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In the study by Jain et al. presented in this issue, vascular brachytherapy was performed, applying a betaradiation source (BetaCath TM) to reduce restenosis rates after PTCA of chronic total occlusions (CTOs). The outcome of radiotherapy after percutaneous revascularization of 82 CTOs were analyzed from the RENO registry database, which contains 1,098 consecutive patients undergoing brachytherapy. The results were comparable with those known for brachytherapy of nonocclusive in-stent restenosis with respect to prevention of new restenosis. Why is this finding remarkable?It has become general knowledge that treating chronic coronary occlusions by conventional PTCA is a "different animal" compared with PTCA of plain coronary artery stenosis [1]. Many studies have shown that restenosis rates are extremely high in patients with CTO, even when stenting is performed [2]. Some institutions leave treatment of symptomatic CTOs primarily to the cardiac surgeon. Revascularization of CTO is favorable over medical treatment at least when treated surgically [3]. Therefore, it is important to realize from the report by Jain et al. that restenosis rates of PTCA in CTO have been reduced dramatically using vascular brachytherapy. However, there is the problem of thrombotic vessel occlusion increasing MACE rates, which needs to be understood and acted on. Brachytherapy was plagued from the beginning with the occurrence of late and "late late" thrombosis [4]. Yet only half of all patients of the RENO registry were kept on the combined antiplatelet therapy of aspirin and clopidogrel for a period of 6 months. In addition, new stents were implanted, which tended to reocclude the coronary arteries. What are the lessons we learn from this report? In the words of Gesta Romanorum: "Quidquid agis, prudenter agas, et respice finem." Whatever you do, do it thoughtfully, and kept in mind the goal.Brachytherapy of chronic coronary occlusions requires special attention to the increased risk of thrombotic vessel occlusion. Potential means for reducing the risks of MACE are as follows: apply aspirin and clopidogrel for a minimum period of 12 months (perhaps as lifelong addition of clopidogrel to aspirin medication); use a minimum of new stents to reduce foreign-body activation of platelets; study an increased loading and maintenance dose of clopidogrel in a randomized fashion in the setting of CTO; and, most importantly, remember that CTO patents only benefit from revascularization if viable myocardium is present [5].Mixed results were obtained by other investigators in two recent studies applying brachytherapy in CTO. One group reported similar efficacy and complication rates with intracoronary brachytherapy of occluded in-stent restenosis using a gamma-emitter (Ir-192) compared with irradiation for nonocclusive in-stent restenosis [6]. The other group, however, clearly pointed out that radiotherapy of total occlusions from in-stent restenosis causes increased MACE rates compared with brachytherapy of plain in-stent restenosis [7]. In summary, m...
In the study by Jain et al. presented in this issue, vascular brachytherapy was performed, applying a betaradiation source (BetaCath TM) to reduce restenosis rates after PTCA of chronic total occlusions (CTOs). The outcome of radiotherapy after percutaneous revascularization of 82 CTOs were analyzed from the RENO registry database, which contains 1,098 consecutive patients undergoing brachytherapy. The results were comparable with those known for brachytherapy of nonocclusive in-stent restenosis with respect to prevention of new restenosis. Why is this finding remarkable?It has become general knowledge that treating chronic coronary occlusions by conventional PTCA is a "different animal" compared with PTCA of plain coronary artery stenosis [1]. Many studies have shown that restenosis rates are extremely high in patients with CTO, even when stenting is performed [2]. Some institutions leave treatment of symptomatic CTOs primarily to the cardiac surgeon. Revascularization of CTO is favorable over medical treatment at least when treated surgically [3]. Therefore, it is important to realize from the report by Jain et al. that restenosis rates of PTCA in CTO have been reduced dramatically using vascular brachytherapy. However, there is the problem of thrombotic vessel occlusion increasing MACE rates, which needs to be understood and acted on. Brachytherapy was plagued from the beginning with the occurrence of late and "late late" thrombosis [4]. Yet only half of all patients of the RENO registry were kept on the combined antiplatelet therapy of aspirin and clopidogrel for a period of 6 months. In addition, new stents were implanted, which tended to reocclude the coronary arteries. What are the lessons we learn from this report? In the words of Gesta Romanorum: "Quidquid agis, prudenter agas, et respice finem." Whatever you do, do it thoughtfully, and kept in mind the goal.Brachytherapy of chronic coronary occlusions requires special attention to the increased risk of thrombotic vessel occlusion. Potential means for reducing the risks of MACE are as follows: apply aspirin and clopidogrel for a minimum period of 12 months (perhaps as lifelong addition of clopidogrel to aspirin medication); use a minimum of new stents to reduce foreign-body activation of platelets; study an increased loading and maintenance dose of clopidogrel in a randomized fashion in the setting of CTO; and, most importantly, remember that CTO patents only benefit from revascularization if viable myocardium is present [5].Mixed results were obtained by other investigators in two recent studies applying brachytherapy in CTO. One group reported similar efficacy and complication rates with intracoronary brachytherapy of occluded in-stent restenosis using a gamma-emitter (Ir-192) compared with irradiation for nonocclusive in-stent restenosis [6]. The other group, however, clearly pointed out that radiotherapy of total occlusions from in-stent restenosis causes increased MACE rates compared with brachytherapy of plain in-stent restenosis [7]. In summary, m...
