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Das solu&#231;&#245;es tentadas para controlar essa hiperplasia da neo&#237;ntima&#44; a braquiterapia &#40;BT&#41; com radia&#231;&#227;o intracoron&#225;ria pelo seu mais potente efeito antiproliferativo<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;6</span></a> foi a que apresentou melhores resultados&#46; V&#225;rios estudos aleatorizados com radia&#231;&#227;o gama e beta comprovaram a sua efic&#225;cia e seguran&#231;a<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;11</span></a>&#46; Em novembro de 2000&#44; ap&#243;s a sua aprova&#231;&#227;o pela <span class="elsevierStyleItalic">Food and Drug Administration</span> &#40;FDA&#41;&#44; a t&#233;cnica ficou estabelecida como adjuvante da angioplastia de bal&#227;o para RIS at&#233; &#224; data<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a>&#46; No entanto&#44; a efic&#225;cia cl&#237;nica da BT a longo prazo tem sido questionada<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> e poucos estudos t&#234;m sido publicados com seguimentos tardios ap&#243;s BT com radia&#231;&#227;o beta<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;20</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">O presente estudo tem por objetivo analisar a &#250;nica experi&#234;ncia portuguesa de BT com radia&#231;&#227;o beta em 2001 e avaliar a sua efic&#225;cia e seguran&#231;a tardias&#44; num seguimento cl&#237;nico superior a dez anos&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Popula&#231;&#227;o e m&#233;todos</span><p id="par0015" class="elsevierStylePara elsevierViewall">Foram inclu&#237;dos nesta an&#225;lise 12 doentes consecutivos&#44; submetidos a BT com radia&#231;&#227;o beta para restenose difusa <span class="elsevierStyleItalic">intrastent</span>&#44; entre janeiro e julho de 2001&#46; Os doentes foram selecionados por apresentarem restenose difusa de <span class="elsevierStyleItalic">stents</span> met&#225;licos previamente implantados que foi definida como tendo estenose &#8805;<span class="elsevierStyleHsp" style=""></span>50&#37; e comprimento &#8805;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A m&#233;dia de idades dos doentes era 58&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#44;9 anos &#40;43&#8208;77 anos&#41;&#44; 11 eram do sexo masculino&#46; A preval&#234;ncia dos principais fatores de risco foi dislipidemia em nove doentes &#40;75&#37;&#41;&#44; a hipertens&#227;o arterial em sete doentes &#40;58&#37;&#41; e a diabetes em cinco doentes &#40;42&#37;&#41;&#46; Seis doentes &#40;50&#37;&#41; tinham doen&#231;a vascular perif&#233;rica associada&#46; Todos os doentes tinham angina est&#225;vel havendo hist&#243;ria pr&#233;via de enfarte em quatro &#40;33&#37;&#41; e de cirurgia coron&#225;ria em tr&#234;s &#40;25&#37;&#41;&#46; Havia doen&#231;a de multivaso em oito doentes e apenas um tinha depress&#227;o da fun&#231;&#227;o ventricular esquerda&#46; Tratava&#8208;se da primeira RIS em seis doentes&#44; da segunda em quatro e da terceira em dois&#46; Apenas uma restenose era proliferativa&#46; Todos os indiv&#237;duos faziam terap&#234;utica m&#233;dica m&#225;xima tolerada com aspirina&#44; estatinas&#44; nitratos&#44; bloqueadores beta&#44; antagonistas do c&#225;lcio e inibidores da enzima de convers&#227;o da angiotensina &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A an&#225;lise quantitativa das coronariografias foi realizada usando o sistema CAAS 2&#8482; <span class="elsevierStyleItalic">&#40;Cardiovascular Angiographic Analysis System&#41;</span>&#46; Como refer&#234;ncia foi usado o di&#226;metro do cateter guia de angioplastia&#46; Analisaram&#8208;se quantitativamente o di&#226;metro do vaso de refer&#234;ncia&#44; o comprimento da les&#227;o&#44; o grau de estenose e o di&#226;metro luminal m&#237;nimo &#40;MLD&#41;&#46; Foi considerada restenose angiogr&#225;fica a presen&#231;a de uma estenose intraluminal e <span class="elsevierStyleItalic">intrastent</span> &#8805;<span class="elsevierStyleHsp" style=""></span>50&#37;&#46; Importa real&#231;ar o comprimento longo das les&#245;es tratadas &#40;de 40&#8208;90<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; em vasos pequenos com di&#226;metro m&#233;dio do vaso de refer&#234;ncia de 2&#44;5<span class="elsevierStyleHsp" style=""></span>mm &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Usou&#8208;se para a BT a radia&#231;&#227;o intracoron&#225;ria beta com <span class="elsevierStyleSup">90</span>Sr&#47;Y<span class="elsevierStyleSup">90</span> &#40;Beta&#8208;Cath&#8482;&#47;Novoste&#41;&#46; Foi escolhida a radia&#231;&#227;o beta porque n&#227;o requeria altera&#231;&#245;es log&#237;sticas do laborat&#243;rio de hemodin&#226;mica&#44; necess&#225;rias com a radia&#231;&#227;o gama&#46; Foi estabelecido um protocolo com o Instituto Portugu&#234;s de Oncologia Francisco Gentil de Lisboa&#44; do qual fizeram parte radioterapeutas e f&#237;sicos&#46; Todos os doentes deram o seu consentimento informado e a Comiss&#227;o de &#201;tica do Hospital de Santa Cruz deu parecer favor&#225;vel&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Todos os procedimentos foram efetuados por acesso femoral com cateteres guia 8<span class="elsevierStyleHsp" style=""></span>F&#46; Ap&#243;s a angiografia de controlo e a confirma&#231;&#227;o da RIS&#44; o cateter diagn&#243;stico foi substitu&#237;do por cateter guia de angioplastia&#46; A les&#227;o foi atravessada por fio guia 0&#44;014<span class="elsevierStyleHsp" style=""></span>¿¿ de angioplastia e foi feita a dilata&#231;&#227;o da restenose com bal&#227;o de di&#226;metro e comprimento adaptado ao di&#226;metro do vaso e comprimento das les&#245;es&#46; O cateter de fornecimento da BT com radia&#231;&#227;o beta &#40;Beta&#8208;Cath&#8482; Delivery Catheter&#41; &#233; um cateter 5<span class="elsevierStyleHsp" style=""></span>F de triplo l&#250;men para o fio guia&#44; para fornecimento da radia&#231;&#227;o e para preenchimento com soro fisiol&#243;gico&#46; Usaram&#8208;se exclusivamente cateteres de 40<span