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How to Fix the Edge Effect of Catheter-Based Radiation Therapy in Stented Arteries

Background—Edge stenosis remains a serious limitation of catheter-based vascular brachytherapy (VBT). This study aims to identify the mechanisms and evaluate strategies to minimize edge restenosis in patients treated with VBT. Methods and Results—Thirty-four porcine stented coronary arteries were irradiated (doses of 15 or 22 Gy) with 192Ir trains of either 6 seeds (23 mm) with 0 mm coverage at the distal stent edge and 10 mm at the proximal stent edge or 14 seeds (55 mm) centered at the distal edge of the stent with 27.5 and 14.5 mm coverage at the distal and proximal edges, respectively. After VBT, an additional 13-mm stent was positioned overlapping the distal margin of the first stent. Animals were killed at 28 days, and arteries were analyzed. Longer radiation margins were associated with reduced intimal area (IA) at the stent edge: 2.3±0.9, 3.6±2.0, and 5.3±2.2 mm2 with 15 Gy for a radiation margin of 14.5, 10, and −13 mm (−13 versus 10, P =0.06; 10 versus 14.5, P =0.06). Additional stenting was associated with an increase of IA: 4.0±2.3 mm2 at the overlapped segment. Increasing the dose to 22 Gy resulted in a reduction of the IA at the overlap segment to 1.31±0.57 mm2 with 14 seeds (27.5 mm coverage) but was not helpful with 6 seeds (0 mm coverage): IA, 5.56±2.28 mm2. Conclusions—Extending the radiation margins to 14.5 mm from each end of the stent minimized the edge-effect phenomenon. A higher dose is essential to eliminate further increases in IA at the overlapped segment with additional stents.