ARTICLE IN PRESS

IJCA-10953; No of Pages 2

International Journal of Cardiology xx (2008) xxx – xxx

www.elsevier.com/locate/ijcard

1 Letter to the Editor

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2 Alpha particle vascular brachytherapy in the treatment
3 of in-stent Restenosis
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4 Alireza Mehdizadeh a,⁎, Afsoon Fazelzadeh b , Hamed karimi c

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a
5 Department of Medical Physics, School of Medicine, Mashad University of Medical Sciences (MUMS), PO Box: 13975-1471 Mashad, Iran
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School of Medicine, Fasa University of Medical Sciences, Iran

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c
7 School of Medicine, Mashad University of Medical Sciences (MUMS), Iran
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9 Received 23 December 2007; accepted 5 April 2008

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Abstract

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In-stent Restenosis (ISR) is the Achilles heel for using of stent. Vascular brachytherapy (VBT) has been the principal scientifically
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investigated local therapy for coronary artery ISR. In our suggested method, a new type of stent, which is coated with Boron (10B)
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13 compound, is used. The coating layer of the stent consists of stable isotype of 10B. Boron Neutron Capture Therapy produced alpha particle
14 has enough energy to kill the cells adjacent to the stent, which is the site of boron deposition. It would prevent from ISR and intimal
15 proliferation.
16 After percutaneous coronary intervention (PCI) and insertion of stent, follow-up should be done continuously, and if ISR is detected,
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17 BNCT will be used to treat the recurrence. Using this modality of VBT would help us to overcome the pitfalls in en vogue radiotherapy
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18 methods.
19 © 2008 Published by Elsevier Ireland Ltd.
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21 Keywords: Stent; Restenosis; Coronary artery disease; Vascular brachytherapy; Boron Neutron Capture Therapy; Alpha particle
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23 1. Introduction 1.1. Boron Neutron Capture Therapy 38

24 In-stent Restenosis (ISR) is the Achilles heel of using the Boron Neutron Capture Therapy (BNCT) relies on initial 39
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25 stent. Vascular brachytherapy (VBT) has been the principal targeting of cells by an appropriate chemical compound 40
26 scientifically investigated local therapy for coronary artery tagged with 10B. During irradiation of the site by thermal 41
27 ISR [1].VBT has arisen some problems,1—after VBT, ISR neutrons, (Energy b 0.5 eV), the 10B absorbs a low energy 42
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28 will be delayed rather than prevented [2].2—stent thrombo- neutron and ejects an energetic short-range alpha particle and 43
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29 sis has been the only major adverse clinical consequence of lithium ion called 10B (n, alpha) 7Li reaction which is shown 44
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30 VBT. In the absence of VBT, stent thrombosis typically in Eq. (1) 45

31 occurs soon after the procedure, and usually within 1 month.
32 In the setting of VBT, stent thrombosis may be more com- 10
B þ N Y 11 BTðexcited atomÞY 4 He2þ ðaÞ½1:47 Mev
33 mon, and its temporal pattern is different, with episodes þ 7 Li½0:84 Mev þ g½0:84 Mev: ð1Þ
34 occurring between 1 and 15 months [3]. 3—involvement of
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35 cardiac structures remote from the lesion targeted for Thermal neutrons are the most important for BNCT 48
36 radiation has been another concern.4—excessive prolonga- because they initiate the 10 B(n,a)7 Li capture reaction. 49
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37 tion of procedure duration is another concern. However, because they have a limited depth of penetration, 50
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epithermal neutrons, (0.5 ev b Energy b 10 kev), which lose 51
⁎ Corresponding author. Tel.: +98 915 510 3108; fax: +98 511 800 2320. energy and fall into the thermal range as they penetrate 52
E-mail address: mahdizadehta831@mums.ac.ir (A. Mehdizadeh). tissues, are now preferred for clinical therapy. 53

0167-5273/$ - see front matter © 2008 Published by Elsevier Ireland Ltd.

