STROBE--Radiation Ulcer: An Overlooked Complication of Fluoroscopic Intervention: A Cross-Sectional Study

Abstract

With increasing numbers of percutaneous coronary intervention (PCI) and complex cardiac procedures, higher accumulated radiation dose in patient has been observed. We speculate cardiac catheter intervention induced radiation skin damage is no longer rare.To study the incidence of cardiac fluoroscopic intervention induced radiation ulcer. We retrospectively reviewed medical records of those who received cardiac fluoroscopic intervention in our hospital during 2012 to 2013 for any events of radiation ulcer. Only patients, whose clinical photos were available for reviewing, would be included for further evaluation. The diagnosis of radiation ulcers were made when there is a history of PCI with pictures proven skin ulcers, which presented typical characteristics of radiation injury. Nine patients with radiation ulcer were identified and the incidence was 0.34% (9/2570) per practice and 0.42% (9/2124) per patient. Prolonged procedure time, cumulative multiple procedures, right coronary artery occlusion with chronic total occlusion, obesity, and diabetes are frequent characteristics. The onset interval between the first skin manifestation and the latest radiation exposure varied from 3 weeks to 3 months. The histopathology studies failed to make diagnosis correctly in 5 out of 6 patients. To make thing worse, skin biopsy exacerbated the preexisting radiation dermatitis. Notably, all radiation ulcers were refractory to conventional wound care. Surgical intervention was necessary to heal the wound. Diagnosis of cardiac fluoroscopy intervention induced radiation skin damage is challenging and needs high index of clinical suspicion. Minimizing the radiation exposure by using new approaches is the most important way to prevent this complication. Patient education and a routine postprocedure dermatology follow up are mandatory in high-risk groups for both radiation skin damage and malignancies. This is a retrospective study, thus the true incidence of radiation ulcer caused by cardiac fluoroscopic intervention could be higher.

FIGURE 1

Typical presentation of cardiac fluoroscopy-induced radiation dermatitis before ulceration. An 81-year-old man presented with a painful sharply demarcated concentric target-like patch. A central erosion with a peripheral white sclerotic zone and an outer hyperpigmented “flame burn-like” zone.

FIGURE 2

Radiation dermatitis mimicking contact dermatitis. An 82-year-old man presented with an itchy painful sharply demarcated rectangular erythematous patch with dry fish scale-like desquamation on right subscapula, auxiliary and inner arm. The initial clinical diagnosis was contact dermatitis.

FIGURE 3

Radiation dermatitis mimicking scleroderma. A 62-year-old man presented an itchy painful bizarre-shaped atrophic telangiectatic plaque with a central small ulcer and heterogeneous color change on his mid back.

FIGURE 4

A fully developed cardiac fluoroscopy-induced radiation ulcer. A 60-year-old man had a painful deep large ulcer surrounded by a well-demarcated sclerotic dyspigmented patch on right subscapular and arm for 2 months.

FIGURE 5

Histopathology of cardiac fluoroscopy induced skin damage. (A) Histopathology showed a patchy lymphatic infiltration and dilated vessels in the superficial dermis. In the mid and lower dermis, there is a sclerotic background composed of haphazardly arranged thick collagen fibers, absence of adnexal structures, and scattered atypical fibroblasts in the reticular dermis. These features are consistent with the diagnosis of radiation dermatitis. However, scleroderma may present the similar changes. (B) Nevertheless, the atypical fibroblasts (arrow) were conspicuously seen in some foci. That was the feature of radiation skin damage, not of scleroderma.

FIGURE 6

Outcome of surgical intervention for cardiac fluoroscopy-induced radiation ulcer. A 52-year-old man had radical excision of radiation ulcer and reconstruction of rotation flap. One month after the operation, good healing was noted.