Group 1-Dana, Ryan, Alyx, Joanne, Megan & Travis

IVBT
Purpose/use of IVBT Delivery

People with coronary artery disease have reduced blood flow to the heart due to narrowed
or blocked arteries due to atherosclerosis or plaque formations.1 These patients can have a
cardiac stent or a balloon angioplasty used to dilate the diameter of the arterial lumen to increase
the blood flow.2 While beneficial, these types of procedures are prone to cause restenosis.
Restenosis involves extra tissue growth in the areas where cracks may have formed in the arterial
wall due to the stretching of the lumen during a heart catheter procedure. When drugs can no
longer control restenosis, intravascular brachytherapy can be used to treat restenosis by locally
delivering a small amount of radiation to help limit the overgrowth of tissue.2 IVBT can decrease
restenosis by about 50% for a period of time lasting approximately 5 years. The advantage of
IVBT is that it allows for high conformal dose distribution to the arterial wall while sparing the
surrounding normal vessels due to the sources close proximity and the inverse square fall off.2
The use of IVBT to treat stent induced restenosis is rare and is only used in about 20 out of
10,000 heart catheter patients each year. Candidates for IVBT are usually patients who may have
had two to three other prior catheter related restenosis issues.2

The Insertion of the implant

There are three commonly used catheter-based devices for intravascular brachytherapy (IVBT):
Novoste Beta-Cath, beta-emitting liquid-filled balloon, and radioactive stents.2 The Beta-Cath
and liquid-filled balloon are used for temporary implants while the radioactive stents are used for

Group 1-Dana, Ryan, Alyx, Joanne, Megan & Travis

permanent implant. The Novoste Beta-Cath system is one of the approved devices by the US
Food and Drug Administration (FDA) commonly used in coronary restenosis. It is a manual
afterloader device using high dose rate (HDR) beta sources of Sr-90/Y-90 isotope. The procedure
is performed in the cardiac catheterization laboratory by a team joined by radiation oncologists
and interventional cardiologists. The simulation of the source placement is generated from
contrast-enhanced angiographic images guided by a fluoroscopic image receptor with a live
video camera. The Novoste Beta-Cath system has a triple lumen coronary delivery catheter
connected to a transfer device. The guidewire is inserted through the first lumen to identify the
target treatment area. Once the position of the catheter is confirmed by the cardiologist and
radiation oncologist, the radiation source train containing sealed Sr-90/Y-90 seeds is loaded into
the second lumen in a one-way transportation toward the distal end of the delivery catheter while
the third lumen delivers certain amount sterile water from a syringe with opposite hydraulic
pressure to push the source train forward to the location and to bring the source train back to the
transfer device. The radiation source train has radiopaque nonradioactive tip which can be
identified and tracked on the screen by fluoroscopic image receptor. Prior to the delivery of the
source, cardiologist once again communicates with the radiation oncologist regarding to the
location, dose, and treatment time. Each seed source has an average of 3.5 mCi activities with
8.5 mGy/s dose rate.3 Radiosafety is highly considered in the operating room with adequate
shielding, distance, leakage survey, and mandatory dosimeter badges. See images.4

Group 1-Dana, Ryan, Alyx, Joanne, Megan & Travis

Figure 1: An example of Novoste Beta-Cath system

Group 1-Dana, Ryan, Alyx, Joanne, Megan & Travis

Dose/Fractionation of IVBT

Intravascular Brachytherapy (IVBT) was once commonly used as a technique for keeping the
vessels open and free of scar tissue after angioplasty.1 IVBT can reduce restenosis to below 10%.
Today with the availability of anti-stenotic medications this procedure is not as prevalent.
Interventional cardiologists work with radiation oncologist to deliver precise doses of radiation
to the vessels. Ultrasound or X-ray guided catheters deliver either gamma or beta sources
through a radioactive ribbon, pellet, which is done in one fraction.

