Characterization of the dose perturbation by stents as a function of X-ray beam energy

External beam irradiation of coronary arteries has been shown to be detrimental in an animal model for the prevention of neointimal hyperplasia in the presence of stents when orthovoltage x-ray beams are used. The present study investigated the effect of beam energy on the dose distribution in the wall of the artery in the presence of stents.

We used 250-kVp x-rays and 6-MV x-rays to irradiate a stent placed in a homogeneous phantom. Radiochromic film densitometry and Monte Carlo calculations were used to measure and to simulate the dose distribution in the proximity of the stent.

External beam irradiation not only failed to prevent neointimal hyperplasia, but actually accentuated the neointimal response to a prompt mechanical injury in the artery. The photoelectric effect, which dominates low-energy x-ray interactions, produces recoil electrons in the stent, which enhance the dose surrounding the intima. The photoelectrons generated in nickel and iron have an extremely short range in normal tissue, approximately 0.1 mm. Initial estimates of orthovoltage x-ray interactions with the stent indicate a dose enhancement in the orthovoltage range by a factor of 2-6 due to the rise in the photoelectric cross section in this energy range depending on the elemental composition of the stent. Film densitometry verifies this dose enhancement. The Monte Carlo calculation yields a dose enhancement and the dose fall-off with distance from the stent when irradiated with orthovoltage x-rays. Conversely when the tissue and stent are irradiated with megavoltage x-rays, the dose enhancement in this region is a factor of 1.15 in close proximity to the stent and 1.0 at distances greater than 0.1 mm. The 6-MV photon interactions in tissue and Ni/Ti are predominantly through Compton scattering. The Compton effect is dependent on the electron density in the medium, in contrast to the atomic number, which is more relevant for photoelectric absorption. The dose estimates for megavoltage x-rays adjacent to the stent are complicated by the lack of charged particle equilibrium.

There is a limited but definite increase in the dose delivery to the arterial wall when stents are irradiated with orthovoltage x-ray energies. This increase may explain the negative response in other studies. The presence of the stent does perturb the character and magnitude of the dose in the normal arterial wall as a function of beam quality.