class="elsevierStyleHsp" style=""></span>mm de comprimento&#46; O cateter foi avan&#231;ado atrav&#233;s do fio guia&#44; iniciando&#8208;se a aplica&#231;&#227;o de radia&#231;&#227;o pela parte mais distal at&#233; &#224; parte mais proximal da les&#227;o&#44; ultrapassando&#8208;se sempre para a por&#231;&#227;o do territ&#243;rio vascular adjacente sem doen&#231;a angiograficamente detet&#225;vel&#46; Fez&#8208;se um ou mais per&#237;odos de BT de acordo com o comprimento das les&#245;es &#40;um em sete doentes&#44; dois em tr&#234;s doentes e tr&#234;s per&#237;odos em dois doentes&#41;&#46; A dose e o tempo de radia&#231;&#227;o variou de acordo com tabelas pr&#233;&#8208;definidas para o di&#226;metro do vaso&#47;<span class="elsevierStyleItalic">stent</span> &#40;18&#44;4<span class="elsevierStyleHsp" style=""></span>Gr para di&#226;metros &#8805;<span class="elsevierStyleHsp" style=""></span>2&#44;7 e &#60;<span class="elsevierStyleHsp" style=""></span>3&#44;35<span class="elsevierStyleHsp" style=""></span>mm com tempo de radia&#231;&#227;o de 215<span class="elsevierStyleHsp" style=""></span>seg e 23&#44;0<span class="elsevierStyleHsp" style=""></span>Gr para vasos &#62;<span class="elsevierStyleHsp" style=""></span>3&#44;35 e &#8804;<span class="elsevierStyleHsp" style=""></span>4&#44;00<span class="elsevierStyleHsp" style=""></span>mm com tempo de radia&#231;&#227;o de 268<span class="elsevierStyleHsp" style=""></span>seg&#41;&#46; Sempre que necess&#225;rio&#44; as les&#245;es voltaram a ser dilatadas com o cateter de bal&#227;o usado inicialmente&#46; Todas as manobras de manipula&#231;&#227;o da radia&#231;&#227;o desde a sua fonte at&#233; ao cateter e a sua aplica&#231;&#227;o foram efetuadas pelos f&#237;sicos e radioterapeutas&#46; Todos os outros passos da t&#233;cnica foram executados por cardiologistas&#46; Foram efetuadas an&#225;lises quantitativas das v&#225;rias angiografias antes&#44; durante e ap&#243;s o procedimento&#46; A dose de heparina inicial foi de 5000 unidades e 2500<span class="elsevierStyleHsp" style=""></span>U por cada hora adicional ou de acordo com o tempo de coagula&#231;&#227;o ativado &#40;ACT&#41; regularmente avaliado&#46; Em 11 dos 12 doentes foi administrado abciximab profilaticamente&#46; O tempo m&#233;dio de radioescopia foi de 10&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>min &#40;4&#44;8&#8208;24&#44;4&#41; e o tempo m&#233;dio do procedimento de 50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16<span class="elsevierStyleHsp" style=""></span>min&#46; &#40;33&#8208;79&#41;&#46;Foram definidos&#44; como sucesso angiogr&#225;fico&#44; a estenose residual m&#225;xima no final no segmento tratado &#60; 50&#37; e&#44; como sucesso clinico&#44; a presen&#231;a de sucesso angiogr&#225;fico na aus&#234;ncia de complica&#231;&#245;es cl&#237;nicas durante o internamento hospitalar&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A medica&#231;&#227;o inicial foi mantida com institui&#231;&#227;o de dupla antiagrega&#231;&#227;o plaquet&#225;ria &#40;DAP&#41; com aspirina e clopidogrel ou ticlopidina&#46; Todos os doentes foram seguidos regularmente at&#233; ao presente ou at&#233; &#224; morte e em todos foi programada coronariografia de controlo aos nove meses ap&#243;s a interven&#231;&#227;o&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">No seguimento cl&#237;nico obtido e de acordo com a defini&#231;&#227;o do <span class="elsevierStyleItalic">Academic Research Consortium</span> &#40;ARC&#41;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> foram considerados os seguintes objetivos para an&#225;lise&#58; a morte cardiovascular e de qualquer causa&#44; qualquer enfarte do mioc&#225;rdio&#44; qualquer nova revasculariza&#231;&#227;o&#44; restenose angiogr&#225;fica e incid&#234;ncia de trombose de <span class="elsevierStyleItalic">stent</span> de acordo com a nova defini&#231;&#227;o ARC<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46; Foi avaliada tamb&#233;m a incid&#234;ncia hier&#225;rquica do evento combinado de morte cardiovascular&#44; EM n&#227;o fatal e TVR urgente&#44; definido como MACE&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">An&#225;lise estat&#237;stica</span><p id="par0055" class="elsevierStylePara elsevierViewall">Nesta an&#225;lise&#44; os grupos de doentes foram caracterizados segundo vari&#225;veis cont&#237;nuas e categ&#243;ricas&#46; As vari&#225;veis categ&#243;ricas foram caracterizadas recorrendo a frequ&#234;ncias absolutas e frequ&#234;ncias relativas&#46; A caracteriza&#231;&#227;o da tend&#234;ncia central e a da dispers&#227;o dos valores das vari&#225;veis cont&#237;nuas foi estimada recorrendo &#224; m&#233;dia amostral e ao desvio padr&#227;o&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">A an&#225;lise da sobreviv&#234;ncia livre de eventos foi efetuada com recurso &#224;s curvas de Kaplan&#8208;Meier&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">A an&#225;lise estat&#237;stica foi realizada com o <span class="elsevierStyleItalic">software</span> estat&#237;stico SPSS&#44; vers&#227;o 19&#46;0&#46;0&#46;2&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Resultados</span><p id="par0070" class="elsevierStylePara elsevierViewall">Obteve&#8208;se sucesso angiogr&#225;fico e cl&#237;nico do procedimento em todos os doentes&#46; O grau de estenose reduziu&#8208;se de 64&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;9 para 25&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;3&#37; e o di&#226;metro luminal m&#237;nimo aumentou de 1&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;12 para 2&#44;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;32<span class="elsevierStyleHsp" style=""></span>mm&#46; N&#227;o se verificaram quaisquer eventos cl&#237;nicos durante o internamento hospitalar&#46;No seguimento clinico aos 9 meses&#44; apenas 1 doente mantinha queixas de angor&#44; tendo sido documentada restenose e esse doente foi posteriormente submetido a revasculariza&#231;&#227;o cir&#250;rgica&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Realizou&#8208;se