Per the AAPM dose formalisms for IVBT are referenced at depth of 2mm radial dose rather than
1cm for traditional brachytherapy and 2mm beyond the lumen for peripheral arteries. 5 A typical
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Group 1-Dana, Ryan, Alyx, Joanne, Megan & Travis

dose usually is 5 GY per minute or total dose of 10-20 Gy to a 2-3 length of arterial wall. This
produces highly conformal dose distribution due sparing normal tissue due to rapid falloff.
Temporary implants via sealed sources or liquid filled balloons can be used or a permanent
implant such as a radioactive stent can be utilized with the later a more desirable method.
Higher energy beta sources are preferred such as strontium-90, yttrium -90, and phosphorus-32.5
Furthermore, a high energy gamma source such as iridium-192 has become more popular as it
offers increased personnel protection and uniform target dose. Additionally IR-192 higher dose
rate delivers treatment in around 5 minutes.6 Ir-192 can also be used as an HDR technique since
the application is small enough to load for IVBT.

Today, there are 3 radiation delivery systems approved for clinical use by the U.S. Food and
Drug Administration for treatment of in-stent coronary restenosis including the following:

1. Novoste beta Cath- a manual afterloader utilizing a catheter to hydraulically administer a

radiation source train. A guidewire travels the vessel paving the way for the sealed sources of
either SR-90 or Y-90 which is further pushed by a syringe of sterile water attached to the device.

2. Beta Emitting liquid filled Balloon-balloon filled with radioactive liquid inserted into the
vessel wall. Emits P-32, Y-90, Re-188. Higher surface dose is obtained with this technique and
potential rupture could be a concern
3. Radioactive stents- a radioactive stent is placed into the vessel utilizing .5 to 5 uCi of beta
isotope. This technique offers less exposure to the personnel.

Group 1-Dana, Ryan, Alyx, Joanne, Megan & Travis

Of note, I spoke with one of our senior physicist he stated that in the past we manually loaded
catheters with phosphorus-32 until purchased a small HDR type machine to deliver Ir -192 to
between 1000 to 2000Gy. We no longer have the machine or do these procedures it has been
replaced by drug inducing stents to prevent clotting.

Treatment Volume

IVBT is a very effective form of treatment for restenosis. An important aspect of treatment is
defining the target volume to treat. The length of the artery being treated is typically 2 to 5 cm,
while the thickness is 0.5 to 2mm in thickness. The radius at which the treatment dose may
extend is about 5 mm. This may seem bigger than the treatment volume but because of the
radiation fall off caused by the inverse square law effect, the dose is conformed to the artery.
This spares the normal tissue, myocardium, and vessels from unnecessary dose. Beta particles
will be the preferred source than y-ray sources because beta particles will give higher dose rate to
the target volume and have faster dose fall off to spare critical structures. The American
Association of Physicists in Medicine recommends that the prescription dose is 2 mm from the
center of the source and 2 mm beyond the average lumen radius for the peripheral arteries. When
checking dose distribution, you should consider dose along the catheter and three planes
perpendicular to the catheter. The targets volumes average, maximum, and minimum dose
should also be reported.2

Group 1-Dana, Ryan, Alyx, Joanne, Megan & Travis

DOSE CALCULATION SYSTEMS FOR IVBT

In order to determine dose distributions for treatment planning systems in regards to

conventional brachytherapy cases, the calculation model of TG-43 formalism was created.2 This
takes into account the:

Dose rate constant,

Air Kerma Strength, Sk at 1 cm

Geometry factor, G(r, )

Radial dose function, g(r)

Anisotropy factor, F(r, )

These factors contribute to the following calculation model to determine the dose rate:

The reference distance for this TG-43 formalism is r0 = 1 cm and the reference angle is
0= /2.
When discussing catheter-based IVBT systems, the TG-43 formalism is slightly modified.1 The
first modification is in regards to catheter-based -ray emitters and takes into account a reference
distance of r0 = 2 mm. Meanwhile the reference angle of 0= /2 remains the same. This is by
recommendation of TG-60. This reference distance of 2 mm applies to all of the factors that
contribute to this calculation model. Therefore, catheter-based -ray emitters can determine dose
at a point by the following equation:

Group 1-Dana, Ryan, Alyx, Joanne, Megan & Travis

When discussing catheter-based -ray emitters, the reference distance is 2 mm, the reference
angle is 0= /2, and air kerma strength, Sk, does not apply. Based on the TG-60 report, dose at a
point for catheter-based -ray emitters can be found based on the following equation:

Quality Assurance

Just like all radioactive sources, the regulation of the NRC is necessary to assure quality
care. Brachytherapy including, intravascular radiotherapy, should have a program designed by
the facility following the AAPM TG 40, 56, and 60.2 Being that the TG 60 is most pertinent to
IVBT quality assurance programs should closely resemble the steps of TG 60.2,8 After further
review of the TG 60 Report, there are 18 key steps of the QA procedure involving intravascular
brachytherapy: 8
1.

Proper radioactive source documentation is required.

2.

Protocols on the purchasing and receiving of sources, to the source commissioning of

source need to be discussed and approved with the radiation safety officer.
3.

Develop a system for the storage and inventory of the sources.

4.

Since intravascular brachytherapy uses sealed sources all must undergo proper seal testing.
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Group 1-Dana, Ryan, Alyx, Joanne, Megan & Travis

5.

Develop a process to determine constant source activity.

6.

Prepare a proper sterilization protocol technique sine sources come into contact to bodily

fluids.
7.

Determine the best system to properly transport the sources to and from different rooms

such as storage and sterilization.

8.

Create a protocol to properly discard sources after use-life.

9.

Procedure equipment must be of access at all time throughout the treatment and placement.

10. Emergency protocols should be made clear to all staff.

11. Lay out precise roles each employee makes for the specific procedure.
12. A treatment planning order must be created and tangible throughout the procedure.
13. Make documentation that there is use of a dose calculation and second calculation checks.
14. Provide a detailed system to make sure the correct source is being used for treatment.
15. Radiation monitoring must be present for the room and patient throughout the entirety of the
procedure.
16. Perform radiation surveys at the conclusion of the procedures.
17. Documentation must be provided to the patient regarding safety after treatment.
18. A radiation safety program must be in effect within the department for all staff.
Without the listed protocols a facility should not be practicing the use of IVBT within their
department.
Although IVBT is a historical procedure in the radiation oncology world, it is still a viable
option of those with recurrent stent failure or restenosis. Giving physicians and patients options
for management of heart disease.

Group 1-Dana, Ryan, Alyx, Joanne, Megan & Travis

References
1. Lenards N, Schmidt K, Berner Paula. Intravascular Brachytherapy. [SoftChalk]. La Crosse,
WI: UW-L Medical Dosimetry Program; 2016.
2. Khan FM. The Physics of Radiation Therapy. 4th ed. Baltimore, MD: Lippincott, Williams,
and Wilkens; 2010: 490-508.
3. Costa R, Joyal M, Harel F, Fox T, Crocker L, Arsenault A, Gregoire J, Ronan R. Treatment of
Bifurcation in-stent restenotic lesions with beta radiation using Strontium 90 and sequential
positioning "Pullback" technique: Procedural details and clinical outcomes. J Invasive Cardiol.
15(8);2003. From Medscape website. http://www.medscape.com/viewarticle/460841. Accessed
April 27, 2016.
4. Images from google.com website. https://www.google.com/search?q=Novoste+BetaCath+system&biw=1455&bih=958&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjGgObja_MAhVHWD4KHZkcDuwQ_AUICSgE#imgrc=m5v6Gqgx7dQlZM%3. Accessed April 27,
2016.
5. Khan F, Gibbons J. The Physics of Radiation Therapy. 5th ed. Philadelphia Pa. Lippincott,
Williams, and Wilkens; 2014: 490-500.
6. Waksman R, Weinberger J. Coronary Brachytherapy in the Drug-Eluting Stent Era Dont
Bury It Alive. Circ Am Heart J.2003; 108: 386-388. doi:
10.1161/01.CIR.0000082928.33891.B7.
7. Dave Wilson, Physics staff at Brown Cancer Center Louisville Kentucky 4/26/16
8. Nath R, Amols H, Coffey C, et al. Intravascular brachytherapy physics: reports of the AAPM
Radiation Therapy Committee Task Group No. 60. Med Phys. 1999; 26: 119-152.

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