Management of fluoroscopy-induced radiation ulcer: One-stage radical excision and immediate reconstruction

Abstract

With increasing use of cardiac fluoroscopic intervention, the incidence of fluoroscopy-induced radiation ulcer is increasing. Radiation ulcer is difficult to manage and currently there are no treatment guidelines. To identify the optimal treatment approaches for managing cardiac fluoroscopy-induced radiation ulcers, we retrospectively reviewed medical records of 13 patients with fluoroscopy-induced radiation ulcers receiving surgical interventions and following up in our hospital from 2012 to 2015. Conventional wound care and hyperbaric oxygen therapy were of little therapeutic benefit. Twelve patients received reconstruction with advancement flap or split thick skin graft. One-stage radical excision of radiation damaged area in eight cases with immediate reconstruction led to better outcomes than conservative excisions in four cases. Radical surgical excision to remove all the radiation damaged tissues in combination with immediate reconstruction appears to offer the optimal treatment results for cardiac fluoroscopy-induced radiation ulcers. Adequate excision of the damaged areas in both vertical (to the muscular fascia) and horizontal (beyond the sclerotic areas) dimension is pivotal to achieve good treatment outcomes.

Figure 1. Depth dose curves in water or soft tissues for various quantities of radiation beams.

Line red: linear accelerator 6 MV photon beam. Line green: linear accelerator 10 MV photon beam. Line purple: 100 kV X-rays filtered with HVL = 2 mm Al.

Figure 2. Group A: Conservative debridement with/without reconstruction flap at later stage.

(a) An 81-year-old man (case 1) had a painful sharply-demarcated square-shaped patch with a centrally located thick eschar (4.5 × 2.5 cm) and surrounding fibrosis for 5 months on his right sub-scapular area. This lesion appeared 2 months after per-cutaneous coronary intervention. (b) After three attempts of conservative debridement (only of the ulcerated area) and regular wound care within two months, the ulcer was clean but not healed. (c) After regular hyperbaric oxygen therapy and wound care with vacuum-assisted closure for 6 months, the ulcer became smaller but still did not heal.

Figure 3. Group B: Radical excision and immediate reconstruction of rotation flap.

(a) A 52-year-old man (case 6) presented with a typical fluoroscopic radiation-induced skin lesion as a target-like plaque with three differently-colored rims and central ulceration. (b) Radical excision of necrotic and sclerotic areas with a deep margin to muscular fascia layer was performed. (c) Immediate reconstruction with local rotation fasciocutaneous flap was done. Wound healed smoothly one month after surgery. No recurrence was noted in the following 15 months.

Figure 4. Group B: Radical excision and immediate local advancement flap.

(a) A 52-year-old man (case 7) had a deep necrotic ulcer with erythematous-to-brownish patch in the periphery for 10 months on his right subscapular and arm region. The lesion occurred 2 months after percutaneous coronary intervention. (b) Radical excision of necrotic and sclerotic areas with a deep margin to muscular fascia layer was performed. (c) Local advancement flap was performed and wound healed two weeks later. No recurrence was noted in the following 14 months.

Figure 5. Group C: Radical excision and immediate split thick skin graft (STSG).

(a) A 70-year-old man (case 11) presented with a large deep necrotic ulcer with bacterial infection and pus formation, surrounded by a square-shaped erythematous sclerotic plaque for 6 months on his right lateral back. The lesion was found 1 month after electrophysiological ablation of cardiac accessory pathway. (b) Excision of all the sclerotic areas deep to the muscular fascia layer was done with immediate coverage with STSG. (c) Following up at 16^th month in the clinic, good uptake of STSG was noted without recurrence.