Retrospective patient-specific intravascular brachytherapy dosimetry using optical coherence tomography imaging

Drug-eluting stents fail in up to 20% of patients. In failed cases, intravascular brachytherapy (IVBT) is administered with β-emitting ⁹⁰Sr⁹⁰Y through a guidewire. Current clinical dosimetry is water-based, neglecting attenuation from patient-specific materials such as plaques, stents, and the off-centered guidewire, leading to a discrepancy between prescribed and delivered dose. This study retrospectively performed patient-specific IVBT dose calculations using Optical Coherence Tomography (OCT) to quantify uncertainties in clinical dosimetry.

Dose calculations on OCT images from ten patients were performed using RapidBrachyIVBT, a Monte Carlo-based dose calculation software. Heterogeneities, including guidewire(s), stents, and fibrotic and calcified plaques, were contoured and assigned material properties; surrounding tissue was modeled as smooth muscle. Absorbed dose to water and medium were calculated. The prescribed dose to water was 18.4 or 23 Gy at 2 mm from the source, depending on lumen diameter. The dose homogeneity index was defined as the ratio of the maximum to the minimum dose in the target volume.

When heterogeneities were included, median maximum dose attenuation was 76.7% (75.0-77.1) in the artery segment and 56.2% (52.2-65.1) in the target volume. The median dose homogeneity index increased from 1.29 in water to 2.93 (2.44-3.33) with patient-specific materials. The guidewire produced asymmetric dose distributions in all patients, with the greatest attenuation where it opposed thick calcified plaques.

Standard water-based IVBT dosimetry is inaccurate due to dose-attenuating materials present during treatment. Personalized, image-guided IVBT planning that accounts for patient-specific heterogeneities may improve treatment accuracy and clinical outcomes.