Complex coronary cases
PCI of Recurrent DES ISR using Rotational Atherectomy and IVBT – May 2013

63-year old male with prior CABG and multiple PCIs of LM and LCX presented on 2/7/13 with crescendo angina and + MPI in inferolateral segment. Cath revealed III vessel + LM CAD, in stent restenosis (ISR) of LM/proximal LCX with LVEF 55% and patent LIMA to LAD. Patient underwent drug eluting balloon of LM/LCX and did well. Patient is now scheduled for PCI of recurrent DES ISR using rotational atherectomy and intravascular brachytherapy (IVBT).

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Q&A
Q
So it is not true that Washington Hospital Center is the last remaining sites that performs brachytherapy? td>
A.

Currently there are 20 Cath labs in US which are offering intravascular brachytherapy (IVBT). We restarted the program last year in June. Mount Sinai Hospital Cath lab at present performing one of the highest numbers of IVBT (8-10 per month) cases in US.


Q
How many procedures do you perform with Brachytherapy at your center?
A.

Approximately 8-10 per month since June 2012.


Q
Which is your isotope and which is the company that manufactures it?
A.

Best Medical Inc from Novoste has been providing the beta-radiation source using Sr-Yr90.


Q
Are you employing brachytherapy for the sole indication for instent restenosis?
A.

Yes we are employing IVBT for only recurrent DES ISR; after atleast 2 layers of DES and 3rd or 4th episode of DES ISR. Based on the available data, IVBT is not recommended in the treatment of denovo coronary lesions.


Q
Have you established a protocol for instent (DES) restenosis - when should a patient consider brachytherapy?
A.

Yes it should be used only for recurrent DES ISR. Once DES restenose, then either same or different type of DES should be used. Then if restenose again; if focal ISR then may be Cutting or scoring/ high pressure balloon PTCA but if diffuse/TO ISR, then IVBT will be appropriate.


Q
If you had a drug-coated balloon available, then which cases will still have more favorable outcomes with brachytherapy?
A.

I recommend to use Drug Eluting balloon (DEB) first before IVBT. Based on the available data, DEB if available, should be the first line treatment for DES ISR.


Q
Any issue about brachytherapy and Bivalirudin?
A.

Currently all cases are being done with Bivalirudin and there have been no issues in terms of thrombus formation or embolization during the procedure. Since dwell time could be upto 4-5 minutes, make sure to disengage the guide from the ostium to have unobstructed antegrade coronary flow.


Q
How relevant is still the issue of the geographic miss?/td>
A.

Yes the geographical miss with IVBT will always be an important issue and hence recommend to use longer source train to provide full lesion radiation coverage. In fact 80% of our IVBT cases are done with 60mm source train and 20% with 40mm and we donot use 30mm source train at all.


Q
Does a lesion preparation for brachytherapy be as meticulous as for placing a BVS?
A.

For IVBT purposes, lesion needs to be opened optimally and not maximally as to avoid any dissection or need for re-stenting. IVBT thereafter will 'freeze' that lumen by abolishing subsequent intimal hyperplasia. On the other hand proper lesion preparation is vital for delivery and implantation of BVS.


Q
Is the procedure being reimbursed?
A.

Yes IVBT procedure has the Inhospital modifiers and the CPT codes for added reimbursement and professional payment to Radiation & Interventional MDs.


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