o seguimento em 100&#37; dos doentes durante 10&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;5 anos &#40;130<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30 meses&#41;&#46; Ocorreram 19 eventos em sete doentes &#40;<a class="elsevierStyleCrossRefs" href="#tbl0015">Tabelas 3 e 4</a>&#41;&#46; Tr&#234;s doentes faleceram &#40;25&#37;&#41;&#44; um de neoplasia aos 90 meses ap&#243;s a BT e um doente por s&#233;psis aos 132 meses&#44; nenhum dos dois teve qualquer evento card&#237;aco ap&#243;s a BT&#46; Registou&#8208;se uma morte s&#250;bita card&#237;aca &#40;8&#44;3&#37;&#41; aos 43 meses ap&#243;s a BT&#44; poucos dias depois de ter sido submetido a angioplastia e implanta&#231;&#227;o de dois <span class="elsevierStyleItalic">stents</span> farmacol&#243;gicos num vaso distinto do tratado por BT&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Aos 120 meses ap&#243;s BT um doente sofreu um EAM com eleva&#231;&#227;o de ST&#44; por trombose de <span class="elsevierStyleItalic">stent</span> implantado num vaso n&#227;o alvo &#40;8&#44;3&#37;&#41;&#44; tendo sido submetido a angioplastia prim&#225;ria com sucesso&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Cinco doentes &#40;42&#37;&#41; foram submetidos a 15 novas revasculariza&#231;&#245;es&#46; Todos estes doentes tiveram pelo menos uma revasculariza&#231;&#227;o do vaso alvo &#40;no total de nove&#41;&#44; sobretudo nos primeiros dois anos&#44; incluindo quatro doentes &#40;33&#44;3&#37;&#41; submetidos a cirurgia de revasculariza&#231;&#227;o coron&#225;ria&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">A primeira revasculariza&#231;&#227;o do vaso alvo ocorreu em m&#233;dia 12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#44;5 meses ap&#243;s a BT &#40;de 9&#8208;21 meses&#41;&#46; De notar que dos cinco doentes que foram submetidos a revasculariza&#231;&#227;o do vaso alvo&#44; tr&#234;s foram&#8208;no na sequ&#234;ncia da angiografia eletiva agendada&#44; que revelou restenose do vaso alvo&#44; sendo que dois estavam assintom&#225;ticos&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Ocorreu uma trombose de <span class="elsevierStyleItalic">stent</span> definitiva&#44; j&#225; referida&#44; num vaso n&#227;o alvo &#40;1&#47;12<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#44;3&#37;&#41;&#44; 120 meses ap&#243;s a BT&#44; num indiv&#237;duo submetido tr&#234;s meses antes a angioplastia com bal&#227;o eluidor de f&#225;rmaco de uma restenose de <span class="elsevierStyleItalic">stent</span> eluidor de f&#225;rmaco previamente implantado neste vaso&#46; Um doente teve uma trombose de <span class="elsevierStyleItalic">stent</span> prov&#225;vel &#40;1&#47;12<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#44;3&#37;&#41;&#44; por morte s&#250;bita&#44; ocorrida ap&#243;s revasculariza&#231;&#227;o dum vaso n&#227;o alvo&#44; 45 meses ap&#243;s a BT&#46; N&#227;o se registaram tromboses de <span class="elsevierStyleItalic">stent</span> poss&#237;veis nem qualquer trombose de <span class="elsevierStyleItalic">stent</span> definitiva ou prov&#225;vel nos vasos previamente submetidos a BT&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">No seguimento de dez anos a incid&#234;ncia de MACE foi de 16&#44;6&#37; &#40;dois doentes&#41;&#58; uma morte s&#250;bita e um doente com EAM n&#227;o fatal com eleva&#231;&#227;o de ST&#46; Nenhum doente teve qualquer revasculariza&#231;&#227;o urgente do vaso alvo&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">A coronariografia de controlo para avalia&#231;&#227;o da restenose foi realizada em m&#233;dia 271&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>50&#44;6 dias ap&#243;s a BT&#44; nos 11 doentes que aceitaram realiz&#225;&#8208;la&#46; A taxa de restenose angiogr&#225;fica nestes doentes foi de 27&#37; &#40;3&#47;11 doentes&#41;&#44; observando&#8208;se oclus&#227;o assintom&#225;tica do vaso alvo em dois casos &#40;2&#47;11<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>18&#37;&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A taxa de sobreviv&#234;ncia livre de qualquer evento cardiovascular aos dez anos foi de 42&#37; &#40;5 doentes&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discuss&#227;o</span><p id="par0120" class="elsevierStylePara elsevierViewall">O presente trabalho apresenta os resultados iniciais e a longo prazo&#44; da &#250;nica e limitada experi&#234;ncia&#44; da radia&#231;&#227;o intracoron&#225;ria para tratamento da restenose difusa <span class="elsevierStyleItalic">intrastents</span> met&#225;licos em Portugal&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">O pequeno n&#250;mero de doentes tratados n&#227;o permite tirar ila&#231;&#245;es sobre o valor da BT comparativamente a outras t&#233;cnicas usadas na altura para o tratamento da restenose <span class="elsevierStyleItalic">intrastent</span>&#46; No entanto&#44; o seguimento cl&#237;nico a t&#227;o longo prazo oferece a oportunidade de contribuir para o conhecimento dos efeitos tardios da radia&#231;&#227;o intracoron&#225;ria&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Na altura da introdu&#231;&#227;o da t&#233;cnica em Portugal&#44; a BT constitu&#237;a a melhor alternativa para o tratamento da RIS&#44; que se revelava a maior limita&#231;&#227;o ao uso mais alargado de <span class="elsevierStyleItalic">stents</span> met&#225;licos em certas situa&#231;&#245;es&#44; como les&#245;es longas&#44; restenoses repetitivas e em doentes diab&#233;ticos&#46; V&#225;rios estudos revelaram a sua efic&#225;cia e seguran&#231;a a curto prazo&#44; com vantagem comparativamente a tratamentos farmacol&#243;gicos&#44; dilata&#231;&#227;o com bal&#227;o ou <span class="elsevierStyleItalic">cutting balloon</span>&#44; aterectomia rotacional&#44; laser intracoron&#225;rio ou <span class="elsevierStyleItalic">stent intrastent</span><a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;11&#44;22</span></a>&#46; As preocupa&#231;&#245;es relativamente &#224; BT resultaram sobretudo de tr&#234;s fatores&#58; 1&#41; o fen&#243;meno