Repeat intracoronary radiation for recurrent in-stent restenosis in patients who failed intracoronary radiation

improved lumen cross-sectional area and a low plaque burden in the LMCA after intervention. All-cause mortality, angiographic restenosis, and the target lesion revascularization rates at 6 months were 7.4%, 23.8% and 20.0%, respectively. Conclusions: The authors concluded that with IVUS guidance, aggressive DCA can be performed safely in unprotected LMCA bifurcation lesions, and optimal angiographic and IVUS results can be achieved with low residual plaque burden, which leads to a low restenosis rate. Optimal lesion debulking by DCA does not necessarily need adjunctive stenting in this specific anatomic subset. Perspective: This small pilot study demonstrated the safety and feasibility of IVUS-guided DCA for unprotected LMCA stenoses in a selected group of high-risk patients. Coronary artery bypass surgery remains the treatment of choice for patients with LMCA stenosis and only patients who are not candidates for surgery or those who refuse surgery should be considered for catheter based intervention. DM

aortic vessels to be a major risk factor for cerebral embolism during neuroprotected CAS. Perspective: The main finding of this study is that neuroprotected CAS is still associated with frequent, predominantly silent cerebral ischemia. However, it is difficult to ascertain the clinical relevance of this study. DW MRI lesions cannot be considered to always represent brain infarction and for the time being, the gold standard for measuring ischemic brain injury, either spontaneous or post-procedural, remains a careful neurologic examination. DM

Repeat Intracoronary Radiation for Recurrent InStent Restenosis in Patients Who Failed Intracoronary Radiation Waksman R, Lew R, Ajani AE, et al. Circulation 2003;108:654 – 6. Study Question: The study evaluated the outcomes of patients who underwent repeat intracoronary radiation for recurrent in stent restenosis [ISR]. Methods: The study is a retrospective analysis of 51 consecutive patients who failed a previous radiation treatment. These individuals presented with angina and angiographic evidence of ISR and were treated with percutaneous coronary intervention (PCI) and repeat radiation to the same segment. Twenty-five patients were treated with gamma radiation in a dose of 15 Gy, and 26 were treated with beta radiation doses of 18.3–23 Gy. The mean cumulative dose for this cohort was 39.5⫾11.9 Gy (range, 29 –75.6 Gy). The outcomes of those patients were compared with outcomes of 299 patients who also failed initial radiation but were treated with repeat conventional PCI to a previously irradiated segment without repeat radiation. Results: At 9 months after treatment, the repeat intracoronary radiation group had lower rates of target lesion revascularization (23.5% vs. 54.6%; p⬍0.001) and major adverse cardiac events. No side effects from the radiation therapy were observed. Conclusions: The authors conclude that repeat gamma or beta radiation to treat failed intracoronary radiation for ISR after conventional PCI is safe and effective at 9 months and should be considered as a therapeutic option for this difficult patient subset. Perspective: The optimal treatment strategy for patients treated with intracoronary radiation who requires repeat revascularization is unclear. The present study examined the safety and clinical outcome of patients who received repeat intracoronary radiation to a previously irradiated site after PCI for recurrent ISR. This study demonstrates that repeat intracoronary radiation was safe and effective at 9 months when compared with outcomes of patients who also failed initial radiation therapy but were treated with conventional PCI alone. These preliminary results are encouraging but need to be confirmed in larger studies with longer term follow-up. DM

Focal Ischemia of the Brain After Neuroprotected Carotid Artery Stenting Schlu¨ ter M, Tu¨ bler T, Steffens JC, Mathey DG, Schofer J. J Am Coll Cardiol 2003;42:1007–13. Study Question: The investigators sought to assess the incidence of cerebral ischemia in nonselected patients undergoing neuroprotected carotid angioplasty and stenting (CAS) without preceding multiple-vessel diagnostic angiography. Methods: The study was an analysis of a cohort of patients undergoing elective CAS. Elective CAS was performed in 42 consecutive patients (15 female, 27 male; mean age, 67⫾9 years) using six different types of cerebral protection systems. All patients underwent diffusion-weighted MRI [DW MRI] of the brain before and after a total of 44 interventions. Results: Placement and retrieval of the devices and stent deployment was achieved in all procedures [100% technical success]. New ischemic foci were seen on postinterventional MRI in 10 cases (22.7%). One patient sustained a major stroke, whereas no adverse neurological sequelae were associated with the other nine procedures. In the latter, one to three foci (maximum area 43.0 mm2) were detected in cerebral regions subtended by the ipsilateral carotid artery in eight cases and by the contralateral carotid artery in one case. In the stroke patient, 12 ischemic foci (maximum area 84.5 mm2) were exclusively located in the contralateral hemisphere. Follow-up MRI at 4.1 months (median, n⫽7) identified a residual of cerebral ischemia only in this single patient. Conclusions: The authors concluded that neuroprotected CAS is associated with predominantly silent cerebral ischemia in approximately 25% of patients. The findings suggest manipulation of endoluminal equipment in the supra-

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