To the Editor: Dr Holmes and colleagues1 reported the results of the Sirolimus-Eluting Stent vs Brachytherapy in Patients With Bare Metal In-Stent Restenosis (SISR) trial, in which they demonstrated that sirolimus-eluting stents are superior to brachytherapy in patients with in-stent restenosis. Rather than merely abandoning brachytherapy because of logistical difficulties, it would be helpful if the authors provided additional information.
First, because the irradiated segment (39.7 mm) was longer than the segment covered by sirolimus-eluting stents (32.4 mm), the “analysis segment” was biased in a way that would penalize the brachytherapy group. Adjusting the results for the difference in the analysis segment lengths in the 2 groups would be important.
Second, the geographic miss phenomenon after brachytherapy may be clinically important.2 The unexpectedly high number of edge restenoses in the brachytherapy group raises a question of whether the efforts made by the investigators to prevent this phenomenon were insufficient. This is suggested not only by the pattern of recurrent in-stent restenosis, but the late loss (0.23 mm vs 0.33 mm, respectively) and restenosis rate (17.1% vs 18.1%, respectively) at the “injured segment” were marginally lower in the brachytherapy group compared with the sirolimus-eluting stent group. Therefore, extending irradiation to only 5 mm beyond the injured margins might have been too conservative. Finally, no data regarding duration of clopidogrel therapy or its potential association with these complications were provided.
It remains possible that brachytherapy could still benefit selected patients with recurrent in-stent restenosis after receiving sirolimus-eluting stents.
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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