Treatment of Patients with Recurrent Coronary In-Stent Restenosis with Failed Intravascular Brachytherapy.
Intravascular brachytherapy (VBT) is an effective and safe treatment option for recurrent drug-eluting stent (DES) in-stent restenosis (ISR). However, the optimal therapy for patients with failed VBT is not well-defined. In this study, we sought to evaluate the optimal treatment strategy for patients after a failed VBT. Patients with recurrent ISR after an initial unsuccessful VBT were identified from our percutaneous coronary intervention database. Patients were divided into 2 cohorts (standard treatment with DES or balloon angioplasty vs. repeat VBT). Baseline characteristics and clinical outcomes during follow-up were extracted. A total of 279 patients underwent PCI after an initial unsuccessful VBT at our institution. Of those, 215 (77%) patients underwent standard treatment with balloon angioplasty with or without DES, and 64 (33%) underwent balloon angioplasty followed by repeat VBT. The mean age of the cohort was 64±11 years. Overall, 71% were men, 47% had diabetes, and 22% had heart failure. The majority (64%) presented with unstable angina. The groups had similar baseline characteristics. The rate of major adverse cardiovascular events (MACE, defined as all-cause mortality, myocardial infarction, or target vessel revascularization) was significantly lower in the repeat VBT group at 1 year (31% vs. 14%, p=0.03), 2 years (51% vs. 31%, p=0.03), and 3 years (57% vs 41%, p=0.08). Target lesion revascularization and target vessel revascularization were consistently lower in the repeat VBT group at all follow-up intervals than in the standard treatment group. Treatment of recalcitrant ISR following an initial failed VBT is associated with a high MACE rate at 3-year follow-up. Repeat VBT is safe and effective and should be considered as the preferred strategy.