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Patient 1
THE SITE REPORTED THAT DURING TREATMENT OF IN-STENT RESTENOSIS OF THE DISTAL ANTERIOR DESCENDING CORONARY ARTERY, AFTER THE AREA WAS TREATED WITH MULTIPLE ANGIOPLASTIES WITH A 3.0MM BALLOON, A 60MM RADIOACTIVE SOURCE TRAIN WAS SELECTED. AFTER SENDING SOURCE TRAIN, IT WAS RECOGNIZED THAT THE SOURCE TRAIN WAS NOT LONG ENOUGH TO TREAT THE ENTIRE INJURY AREA. THE CATHETER WAS PULLED BACK IN ORDER TO TREAT THE SECOND SEGMENT. THE SOURCE TRAIN WAS SENT AGAIN, THERE WAS SOME DIFFICULTY GETTING THE SOURCE TRAIN TO THE DISTAL TIP OF THE CATHETER, BUT THE SOURCE TRAIN DID REACH THE DISTAL TIP. THE PROXIMAL SEGMENT WAS TREATED. AFTER TREATMENT WAS COMPLETED, FILMS WERE REVIEWED TO DETERMINE WHY THE RADIOACTIVE SOURCE TRAIN WAS NOT LONG ENOUGH TO TREAT THE ENTIRE INJURY AREA. IT WAS DETERMINED THAT UPON INITIAL DELIVERY OF THE RADIOACTIVE SOURCE TRAIN, THE SOURCE TRAIN STOPPED SHORT OF THE DISTAL END OF THE DELIVERY CATHETER BY 25 - 30MM. THE PROXIMAL MARKER WAS NOT CLEARLY VISIBLE BECAUSE IT RAN POSTERIORLY BEHIND THE GUIDE CATHETER AND OTHER RADIOACTIVE SEEDS. THE DISTAL MARKER WAS RECOGNIZED AS THE PROXIMAL MARKER BECAUSE OF WHERE IT WAS IN RELATIONSHIP TO THE DISTAL TIP OF THE CATHETER, THUS THE DISTAL SEGMENT OF THE CATHETER NEVER REC'D THE PRESCRIBED RADIATION. BECAUSE THE SOURCE TRAIN NEVER REACHED THE DISTAL ENDO F THE CATHETER ON THE FIRST DWELL, AND A SECOND DWELL WAS USED TO TREAT THE PROXIMAL SEGMENT, A 35-40MM SEGMENT REC'D TWICE THE PRESCRIBED AMOUNT OF RADIATION.