chamado <span class="elsevierStyleItalic">geographic miss</span> pelo qual a radia&#231;&#227;o podia n&#227;o cobrir os bordos proximais e distais dos <span class="elsevierStyleItalic">stents</span> provocando novas estenoses&#59; 2&#41; a possibilidade de trombose dos <span class="elsevierStyleItalic">stents&#59;</span> e 3&#41; a possibilidade de restenose tardia do vaso alvo da BT &#40;chamado <span class="elsevierStyleItalic">late catch&#8208;up</span>&#41;&#46; Na nossa experi&#234;ncia&#44; os dois primeiros problemas tinham sido j&#225; incorporados ao termos usado uma fonte de radia&#231;&#227;o de 40<span class="elsevierStyleHsp" style=""></span>mm com t&#233;cnica de <span class="elsevierStyleItalic">pull back</span> e por terem todos feito dupla antiagrega&#231;&#227;o plaquet&#225;ria&#44; com tienopiridinas associadas &#224; aspirina pelo menos at&#233; &#224; angiografia de controlo&#46; O longo per&#237;odo de seguimento obtido poderia elucidar o risco e a dimens&#227;o da restenose tardia e da trombose de <span class="elsevierStyleItalic">stent</span> do segmento irradiado&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">N&#227;o houve complica&#231;&#245;es imediatas&#44; cl&#237;nicas ou de vaso&#44; em todos os doentes submetidos a BT e os resultados iniciais foram excelentes na angiografia quantificada&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">No nosso estudo&#44; a taxa de restenose &#40;27&#37;&#41; na angiografia de controlo aos nove meses est&#225; de acordo com o descrito na literatura&#46; Nos v&#225;rios estudos aleatorizados com radia&#231;&#227;o beta para RIS&#44; a taxa de restenose aos 6&#8208;9 meses foi em m&#233;dia de 30&#37; &#40;26&#8208;34&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11</span></a>&#46; O que surpreende foi a ocorr&#234;ncia em doentes assintom&#225;ticos e sem qualquer s&#237;ndrome coron&#225;ria aguda&#44; de duas restenoses por oclus&#227;o do vaso alvo &#40;18&#37;&#41; apesar da DAP&#46; Numa revis&#227;o de Walksman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> em 473 doentes&#44; ap&#243;s BT com radia&#231;&#227;o beta e gama&#44; a oclus&#227;o tardia &#40;&#62;<span class="elsevierStyleHsp" style=""></span>30 dias&#41; ocorreu em 9&#44;1&#37; dos doentes que fizeram apenas um m&#234;s de DAP&#46; Destes&#44; apenas uma minoria &#40;7&#37;&#41; teve oclus&#227;o assintom&#225;tica&#44; enquanto 43&#37; tiveram enfarte agudo e 50&#37; angina inst&#225;vel&#46; A possibilidade de restenose tardia ap&#243;s BT para RIS era reconhecida em estudos de seguimento mais longo at&#233; cinco anos&#44; sendo respons&#225;vel pela continuada e tardia necessidade de revasculariza&#231;&#227;o do vaso alvo<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Neste estudo e no seguimento m&#233;dio de dez anos ap&#243;s o tratamento com BT&#44; a incid&#234;ncia de eventos cardiovasculares <span class="elsevierStyleItalic">majo</span>r foi de 16&#44;6&#37;&#46; Este valor pode ser considerado baixo tendo em conta a gravidade dos doentes tratados e o longo seguimento cl&#237;nico&#46; Em estudos com seguimento at&#233; um ano&#44; a incid&#234;ncia de eventos <span class="elsevierStyleItalic">major</span> foi em m&#233;dia de 23&#37; &#40;15&#8208;34&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11</span></a>&#46; No &#250;nico estudo publicado com seguimento a dez anos do Thoraxcenter<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#44; incluiu 124 doentes com BT para tratamento da RIS&#44; a incid&#234;ncia de morte por qualquer causa foi de 16&#37; e de morte ou enfarte n&#227;o fatal foi de 25&#37;&#46; A incid&#234;ncia associada de mortalidade global&#44; qualquer enfarte e qualquer nova revasculariza&#231;&#227;o foi nestes doentes de 70&#37;&#44; devido sobretudo a novas revasculariza&#231;&#245;es do vaso alvo &#40;47&#37;&#41;&#44; que ocorreram entre os cinco meses e dois anos de seguimento&#46; A restenose tardia <span class="elsevierStyleItalic">&#40;late catch&#8208;up&#41;</span> ap&#243;s radia&#231;&#227;o beta verificou&#8208;se sobretudo nos doentes sem <span class="elsevierStyleItalic">stents &#40;</span>les&#245;es <span class="elsevierStyleItalic">de novo&#41;</span>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Em rela&#231;&#227;o aos receios do aumento da incid&#234;ncia de eventos coron&#225;rios agudos&#44; durante este longo per&#237;odo de seguimento&#44; apenas um doente &#40;8&#44;3&#37;&#41; teve uma s&#237;ndroma coron&#225;ria aguda&#44; complica&#231;&#227;o de uma angioplastia pr&#233;via noutro vaso&#46; A &#250;nica morte cardiovascular ocorre tardiamente e na sequ&#234;ncia quase imediata de uma angioplastia complexa num vaso n&#227;o alvo&#46; Podemos considerar&#44; com alguma seguran&#231;a&#44; que estes eventos coron&#225;rios agudos dificilmente poder&#227;o ser atribu&#237;dos &#224; BT&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Na nossa experi&#234;ncia&#44; 42&#37; dos doentes &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41; necessitaram de m&#250;ltiplas &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#41; revasculariza&#231;&#245;es dos vasos previamente tratados por BT&#46; Esta percentagem &#233; elevada&#44; quando comparada com a efic&#225;cia atual dos <span class="elsevierStyleItalic">stents</span> eluidores de f&#225;rmacos&#44; aspeto posto em evid&#234;ncia nos ensaios comparativos com a BT<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;28</span></a>&#46; No entanto&#44; devemos considerar a complexidade da popula&#231;&#227;o estudada&#58; 50&#37; com mais de uma restenose pr&#233;via do segmento tratado&#44; 67&#37; com doen&#231;a multivaso&#44; 42&#37; de diab&#233;ticos e 50&#37; com doen&#231;a arterial perif&#233;rica&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">O facto de se ter programado angiografia de controlo aos nove meses poder&#225; ter implica&#231;&#245;es na taxa de novas revasculariza&#231;&#245;es observadas&#46; &#201; conhecido desde o estudo BENETENT II o fen&#243;meno do reflexo &#243;culo&#8208;esten&#243;tico<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&#46; Dos cinco doentes submetidos a revasculariza&#231;&#227;o do vaso alvo&#44; quatro doentes fizeram&#8208;no por restenose angiogr&#225;fica sem queixas de angor ou sem teste de isquemia positivo &#224; data do procedimento &#40;angioplastia n&#227;o guiada por isquemia&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">A efic&#225;cia demonstrada pelos <span class="elsevierStyleItalic">stents</span> revestidos no tratamento das restenoses <span class="elsevierStyleItalic">intrastent</span> veio diminuir a utiliza&#231;&#227;o de BT para esse efeito&#46; Numa meta&#8208;an&#225;lise de estudos aleatorizados&#44; comparando <span class="elsevierStyleItalic">stents</span> revestidos de primeira gera&#231;&#227;o &#40;sirolimus e paclitaxel&#41; com angioplastia de bal&#227;o ou BT no tratamento da RIS&#44; verificou&#8208;se uma redu&#231;&#227;o de 64&#37; na taxa de restenose angiogr&#225;fica e de 65&#37; nas revasculariza&#231;&#245;es do vaso alvo&#44; sem diferen&#231;as na incid&#234;ncia de morte ou enfarte&#44; num seguimento cl&#237;nico de 9&#8208;12 meses<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; No estudo TAXUS V ISR<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#44; os <span class="elsevierStyleItalic">stents</span> revestidos com placlitaxel comparados com a BT com radia&#231;&#227;o beta diminu&#237;ram de forma significativa a necessidade da revasculariza&#231;&#227;o do vaso alvo por raz&#245;es isqu&#233;micas &#40;18&#44;1 <span class="elsevierStyleItalic">versus</span> 27&#44;5&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41;&#44; num seguimento a dois anos&#46; No estudo SISR<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> comparando <span class="elsevierStyleItalic">stents</span> revestidos com sirolimus com BT com radia&#231;&#227;o beta ou gama e seguimento a tr&#234;s anos&#44; as revasculariza&#231;&#245;es do vaso alvo n&#227;o foram estatisticamente inferiores com os <span class="elsevierStyleItalic">stents</span> &#40;20&#44;8 <span class="elsevierStyleItalic">versus</span> 29&#44;6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;073&#41;&#46; A revasculariza&#231;&#227;o do vaso alvo manteve&#8208;se semelhante no seguimento a cinco anos do mesmo estudo &#40;24&#44;7&#37; com <span class="elsevierStyleItalic">stents</span> de sirolimus <span class="elsevierStyleItalic">versus</span> 31&#44;2&#37; com BT&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;179&#41;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&#46; Noutro estudo mais recente de Wiemer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> comparando BT com radia&#231;&#227;o beta e <span class="elsevierStyleItalic">stents</span> revestidos com sirolimus e seguimento a tr&#234;s anos&#44; a revasculariza&#231;&#227;o do vaso alvo que era aos seis meses de 10&#44;4&#37; com BT &#40;<span class="elsevierStyleItalic">versus</span> 2&#44;3&#37; para os <span class="elsevierStyleItalic">stents</span>&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;25&#41; aumentou aos tr&#234;s anos para 46&#44;7&#37; &#40;comparativamente aos 11&#44;6&#37; com <span class="elsevierStyleItalic">stents</span>&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Um aspeto que vale a pena salientar neste seguimento longo &#233; que dos cinco doentes com TVR&#44; em tr&#234;s a op&#231;&#227;o foi a revasculariza&#231;&#227;o cir&#250;rgica e n&#227;o voltaram a ter mais eventos relacionados com o vaso alvo nos anos seguintes&#46; Pelo contr&#225;rio&#44; nos dois doentes em que a op&#231;&#227;o foi a implanta&#231;&#227;o de <span class="elsevierStyleItalic">stents</span> eluidores de f&#225;rmacos&#44; ambos voltaram a ter restenose cl&#237;nica&#58; um acabou por ser submetido a cirurgia e n&#227;o voltou a ter eventos e o outro teve morte s&#250;bita ap&#243;s angioplastia de um vaso n&#227;o alvo&#46; Claro que &#233; necess&#225;rio esclarecer que nestes dois doentes em que a op&#231;&#227;o inicial n&#227;o foi cir&#250;rgica&#44; a art&#233;ria descendente anterior n&#227;o tinha doen&#231;a obstrutiva significativa&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">A hip&#243;tese de BT para o tratamento da restenose de <span class="elsevierStyleItalic">stents</span> eluidores de f&#225;rmaco voltou recentemente a ser considerada&#44; mas o seu uso &#233; atualmente muito limitado<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Em conclus&#227;o&#44; a utiliza&#231;&#227;o da radia&#231;&#227;o intracoron&#225;ria para o tratamento da restenose difusa de <span class="elsevierStyleItalic">stents</span> met&#225;licos na nossa pequena experi&#234;ncia demonstrou&#8208;se segura com taxa de restenose angiogr&#225;fica aos nove meses e de eventos card&#237;acos <span class="elsevierStyleItalic">major</span> aos dez anos aceit&#225;vel&#44; tendo em conta as caracter&#237;sticas da popula&#231;&#227;o tratada&#46; Apesar de o elevado n&#250;mero de novas revasculariza&#231;&#245;es&#44; estas ocorreram apenas em cinco doentes e 41&#37; dos doentes estavam livres de eventos no final do seguimento cl&#237;nico&#44; confirmando a seguran&#231;a da BT a longo prazo&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Limita&#231;&#245;es</span><p id="par0185" class="elsevierStylePara elsevierViewall">Os autores reconhecem as seguintes limita&#231;&#245;es ao presente trabalho&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Trata&#8208;se de um estudo retrospetivo observacional de centro &#250;nico e com pequeno n&#250;mero de doentes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0195" class="elsevierStylePara elsevierViewall">N&#227;o foi feita compara&#231;&#227;o com um grupo controlo&#44; sendo a interpreta&#231;&#227;o dos resultados feita por compara&#231;&#227;o com a literatura&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Os doentes inclu&#237;dos representam um subgrupo altamente selecionado de doentes com elevada complexidade cl&#237;nica e angiogr&#225;fica&#44; seguidos ao longo