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Brachytherapy with iridium-192 HDR to prevent from restenosis in peripheral arteries

Sieben Jahre Nachbeobachtung der Brachytherapie mit Iridium 192 zur Verhütung von Restenosen in peripheren Arterien-Eine Aktualisierung

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Abstract

The use of stents does not appreciably improve restenosis (usually resulting from intimal hyperplasia) as compared to percutaneous transluminal angioplasty (PTA) alone. The development of small-caliber probes for afterloading therapy in the biliary tract allowed us to use these for therapy in the vascular system. Using a special 9 F catheter, exact measurement of the length of the stented vascular segment and of the insertion length of the afterloading probe could be reproducibly performed. We used a Nucletron (Micro) Selectron HDR planning system version 10.10 for exact calculation, monitoring, and control of the afterloading procedure. Our source was iridium 192 (10 Ci) with a diameter of 1.1 mm. The program controls and monitors the insertion and removal of the iridium probe from the source into the special catheter through to the tip, and monitors the irradiation duration. The exposure time was around 200 seconds for a surface dose of 12 Gy.

To date, a total of 40 patients have been treated with endovascular afterloading. All patients suffered from clinically relevant reocclusions or restenoses in stented vascular segments of the superficial femoral artery following successful PTA or laser treatment, within 6 to 8 months after the last therapy. In all patients it was possible to perform re-PTA treatment without remaining residual stenoses in the stented region. The additional time required as compared to PTA alone was approximately 45 minutes with most of this time spending for transportation between the cath lab and afterloading room.

The follow-up period of the 40 patients ranged from 4 months to 7 1/2 years. In 33 patients, there was no deterioration of the clinical stage and no restenosis. One patient suffered from an acute thrombosis approximately 3 months after stent implantation, another patient had a stenosis 3 cm above the stented vascular segment 12 months after irradiation treatment. Follow-up examinations have revealed no evidence of nerve lesions following irradiation therapy. The tissue, surrounding the artery showed no change following irradiation therapy, either in the CT, color-coded Doppler, endovascular ultrasonic scan or MRI. No complaints of discomfort were reported during or after irradiation. With the exceptions mentioned above, there was no evidence of any complications.

Zusammenfassung

Der Gebrauch von Stents hat nicht wesentlich die Problematik der Restenose (meist Intimahy-perplasie) im Vergleich zur alleinigen perkutanen transluminalen Angioplastie (PTA) gelöst. Die Entwicklung dünner Drähte zur Afterloading-Therapie im Gallengang hat uns Gelegenheit gegeben, diese auch zur endovaskulären Bestrahlung zu nutzen. Mit Hilfe eines speziellen 9-F-Katheters können exakte Messungen der Länge des gestenteten Gefäßsegments und der Einführlänge des Afterloading-Drahtes reproduzierbar durchgeführt werden. Wir verwendeten ein Nucletron-(Micro-)Selectron-HDR-Gerät zur Therapieplanung (Version 10.10), exakten Berechnung, Monitoring und zur Kontrolle des Afterloadings. Die von uns verwendete Strahlenquelle war Iridium 192 (10 Ci) mit einem Durchmesser von 1,1 mm. Das Programm kontrolliert und überwacht das Einführen und Zurückbringen des Iridium-drahtes und auch die Bestrahlungszeit. Diese beträgt etwa 200 Sekunden für eine Oberflächendosis von 12 Gy.

Bis heute haben wir insgesamt 40 Patienten mit endovaskulärem Afterloading behandelt. Alle Patienten litten an klinisch relevanter Restenose bzw. Reverschluß in den gestenteten Gefäßsegmenten der Arteria femoralis superficialis nach primär erfolgreicher PTCA bzw. Laserbehandlung. Die Bestrahlung fand sechs bis acht Monate nach der letzten Intervention statt. Bei einem Patienten konnten wir eine erfolgreiche Re-PTA ohne Residualstenose im Stentbereich durchführen. Die zusätzliche Zeit, die für die Nachbestrahlung erforderlich ist, beträgt etwa 45 Minuten, der größe Teil wird für den Transport vom Katheterlabor in die Strahlentherapieabteilung benötigt.

Die Nachbeobachtungszeit dieser 40 Patienten liegt zwischen vier Monaten und siebeneinhalb Jahren. Bei 33 Patienten trat keine Verschlechterung des klinischen Stadiums bzw. keine Restenose ein. Ein Patient erlitt drei Monate nach der Bestrahlung eine akute Stentthrombose, ein anderer entwickelte eine neue Stenose 3 cm proximal des gestenteten Segments zwölf Monate nach der Bestrahlungstherapie. Die Nachbeobachtungsuntersuchungen gaben bei keinem Patienten Hinweise auf Nervenschädigungen. Das die Arterie umgebende Gewede zeigte weder im CT, farbkodierten Doppler, intravasalen Ultraschall noch in der Kernspintomographie Zeichen einer Gewebsschädigung. Während oder nach der Bestrahlung traten keine Beschwerden auf. Mit Ausnahme der oben genannten Patienten, gab es im Rahmen der Langzeitbeobachtung keine Komplikationen.

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Authors and Affiliations

  1. Clinic of Radiology and Nuclear Medicine, Hospital of the Ruhr University Bochum, Bochum, Germany

    Dieter Liermann (Chairman and Director Clinic of Radiology and Nuclear Medicine) & Johannes Kirchner

  2. Department of Radiotherapy, Klinikum der Johann-Wolfgang-Goethe-Universität, Frankfurt Main, Germany

    Bernhard Schopohl & Heinz D. Böttcher

  3. Department of Angiology, Klinikum der Johann-Wolfgang-Goethe-Universität, Frankfurt Main, Germany

    Ruppert Bauernsachs

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  1. Dieter Liermann
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  3. Ruppert Bauernsachs
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Correspondence to Dieter Liermann.

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Liermann, D., Kirchner, J., Bauernsachs, R. et al. Brachytherapy with iridium-192 HDR to prevent from restenosis in peripheral arteries. Herz 23, 394–400 (1998). https://doi.org/10.1007/BF03043605

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