[Treatment strategy for severe radiation-induced ulcers near major blood vessels]

Abstract

Objective: To investigate the treatment strategy for severe radiation-induced ulcers near major blood vessels. Methods: This study was a retrospective observational study. From January 2016 to December 2023, 23 patients with radiation-induced ulcers near major blood vessels who met the inclusion criteria were admitted to Beijing Jishuitan Hospital of Capital Medical University, including 18 females and 5 males, aged 39 to 77 years. Ulcers were distributed in the axilla in 11 cases, in the groin in 4 cases, in the neck in 5 cases, and in the subclavicular region in 3 cases. According to the distance between the ulcer base and the major blood vessels, the ulcers were classified. The ulcers with major blood vessels exposed at the ulcer base was classified as exposed-vessel type (2 cases), the distance between the ulcer base and the major blood vessel wall ≤1 cm was classified as near-vessel type (8 cases), and the distance between the ulcer base and the major blood vessel wall >1 cm was classified as distant-vessel type (13 cases). After comprehensive preoperative evaluation and multidisciplinary team collaboration, the covered stents were implanted before surgery in patients with exposed-vessel type of ulcers and partial patients with near-vessel type of ulcers and high risk of vascular rupture, while preoperative vascular localization and careful operation were conducted during surgery to prevent vascular injury in other patients. After radical debridement, the wounds were repaired with flaps or myocutaneous flaps, the wound area after debridement was 6 cm×5 cm to 22 cm×12 cm, and the area of the flaps or myocutaneous flaps was 14 cm×9 cm to 27 cm×10 cm. The classification of ulcers in different regions, specific wound repair methods, and bacterial culture results of wound tissue specimens collected during the surgery were recorded. The survivals of flaps or myocutaneous flaps after surgery, the recurrence of infection or sinus, and wound healing were observed during follow-up after surgery. Results: Among the 11 patients with axillary ulcers, 3 had near-vessel type of ulcers, 8 had distant-vessel type of ulcers; among the 3 patients with subclavicular ulcers, one had near-vessel type of ulcer and two had distant-vessel type of ulcers, which were repaired with rectus abdominis myocutaneous flaps or latissimus dorsi myocutaneous flaps. Among the 5 patients with neck ulcers, two had exposed-vessel type of ulcers, and 3 had near-vessel type of ulcers, which were repaired with pectoralis major myocutaneous flaps or transverse carotid artery perforator flaps. Among the 4 patients with groin ulcers, one had near-vessel type of ulcer, and 3 had distant-vessel type of ulcers, which were repaired with tensor fascia lata myocutaneous flaps, anterolateral thigh flaps, or contralateral rectus abdominis myocutaneous flaps. The bacteria detected in the wound tissue specimens collected during surgery were mainly Staphylococcus aureus, Staphylococcus capitis, and Pseudomonas aeruginosa. Follow-up for 1 to 25 months after surgery showed that the flaps or myocutaneous flaps survived well in 14 patients and the wounds healed; two patients with infection at the flap edge healed after dressing change; seven patients had unhealed wounds due to infection recurrence or partial necrosis of the flaps. Among them, five patients underwent perforator flap or local flap transplantation again to repair the wounds, and two patients had wound healing after debridement and suture. Three patients who underwent stent implantation had their wounds healed without recurrence of infection or sinus. Conclusions: A distance-based classification for ulcers between the major blood vessels and the ulcer base, selective covered stent implantation, multidisciplinary team collaboration, and radical debridement enable safe reconstruction of radiation-induced ulcers near major vessels, significantly reducing vascular injury and infection recurrence risks.

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使用覆膜支架植入联合胸大肌肌皮瓣修复例1患者颈部放射性溃疡的效果。1A.术前创面基底糜烂、感染较重；1B.放置覆膜支架后的CT影像, 可见颈动脉直接暴露于创面基底, 为血管裸露型溃疡；1C.术中清创后覆膜支架外露；1D.术中设计以起自腋动脉的胸肩峰动脉为蒂的胸大肌肌皮瓣；1E.术中切取肌皮瓣后；1F.术后创面愈合良好, 未见皮瓣坏死及感染灶形成 Effects of using covered stent implantation combined with pectoralis major myocutaneous flap in repairing the neck radiation-induced ulcer in patient 1

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使用覆膜支架植入及腹直肌肌皮瓣修复例2患者腋部放射性溃疡复发创面的效果。2A.术前创面情况, 可见既往背阔肌肌皮瓣上缘溃疡复发；2B.覆膜支架植入术前腋动脉造影可见各穿支血管尚可显影；2C.覆膜支架植入后, 腋动脉造影可见各穿支血管均被阻断不显影；2D.术中解剖腹直肌肌皮瓣；2E.皮瓣修复术后即刻；2F.术后1年复查可见腋窝创面愈合良好, 未见溃疡复发 Effects of using covered stent implantation combined with rectus abdominis myocutaneous flap in repairing the recurrent axillary radiation-induced ulcer in patient 2