doi:10.1016/j.ijcard.2008.04.036

Please cite this article as: Mehdizadeh A, et al, Alpha particle vascular brachytherapy in the treatment of in-stent Restenosis, Int J Cardiol (2008),
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doi:10.1016/j.ijcard.2008.04.036
 ARTICLE IN PRESS
2 A. Mehdizadeh et al. / International Journal of Cardiology xx (2008) xxx–xxx

54 Alpha particles and lithium ions, from the 10B(n, alpha)7Li would become as safe as any other non-radioactive chemical 80
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55 reaction, give rise to closely spaced ionizing events. They compounds. BNCT needs thermal or epithermal neutron 81
56 have a combined path length of approximately 12 μm, and source, which is not available widely now, neutron fluence 82
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57 have high Linear Energy Transfer (LET). LET is one of may seems harmful for biological structures lied between the 83
58 the major determining factors of Relative Biological Effect source and stent, but thermal or epithermal neutron have 84
59 (RBE) of an ionizing radiation. lower RBE than produced alpha particles. A basic tenet of 85
BNCT is that the dose of neutrons delivered to the target 86
60 2. Methods volume should not exceed the tolerance of normal tissues, 87
and this applies to neutron beam design as well as to treat- 88
61 In our suggested method, Boron (10B) compound coated ment planning. 89

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62 stent is used. The coating layer of the stent consists of stable VBT remains a reasonable option for patients with ISR 90
63 isotype of 10B. lesions until full data from large randomized trials comparing 91
64 After insertion of stent, follow-up should be done drug eluting stents with VBT are available [4] by using new 92
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65 continuously, when ISR is detected, BNCT will be used for technologies coming to the field of interventional cardiology, 93

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66 treatment. BNCT produced alpha particles would kill the it is very soon to hear the swan song of VBT yet [5]. 94
67 immigrant cells in the lumen of stent. It would also prevent
68 intimal proliferation adjacent to stent. References 95

69 3. Discussion [1] Oliver LN, Buttner PG, Hobson H, et al. A meta-analysis of randomised 96 Q1

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controlled trials assessing drug-eluting stents and vascular brachyther- 97
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apy in the treatment of coronary artery in-stent Restenosis. Int J Cardiol 98
70 BNCT could use when ISR diagnosed even after many 2007. doi:10.1016/j.ijcard.2007.03.132.
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71 years of PCI and it does not need any interventional procedure [2] Grise MA, Massullo V, Jani S, et al. Five-year clinical follow-up after 100
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72 again. It does not prolong the catheterization and stent in- intracoronary radiation results of a randomized clinical trial. Circulation 101
73 sertion procedure and it could perform as an elective process 2002;105:2737–40. 102
[3] Costa MA, Sabaté M, van der Giessen WJ, et al. Late coronary occlu- 103
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74 in radiotherapy ward. Other cardiac structures are not in the
sion after intracoronary brachytherapy. Circulation 1999;100:789–92. 104
75 range of alpha particles therefore it is not a problem anymore. [4] Nikas DN, Kalef-Ezra J, Katsouras CS, et al. Long-term clinical outcome 105
76 Even incident thermal neutron has negligible biological ^ ^
of patients treated with beta-brachytherapy in routine clinical practice. 106
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77 effect, BNCT produced alpha particle has enough energy to Int J Cardiol 2007;115(2):183–9. 107
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78 kill the cells adjacent to the site of boron deposition. When [5] Van Limbergen E, Trepuraneni P. Is this the swan song of endovascular 108
brachytherapy. Radiother Oncol 2007;82(1):1–4. 109
79 the neutron fluence has been stopped, the boron compound
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Please cite this article as: Mehdizadeh A, et al, Alpha particle vascular brachytherapy in the treatment of in-stent Restenosis, Int J Cardiol (2008),
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doi:10.1016/j.ijcard.2008.04.036