de dez anos&#44; facto a ter em linha de conta na interpreta&#231;&#227;o da taxa de eventos cl&#237;nicos verificada no seguimento&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#41;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Ao descrever a experi&#234;ncia inicial com esta t&#233;cnica&#44; os resultados incorporam a curva de aprendizagem inerente a qualquer novo procedimento&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#41;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Os procedimentos efetuados h&#225; dez anos podem n&#227;o refletir a pr&#225;tica contempor&#226;nea&#44; com diferen&#231;as nas estrat&#233;gias terap&#234;uticas e nos dispositivos empregues e refletem a evid&#234;ncia cient&#237;fica acumulada&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#41;</span><p id="par0215" class="elsevierStylePara elsevierViewall">A angiografia de controlo&#44; programada para todos os doentes&#44; independentemente da evid&#234;ncia de isquemia&#44; poder&#225; ter sobrevalorizado a incid&#234;ncia de novas revasculariza&#231;&#245;es&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Responsabilidades &#233;ticas</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Prote&#231;&#227;o de pessoas e animais</span><p id="par0220" class="elsevierStylePara elsevierViewall">Os autores declaram que para esta investiga&#231;&#227;o n&#227;o se realizaram experi&#234;ncias em seres humanos ou animais&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidencialidade dos dados</span><p id="par0225" class="elsevierStylePara elsevierViewall">Os autores declaram ter seguido os protocolos do seu centro de trabalho acerca da publica&#231;&#227;o dos dados de pacientes&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Direito &#224; privacidade e consentimento escrito</span><p id="par0230" class="elsevierStylePara elsevierViewall">Os autores declaram ter recebido consentimento escrito dos pacientes e&#47;ou sujeitos mencionados no artigo&#46; O autor para correspond&#234;ncia deve estar na posse deste documento&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflito de interesses</span><p id="par0235" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect1035">Introdu&#231;&#227;o</span><p id="spar1035" class="elsevierStyleSimplePara elsevierViewall">No advento dos <span class="elsevierStyleItalic">stents</span> eluidores de f&#225;rmaco &#40;DES&#41;&#44; a restenose difusa &#40;&#62;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm&#41; <span class="elsevierStyleItalic">intrastent</span> &#40;RDIS&#41; constitu&#237;a a principal limita&#231;&#227;o ao uso de <span class="elsevierStyleItalic">stents</span> met&#225;licos na interven&#231;&#227;o coron&#225;ria &#40;PCI&#41;&#46; Das v&#225;rias solu&#231;&#245;es propostas para o seu tratamento&#44; a braquiterapia intracoron&#225;ria &#40;BT&#41; revelou&#8208;se uma das mais eficazes&#44; sendo praticamente abandonada ap&#243;s a introdu&#231;&#227;o dos DES&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Avaliar os resultados cl&#237;nicos a longo prazo &#40;&#62;<span class="elsevierStyleHsp" style=""></span>10 anos&#41; do uso de BT beta com <span class="elsevierStyleSup">90</span>Sr&#47;Y<span class="elsevierStyleSup">90</span> para o tratamento RDIS&#44; em termos de eventos card&#237;acos <span class="elsevierStyleItalic">major</span> &#40;MACE&#41; e restenose angiogr&#225;fica&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Popula&#231;&#227;o e m&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estudo retrospetivo observacional de centro &#250;nico incluindo 12 doentes &#40;dts&#41; consecutivos entre janeiro e julho de 2001&#44; 11 homens&#44; com a idade m&#233;dia de 58&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#44;9 anos &#40;43&#8208;77 anos&#41;&#46; Todos tinham angor est&#225;vel&#46; Os principais fatores de risco eram dislipidemia &#40;75&#37;&#41;&#44; HTA &#40;58&#37;&#41;&#44; doen&#231;a arterial perif&#233;rica &#40;50&#37;&#41; e diabetes &#40;42&#37;&#41;&#46; Havia doen&#231;a multivaso em seis dts&#44; tratava&#8208;se da 2&#46;<span class="elsevierStyleSup">a</span> ou 3&#46;<span class="elsevierStyleSup">a</span> restenose em seis dts e a fun&#231;&#227;o ventricular era normal em 11&#46; A BT foi feita ap&#243;s dilata&#231;&#227;o com bal&#227;o&#44; usando a fonte emissora de radia&#231;&#227;o beta <span class="elsevierStyleSup">90</span>Sr&#47;Y<span class="elsevierStyleSup">90</span> &#40;Beta&#8208;Cath&#8482;&#47;Novoste&#41;&#46; Todos permaneceram sob dupla antiagrega&#231;&#227;o pelo menos at&#233; &#224; angiografia de controlo&#44; programada para todos aos nove meses&#46; Foi considerada a ocorr&#234;ncia de morte global e cardiovascular&#44; enfarte do mioc&#225;rdio n&#227;o fatal &#40;EAM&#41;&#44; revasculariza&#231;&#227;o coron&#225;ria&#44; trombose de <span class="elsevierStyleItalic">stent</span> e restenose angiogr&#225;fica&#46; Foi avaliada a incid&#234;ncia do evento hier&#225;rquico combinado &#40;MACE&#41; de&#58; morte cardiovascular&#44; EAM&#44; revasculariza&#231;&#227;o coron&#225;ria urgente do vaso alvo &#40;TVRurg&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Verificou&#8208;se sucesso angiogr&#225;fico e cl&#237;nico em 100&#37; dos casos&#46; No seguimento m&#233;dio de 10&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;5 anos&#44; ocorreram 19 eventos em sete dts&#58; morte em tr&#234;s dts &#40;25&#37;&#41;&#44; apenas uma card&#237;aca &#40;8&#44;3&#37;&#41;&#44; EAM com eleva&#231;&#227;o de ST &#40;vaso n&#227;o alvo&#41; num dt &#40;8&#44;3&#37;&#41; e 15 novas revasculariza&#231;&#245;es em cinco dts &#40;42&#37;&#41;&#58; nove relacionadas com o vaso alvo &#40;sobretudo nos primeiros dois anos&#41;&#46; Apenas se verificou uma trombose de <span class="elsevierStyleItalic">stent</span>&#44; prov&#225;vel&#46; A restenose angiogr&#225;fica aos nove meses de seguimento foi de 27&#37; &#40;3&#47;11<span class="elsevierStyleHsp" style=""></span>dts&#41; com duas oclus&#245;es&#46; A taxa de sobreviv&#234;ncia livre de