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CLINICAL STUDY: INTERVENTIONAL CARDIOLOGY

Late acute thrombotic occlusion after endovascular brachytherapy and stenting of femoropopliteal arteries

Robert Bonvini, MD^*, Iris Baumgartner, MD, Do Dai Do, MD, Mario Alerci, MD^*, Jeanne-Marie Segatto, RN^*, Paolo Tutta, MD^*, Kurt Jäger, MD, Markus Aschwanden, MD, Ernst Schneider, MD, Beatrice Amann-Vesti, MD, Richard Greiner, MD^||, Felix Mahler, MD and Augusto Gallino, MD, FACC^*,*

^* Divisions of Vascular Medicine and Interventional Radiology of Ospedale San Giovanni, Bellinzona, Switzerland
Divisions of Angiology of the University Hospital Berne, Berne, Switzerland
University Hospital Basel, Basel, Switzerland
University Hospital Zurich, Zurich, Switzerland
^|| Department of Radiation Oncology of the University of Berne, Berne, Switzerland

Manuscript received May 21, 2002; revised manuscript received November 27, 2002, accepted December 12, 2002.

^* Reprint requests and correspondence: Prof. Augusto Gallino, Division of Vascular Medicine, Ospedale San Giovanni (EOC), 6900 Bellinzona, Switzerland.
agallino{at}bluewin.ch

OBJECTIVES: The aim of this article is to underline the importance of this complication after endovascular brachytherapy (EVBT) and intravascular stenting of the femoropopliteal arteries occurring in a running randomized trial.

BACKGROUND: Endovascular brachytherapy has been proposed as a promising treatment modality to reduce restenosis after angioplasty. However, the phenomenon of late acute thrombotic occlusion (LATO) in patients receiving EVBT after stenting is of major concern.

METHODS: In an ongoing prospective multicenter trial, patients were randomized to undergo EVBT (iridium 192; 14 Gy at a depth of the radius of the vessel +2 mm) after percutaneous recanalization of femoropopliteal obstructions. Of the 204 patients who completed the six months follow-up, 94 were randomized to EVBT.

RESULTS: Late acute thrombotic occlusion occurred exclusively in 6 of 22 patients (27%) receiving EVBT after intravascular stenting and always in concomitance with reduction of antithrombotic drug prevention (clopidogrel). Conversely, none of the 13 patients with stents and without EVBT (0%; p < 0.05) and none of the 72 patients (0%; p < 0.01) undergoing EVBT after simple balloon angioplasty presented LATO.

CONCLUSIONS: Late thrombotic occlusion occurs not only in patients undergoing EVBT after percutaneous coronary recanalization but also after stenting of the femoropopliteal arteries and may compromise the benefits of endovascular radiation. The fact that all our cases with LATO occurred concomitantly with stopping clopidogrel may indicate a possible rebound mechanism. An intensive and prolonged antithrombotic prevention is probably indicated in these patients.

Abbreviations and Acronyms   EVBT   endovascular brachytherapy   IL   interventional length   LATO   late acute thrombotic occlusion   PTCA   percutaneous transluminal coronary angioplasty

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