Endovaskuläre Brachytherapie in der Restenoseprophylaxe nach Angioplastie und Stentimplantation: Eine Übersicht

Zusammenfassung

Die endovaskuläre Radiotherapie stellt das erste erfolgreiche Therapiekonzept in der Restenoseprophylaxe nach PTA und Stentimplantation dar. Am 3. 11. 2000 hat die amerikanische Food and Drug Administration erstmalig zwei Brachytherapiegeräte zur Restenoseprophylaxe nach Koronararterien-Stenting zugelassen. Große multizentrische, kontrollierte Studien wurden für das koronare Stromgebiet mit positiven Ergebnissen publiziert, die Datenlage im peripheren Stromgebiet ist noch ungenügend. Beta-Strahler bieten Vorteile in der Anwendung, möglicherweise auch in der Sicherheit, Gamma-Strahler dagegen sind besser klinisch evaluiert. Die primäre Indikation zur endovaskulären Brachytherapie besteht bei Patienten mit erhöhtem Risiko einer Restenose wie beispielsweise einer Rezidivstenose, einer In-Stent-Hyperplasie, langen überstenteten Läsionen, einer langen PTA-Strecke, kleinen Restlumina und Patienten mit Diabetes mellitus. Daten aus dem koronaren Stromgebiet legen nahe, dass während der Bestrahlung ein Sicherheitsabstand von mindestens 4 - 10 mm beidseits der durch PTA traumatisierten Gefäßstrecke eingehalten werden sollte, um Restenosen an den Bestrahlungsrändern zu vermeiden. Zur Prophylaxe einer Spätthrombosierung nach Bestrahlung wird im koronaren Stromgebiet eine medikamentöse Begleittherapie mit ASS 100 mg und Clopidogrel 75 mg täglich über mindestens 6 Monate nach PTA und 12 Monate nach Stentneuimplantation empfohlen, gesicherte Erkenntnisse für periphere Arterien existieren noch nicht.

Abstract

Endovascular radiotherapy is the first effective prophylaxis of restenosis after percutaneous transluminal angioplasty (PTA) and stenting. The FDA recently approved two devices for the delivery of intracoronary radiation following coronary artery stenting. Published multicenter, double-blind, randomized trials of intracoronary radiation therapy report good results for preventing in-stent restenosis, while the data for the peripheral circulation are still inconclusive. Beta-emitters are easier applicable and probably also safer, whereas gamma-emitters have been more extensively evaluated clinically so far. Primary indication for endovascular brachytherapy are patients at high risk for restenosis, such as previous restenoses, in-stent hyperplasia, long stented segment, long PTA lesion, narrow residual vascular lumen and diabetes. Data from coronary circulation suggest a safety margin of at least 4 to 10 mm at both ends of the angioplastic segment to avoid edge restenosis. To prevent late thrombosis of the treated coronary segment, antiplatelet therapy with clopidogrel and aspirin are recommended for at least 6 months after PTA and for 12 months after a newly implanted stent. An established medication regimen after radiotherapy of peripheral arteries is still lacking.

Schlüsselwörter

Radiotherapie - Restenose - Stents und Endoprothesen, Bestrahlung - Angioplastie - Brachytherapie

Key words

Radiation - restenosis - stents and prostheses, radiation - angioplasty - brachytherapy

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