A comparative kinetic study of the dibutyltin dilaurate (DBTDL) and 1,4‐diazabicyclo[2,2,2]octane (DABCO) catalyzed reactions of α,ω‐bis(hydroxy)‐terminated fluoropolyethers (FPEs)—Z‐DOLs and Z‐DOL TXs—of various molecular weights and purity, with 4,4′‐dicyclohexylmethane diisocyanate (H12MDI), isophorone diisocyanate (IPDI) and 2,4‐toluene diisocyanate (TDI) was carried out in different solvents. An analytical method was used to follow the kinetics of the reactions at four different temperatures. The rate of NCO disappearance measured by two independent methods—IR spectroscopy and chemical titration were found to be very close. Straight proportionality between rate constants kcat and catalyst concentration was found. But in some cases for the DBTDL catalyzed reactions effect of catalyst saturation along with appearance of the limiting DBTDL concentration Clim below which the rate of reaction was close to zero were observed. Reactivity of Z‐DOLs in the tin‐catalyzed urethane reactions was found to decrease with their storage time at RT due to the slow hydrolysis of the end COOR groups impurities, which give the corresponding acids that act as a strong inhibitor of the DBTDL activity. These acid admixtures have no influence on the DABCO catalyzed reactions. For the DBTDL and DABCO catalyzed reactions of Z‐DOLs with IPDI the dependence of effective rate constants keff (where keff = kcat · 0.01/[DBTDL] and catalyst concentration is taken in mol % based on IPDI) on total reagents concentration were found to be described by curves with a maximum. Critical reagents concentration, after which the relationship keff = f (C) changes from proportional to inverse proportional, seems do not substantially depend on the solvent nature. Hydrogenated analog poly(ethylene glycol) MW 400 (PEG‐400) differs greatly from Z‐DOLs: only steady decrease of keff was observed with increase of reagents concentration C from 5 up to 95 wt %. Activation energies for all the studied reactions are within the range of 10.8–16.7 kcal/mol. © 2000 John Wiley & Sons, Inc. J Polym Sci A: Polym Chem 38: 2579–2602, 2000
The effect of catalyst dibutyltin dilaurate (DBTDL) on the kinetics of urethane formation reactions of ␣,-bis(hydroxy)-terminated fluoropolyethers Fomblin ® Z-DOL TXs (FPEs) of various molecular weights and poly(oxyethylene) glycol PEG-400 with isophorone diisocyanate (IPDI) in hexafluoroxylene (HFX) and tetrahydrofuran (THF) at 40°C and NCO:OH ϭ 2:1 have been studied in a broad range of catalyst (0.10 -9.00) ϫ10 Ϫ4 M and total reagents (10.0 -60.1 wt %) concentrations. The rate of tin-catalyzed second-order reactions (with respect to diol and diisocyanate) was found to be proportional to the square root of catalyst concentration [DBTDL] 0.5 both in low polar (HFX) and polar (THF) solvents. Effect of catalyst saturation was revealed for all the reaction systems at higher DBTDL concentrations as well as the appearance of the limiting catalyst concentrations C lim below which the rates of reaction were close to zero. Based on these findings new effective rate coefficients have been derived kЈ eff ϭ k cat /(C cat 0.5 Ϫ C lim 0.5 ) that are independent of the total reagent concentration in the range of 10.0 -60.1 wt % ([OH] ϭ 0.10 -0.91 equiv/L). This new approach highlights that the rate of the tin-catalyzed urethane formation reactions of ␣,-bis(hydroxy)terminated fluoropolyethers Z-DOL TXs with IPDI in HFX at 40°C and NCO:OH ϭ 2:1 increases significantly with increasing MW of FPE from 776 up to 3405.
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