Clinical manifestation, diagnosis, and surgical treatment of chronic radiation ulcer related to percutaneous coronary intervention

Background: 

Chronic radiation ulcers after cardiac catheterization became more common nowadays due to the rapid increase of diagnostic and interventional cardiac catheterization procedures. To date, there is a lack of conclusive evidence for the best treatment, especially NCI grade 4 radiation ulcers. We shared our diagnostic and treatment experience on these cases in recent 5 years.

Methods: 

By retrospective chart review, 10 cases of NCI grade 4 radiation ulcers after cardiac catheterization were included. The inclusion criteria were chronic, non-healing ulcers for more than 4 weeks, full thickness dermis necrosis with associated pain. The skin lesions were located on the posterior aspect of the body, which appeared and progressed slowly after prolong cardiac catheterization. Skin infection, hypersensitivity or malignancy was excluded using skin biopsies. All patients were treated by surgical intervention proven pathologically compatible with a full-thickness, radiation-associated chronic ulcer. Completion of quality of life questionnaires including 6 items: pain, fatigue, activity disturbance, sleep problems, analgesic dependent and blue mood by patients during follow up, each item can be scored 1 to 5 points according to levels of severity: 1. Not at all, 2. A little, 3. A moderate amount, 4. Very much, 5. An extreme amount. The results were compared preoperatively and postoperatively.

Results: 

All patients were male and most lesions (8 of 10) were located at back. All patients received prolonged cardiac catheterization more than three hours at least once, and all coronary artery lesions were chronic total or near total occlusion. The surgical procedure was immediately reconstruction with local/regional fasciocutaneous flap following complete resection until healthy wound bed and margin achieved. Mean follow up time was 23.3 months and all wounds healed well without recurrence. The symptoms relieved and quality of life improved after operation significantly. (Pain, from 3.78±1.302 to 1.33±0.707, P=0.011, fatigue, from 3.22±1.202 to 1.33±0.500, P=0.015, activity disturbance, from 3.89±0.928 to 1.44±0.726, P=0.011, sleep problems, from 3.00±1.323 to 1.22±0.441, P=0.016, analgesic dependent, from 3.11±2.028 to 1.11±0.333, P=0.038 and blue mood, from 3.00±1.323 to 1.11±0.333, P=0.015, Wilcoxon signed rank test)

Conclusions: 

Correct diagnosis for cardiac catheterization related chronic ulcers relies on careful history taking and highly suspicion of clinical presentation. Complete resection and immediate reconstruction with flaps for NCI grade 4 radiation ulcers revealed improved symptomatology and good wound healing in a long-term follow up.