TREATMENT with intravascular brachytherapy (IVBT) for multilayer drug-eluting in-stent restenosis (DES-ISR) is associated with a lower rate of major adverse cardiac events (MACE) at three years compared to non-IVBT strategies.
Multilayer in-stent restenosis (ISR), particularly in patients with multiple layers of drug-eluting stents, remains a significant clinical challenge due to high rates of recurrent adverse cardiac events. Intravascular brachytherapy (IVBT) has emerged as a “metal-free” treatment alternative, but robust long-term outcome data have been limited. This study aimed to evaluate and compare three-year clinical outcomes in patients treated with IVBT versus those managed with non-IVBT strategies for multilayer DES-ISR.
A retrospective analysis was conducted on 647 patients treated for multilayer DES-ISR (defined as two or more stent layers) at Mount Sinai Hospital between 2012 and 2019. Of these, 453 patients (70%) received IVBT, while 194 (30%) were managed with non-IVBT strategies. Baseline characteristics were largely comparable between groups, though IVBT-treated patients had a higher incidence of prior coronary artery bypass grafting and a lower mean SYNTAX score (11.9±10.7 vs 14.2±11.3; p=0.028). Additionally, DES implantation during the index procedure was significantly less common in the IVBT group (0.4% vs 25.8%; p<0.001). The primary endpoint, MACE—a composite of all-cause death, target lesion revascularisation, and myocardial infarction—was assessed at three years. The incidence of MACE was significantly lower in the IVBT group compared to the non-IVBT group (39.5% vs 47.8%; hazard ratio 0.73, 95% confidence interval: 0.53-0.99; p=0.044) after propensity score adjustment. Notably, there were no significant differences in the rates of the individual MACE components between groups.
In conclusion, patients with multilayer DES-ISR experience high rates of adverse events at long-term follow-up. However, IVBT was associated with a significantly lower rate of major adverse cardiac events compared to non-IVBT strategies over three years. These findings support the consideration of IVBT as a viable treatment option for complex ISR cases in clinical practice, particularly in patients unsuitable for further stenting. Further prospective studies are warranted to confirm these results and to refine patient selection for IVBT in routine care.
Reference
Tanner R et al. Long-term clinical outcomes of intravascular brachytherapy for multilayer drug-eluting in-stent restenosis. EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology. 2025;21(7):e356-65.
