Repeat radiation for recurrent in-stent restenosis in patients who failed initial brachytherapy

In-stent restenosis (ISR) is due to neointimal hyperplasia and is shown to be effectively inhibited by vascular brachytherapy (VBT). Despite its efficacy, 20-25% of patients present with recurrent ISR following failed initial VBT. Although conventional percutaneous coronary intervention (PCI) is offered in a majority of patients to treat failed brachytherapy, the requirement for repeat revascularization is about 50%. PCI with repeat radiation to treat this difficult subset of patients is safe and feasible with target lesion revascularization (TLR) rates less than 25%. The lessons learned from randomized trials of brachytherapy, including prevention of edge effect, prolonged antiplatelet therapy and the prescription of a higher mean dose, should be applied to treat these patients with repeat radiation.