MACE aos dez anos foi de 42&#37; &#40;cincodts&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclus&#245;es</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A braquiterapia com radia&#231;&#227;o beta para RDIS&#44; neste pequeno grupo de dts&#44; demonstrou&#8208;se eficaz e segura&#44; sem eventos tardios atribu&#237;veis &#224; radia&#231;&#227;o intracoron&#225;ria&#46;</p>"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introduction</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Until the development of drug&#8208;eluting stents &#40;DES&#41;&#44; diffuse in&#8208;stent restenosis &#40;ISR&#41; was the main limitation of bare&#8208;metal stents in percutaneous coronary intervention &#40;PCI&#41;&#46; Among the different treatments available&#44; intracoronary brachytherapy &#40;BT&#41; emerged as one of the most promising&#44; although it was almost abandoned with the increasing use of DES&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Objective</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">To assess the Portuguese experience with 90Sr&#47;90Y beta brachytherapy for the treatment of diffuse ISR regarding long&#8208;term &#40;&#62;10 years&#41; major adverse cardiac events &#40;MACE&#41; and angiographic restenosis&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Methods</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">This single&#8208;center&#44; retrospective&#44; observational study included 12 consecutive patients treated between January and June 2001&#44; mean age 58&#46;6&#177;9&#46;9 years &#40;range 43&#8208;77 years&#41;&#44; 11 male&#46; All had chronic stable angina&#44; 75&#37; had dyslipidemia&#44; 58&#37; had hypertension&#44; 50&#37; had peripheral arterial disease&#44; 42&#37; had diabetes and 50&#37; had multivessel disease&#46; Recurrent ISR was present in half of the patients and 11 had normal left ventricular function&#46; After balloon dilatation&#44; BT was performed using an Sr90&#47;Y90 &#40;Novoste Beta&#8208;CathTM&#41; beta radiation source&#46; All patients remained under dual antiplatelet therapy until scheduled nine&#8208;month follow&#8208;up angiography&#46; Patients were followed for the occurrence of death &#40;all&#8208;cause and cardiovascular&#41;&#44; non&#8208;fatal myocardial infarction &#40;MI&#41;&#44; revascularization&#44; stent thrombosis and angiographic restenosis&#46; MACE were defined as the combined incidence of cardiac death&#44; MI and urgent target vessel revascularization&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">In all cases there was both clinical and angiographic success&#46; In a mean follow&#8208;up of 10&#46;9&#177;2&#46;5 years&#44; 19 events occurred in seven patients&#58; death in three &#40;25&#37;&#41;&#44; only one cardiac &#40;8&#46;3&#37;&#41;&#59; ST&#8208;elevation MI in one &#40;related to a non&#8208;target vessel&#41; &#40;8&#46;3&#37;&#41;&#59; and 15 revascularizations in five &#40;42&#37;&#41;&#44; of which nine were of the target vessel &#40;mainly in the first two years&#41;&#46; There was only one case of probable stent thrombosis&#46; Angiographic restenosis at nine months was 27&#37; &#40;three out of 11 patients&#41;&#44; of which two were total occlusions&#46; Ten&#8208;year MACE&#8208;free survival was 42&#37; &#40;5 patients&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Intracoronary beta brachytherapy for the treatment of diffuse ISR in this small cohort of patients proved to be safe and efficacious&#44; with no late adverse events related to intracoronary radiation&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Terceira restenose&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>NIRoyal&#8482; &#40;Medinol&#44; Scimed Life Systems&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Di&#226;metro luminal m&#237;nimo m&#233;dio &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Comprimento m&#233;dio &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">55&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#44;5 &#40;40&#8208;90<span class="elsevierStyleHsp" style=""></span>mm&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;8&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Enfarte do mioc&#225;rdio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;8&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>TVR urgente&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">TVR</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;41&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Qualquer revasculariza&#231;&#227;o</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;41&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Trombose stent definitiva</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;8&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Trombose de stent prov&#225;vel</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;8&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Trombose de stent poss&#237;vel</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Eventos relacionados com vaso tratado com braquiterapia &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Restenose angiogr&#225;fica nove meses</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Total de TVR</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Doentes com pelo menos um TVR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Total de TVR por CABG</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">CABG&#58; cirurgia de revasculariza&#231;&#227;o coron&#225;ria&#59; DES&#58; <span class="elsevierStyleItalic">stent</span> eluidor de f&#225;rmaco&#59; Dte&#58; n&#250;mero de doente&#59; Fup&#58; <span class="elsevierStyleItalic">follow&#8208;up</span> cl&#237;nico&#59; M&#58; meses ap&#243;s braquiterapia&#59; MSC&#58; morte s&#250;bita card&#237;aca&#59; Mx&#58; m&#225;ximo&#59; NTVR&#58; revasculariza&#231;&#227;o de vaso n&#227;o alvo&#59; Revasc&#58; revasculariza&#231;&#227;o&#59; RIS&#58; restenose <span class="elsevierStyleItalic">intrastent</span>&#59; <span class="elsevierStyleItalic">Status&#58;</span> situa&#231;&#227;o