of brachytherapy for the prevention of restenosis Vascular Medicine, November 1, 1999; 4(4): 257 - 268. [Abstract] [PDF]
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M. Sabate, P. W. Serruys, W. J. van der Giessen, J. M.R. Ligthart, V. L.M.A. Coen, I. P. Kay, A. L. Gijzel, A. J. Wardeh, A. den Boer, and P. C. Levendag Geometric Vascular Remodeling After Balloon Angioplasty and {beta}-Radiation Therapy : A Three-Dimensional Intravascular Ultrasound Study Circulation, September 14, 1999; 100(11): 1182 - 1188. [Abstract] [Full Text] [PDF]
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R. Waksman Late Thrombosis After Radiation : Sitting on a Time Bomb Circulation, August 24, 1999; 100(8): 780 - 782. [Full Text] [PDF]
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M. A. Costa, M. Sabate, W. J. van der Giessen, I. P. Kay, P. Cervinka, J. M. R. Ligthart, P. Serrano, V. L. M. A. Coen, P. C. Levendag, and P. W. Serruys Late Coronary Occlusion After Intracoronary Brachytherapy Circulation, August 24, 1999; 100(8): 789 - 792. [Abstract] [Full Text] [PDF]
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C. Hehrlein, S. Kaiser, R. Riessen, J.u. Metz, P. Fritz, and W. Kubler External beam radiation after stent implantation increases neointimal hyperplasia by augmenting smooth muscle cell proliferation and extracellular matrix accumulation J. Am. Coll. Cardiol., August 1, 1999; 34(2): 561 - 566. [Abstract] [Full Text] [PDF]
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D. Meerkin, J.-C. Tardif, I. R. Crocker, A. Arsenault, M. Joyal, G. Lucier, S. B. King III, D. O. Williams, P. W. Serruys, and R. Bonan Effects of Intracoronary ß-Radiation Therapy After Coronary Angioplasty : An Intravascular Ultrasound Study Circulation, April 6, 1999; 99(13): 1660 - 1665. [Abstract] [Full Text] [PDF]
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J. Fareh, R. Martel, P. Kermani, and G. Leclerc Cellular Effects of ß-Particle Delivery on Vascular Smooth Muscle Cells and Endothelial Cells : A Dose-Response Study Circulation, March 23, 1999; 99(11): 1477 - 1484. [Abstract] [Full Text] [PDF]
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S. B. King III Radiation for Restenosis : Watchful Waiting Circulation, January 19, 1999; 99(2): 192 - 194. [Full Text] [PDF]
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P. S. Teirstein, V. Massullo, S. Jani, R. J. Russo, D. A. Cloutier, R. A. Schatz, E. M. Guarneri, S. Steuterman, K. Sirkin, S. Norman, et al. Two-Year Follow-Up After Catheter-Based Radiotherapy to Inhibit Coronary Restenosis Circulation, January 19, 1999; 99(2): 243 - 247. [Abstract] [Full Text] [PDF]
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G. Bauriedel, S. Schluckebier, R. Hutter, U. Welsch, R. Kandolf, B. Luderitz, and M. F. Prescott Apoptosis in Restenosis Versus Stable-Angina Atherosclerosis : Implications for the Pathogenesis of Restenosis Arterioscler Thromb Vasc Biol, July 1, 1998; 18(7): 1132 - 1139. [Abstract] [Full Text] [PDF]
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S. B. King, D. O. Williams, P. Chougule, J. L. Klein, R. Waksman, R. Hilstead, J. Macdonald, K. Anderberg, and I. R. Crocker Endovascular ß-Radiation to Reduce Restenosis After Coronary Balloon Angioplasty : Results of the Beta Energy Restenosis Trial (BERT) Circulation, May 26, 1998; 97(20): 2025 - 2030. [Abstract] [Full Text] [PDF]
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