Mark Trombetta, M.D., a radiation oncologist at Allegheny Health Network in Pittsburgh, Pennsylvania, talks about a cutting-edge treatment that is unclogging hearts.
Interview conducted by Ivanhoe Broadcast News in December 2016.
Can you give me an overview of what this condition is?
Dr. Trombetta: In coronary artery disease, the arteries to the heart narrow due to a buildup of plaque. This buildup can hamper the flow of blood to the heart, leading to a heart attack or death. Sometimes a patient has stenting done to open up the coronary artery. So the cardiologist does an angioplasty first, opens up the narrowed area. Then to keep it open the cardiologist can place a metallic stent inside, which is a little spring-loaded device that opens up the artery an. Over time the body will form a new internal layer to cover the stent and allow the blood to flow without any problems. But sometimes even with the stent there is a re-accumulation of debris.
So the stent isn’t foolproof sometimes over time?
Dr. Trombetta: No, sometimes it re-narrows. Sometimes cardiologists can actually put another stent inside of the first one. But at that point some patients’ options are limited. In 2000, when we first started doing internal radiation, it was to prevent an overgrowth of the natural lining that the body lays inside the stent; we call that overgrowth endothelial proliferation and so sometimes it goes a little unchecked and the artery narrows just because of that. We had originally done radiation in the coronary arteries right after the stent was placed to help prevent restenosis. With the advent of the drug-eluting stents that are coated we didn’t need to use the radiation any more. The drug-eluting stent replaced our technology, but then we found that over time that a small number of patients that experienced re-narrowing despite the drug-eluting stent. Some people can’t have another stent placed and have no other options other than making medical management or sometimes coronary bypass surgery. We reintroduced the idea of radiation in those patients and that is where the program developed.
What is it that you were able to do, what is it called and tell me a little bit about it and how it works?
Dr. Trombetta: We call it Intravascular Brachytherapy. Brachytherapy is a form of internal radiation. ‘Brachy’ means close. It is a very potent radiation, not quite a beam, but it is particle or gamma ray radiation and it affects a very tiny area in the coronary artery. It is very potent but it doesn’t penetrate very much and that’s why it’s perfect for these very tiny arteries. When the angioplasty is done we place the catheter in and give it a certain amount of radiation to that vessel to prevent that over growth.
I wanted to ask about potential risks for patients, what would those be?
Dr. Trombetta: The main risks are related to angioplasty itself. Sometimes the vessels will tear, but in hands of a highly qualified interventional cardiologist, it is usually a very safe procedure and the radiation part adds about ten minutes to the procedure. Radiation risks are very minimal, but it is such a very focused amount of radiation that we really don’t see many problems with it.
Mark, if you don’t mind, walk me through this again. You said it is done at the same time as the angioplasty, but would you kind of take me through the steps that would be done from your end to deliver this?
Dr. Trombetta: We have a large hospital system and we have a lot of people that refer in from the periphery, so even though restenosis occurs very infrequently, when you have a big draw area you get many cases. The few percent of patients where this occurs after stenting with the drug-coded stent, a cardiologist from an outlying area may call us and say we have a case. Sometimes it is an internal patient that we already know. So we will identify this patient who cannot have another stent placed or needs radiation. We will take them to the cardiac cath lab, where they will do the coronary catheterization, look at all the vessels and if they see areas where they think another stent can’t be placed or more importantly, where they think that coronary brachytherapy can be done. We are there with the cardiologist and we have a device that has a tiny little radioactive source that goes through the catheter, the cardiac catheter, right into the area, immediately after angioplasty to prevent restenosis or re-overgrowth of the normal lining tissues of the blood vessels.
When you say tiny are you saying it is like the size of a pen dot?
Dr. Trombetta: Millimeters, yes. They are about the size of a pen ink dot. A
Okay and you said it is a small percentage of patients; can you give me an estimate?
Dr. Trombetta: Well it is about three percent; but when you consider the hundreds of thousands of stents placed, many people are affected by this.
What are the benefits for the patient? This is somebody that does not have any other options?
Dr. Trombetta: The best candidates for this procedure have no other option except perhaps cardiac bypass. Some of those patients are not suitable for the bypass, maybe they don’t have good vessels after the blockage, or maybe they are medically not able to go through a big operation like cardiac bypass. Then for people that have to be managed medically, their life expectancies may be shorter. At some point that narrowing might cause someone to have a heart attack.
What is the recovery, does it makes any difference?
Dr. Trombetta: No, it’s really nothing more complex than a catheterization and then the patient goes home.
Can you speak to me about Mike’s case and let me know what’s going on with him? Since he had this procedure and is not a candidate for anything else, could you tell me what was happening at that point?
Dr. Trombetta: He had multiple stents and the attending cardiologist believed that the options were very limited for him. Either bypass, which is, as you know a big operation or just medical management, because he could not have any further stenting done. In his particular case we took him to the catheterization lab, identified a lesion, performed the angioplasty and then placed the radioactive catheter. He did extremely well, the radiation took about six or seven minutes and no side effects, no chest pain during the procedure, no real complications at all and he did quite well afterwards.
Is there anything that I didn’t ask you that you would want to make sure that people know about this particular procedure?
Dr. Trombetta: Well, it’s done almost solely in specialty centers. There is a fair expense to the procedure, fortunately in our case we had our Allegheny General Hospital Auxiliary, which gave money to help us start the program I was just looking at the auxiliary’s history today; it started in 1885.We approached them about it perhaps wanting to contribute to the program and they were very happy to do that. Their main goal or function is to improve patient care, so it was a nice cooperative program with the Auxiliary who have a great and long history of service to AGH.
Is it safe to say that insurance doesn’t cover this at all?
Dr. Trombetta: It is covered by insurance; it is FDA approved so it is covered by insurance. It doesn’t really add much to the overall time of the treatment. The side effects are quite minimal; really any side effects are from the angioplasty, not from the radiation at all. The effectiveness is very high, most of these patients’ arteries stay wide open after we are done.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Mark Trombetta, M.D.
412-359-5822
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