cl&#237;nica&#59; TVR&#58; revasculariza&#231;&#227;o de alvo alvo&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Dte&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Status cl&#237;nico 9 M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">RIS 9 M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Revasc&#46; 9 M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Evento M Fup&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">EventoM Fup&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">EventoM Fup&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">EventoM Fup&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">EventoM Fup&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Status Fup M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#35;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assintom&#225;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90 mesesFalecido &#8208; neoplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#35;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assintom&#225;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sim&#40;Oclus&#227;o&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TVR&#40;CABG&#41;23 M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">149 mesesassintom&#225;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#35;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assintom&#225;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NTVR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NTVR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TVR&#40;CABG&#41;21 M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NTVR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NTVR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">STEMITSNTVR120 M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">145 MAssintom&#225;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#35;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assintom&#225;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sim&#40;Oclus&#227;o&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TVR9 M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TVR&#40;DES&#41;13 M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TVR&#40;DES&#41;19 M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TVR&#40;CABG&#41;35 M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">140 mesesAssintom&#225;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#35;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assintom&#225;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TVR9 M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TVR&#40;DES&#41;30 M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NTVR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MSC43 M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43 mesesMorte s&#250;bita card&#237;aca&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#35;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assintom&#225;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Angio n&#227;o realizada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">132 mesesFalecido &#8208; s&#233;psis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#35;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Angor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TVR&#40;CABG&#41;14 M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assintom&#225;tico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "pt" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Descri&#231;&#227;o dos eventos ocorridos</p>"
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                    0 => array:2 [
                      "titulo" => "Angiographic patterns of in&#8208;stent restenosis&#58; Classification and implications for long&#8208;term outcome"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Directional coronary atherectomy for the treatment of Palmaz&#8208;Schatz in&#8208;stent restenosis"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "N&#46;A&#46; Mahdi"
                            1 => "A&#46;Z&#46; Pathan"
                            2 => "L&#46; Harrell"
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                      ]
                    ]
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Cardiol"
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                        "link" => array:1 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment of instent restenosis with excimer laser coronary angioplasty versus rotational atherectomy&#58; comparative mechanisms and results"
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                          "etal" => true
                          "autores" => array:3 [
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                            2 => "G&#46;S&#46; Mintz"
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                        "tituloSerie" => "Circulation"
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                    0 => array:2 [
                      "titulo" => "Angiographic analysis of the angioplasty versus rotational atherectomy for the treatment of diffuse in&#8208;stent restenosis trial &#40;ARTIST&#41;"
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                      "titulo" => "A randomized comparison of repeat stenting with balloon angioplasty in patients with in&#8208;stent restenosis"
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                        "tituloSerie" => "J Am Coll Cardiol"
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                      "titulo" => "Catheter&#8208;based radiotherapy to inhibit restenosis after coronary stenting"
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                            0 => "P&#46;S&#46; Teirstein"
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                      "doi" => "10.1056/NEJM199706123362402"
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                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "1997"
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