Clinical manifestation diagnosis and surgical treatment of chronic

Clinical manifestation, diagnosis, and surgical treatment of chronic radiation ulcers related to percutaneous coronary intervention Biing-Luen Lee, MD. Hsu Ma, Yu-Chung Shih Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital Taipei, Taiwan

Case report • 59 -year-old man, presented with a 3 x 2 cm central ulcerative wound with peripheral hyper-pigmentation at central back for 2 years

• Initial diagnosis: Allergic dermatitis to unknown cardiovascular drugs/Carbuncle with secondary infection • Responded poorly to topical treatment

• Past history of coronary artery disease, single vessel disease with right coronary artery total occlusion status post percutaneous cardiac intervention twice in May (Duration: 2 hrs) and July (Duration: 4 hrs 34 mins), 2010 • Tracing back the history, he presented with itching red papules with erosion at central back after the PCI was immediately noticed by patient

• Complete excision of the ulcer followed by reconstruction with a rhomboid fasciocutaneous flap Immediately after operation 21 months after operation

Introduction • Chronic radiation ulcers that develop after cardiac catheterization have become common recently because of the rapid increase in the use of diagnostic and interventional cardiac catheterization procedures J Vasc Interv Radiol 2011; 22: 425 -429

• The early diagnosis of chronic radiation ulcers is difficult and conclusive information on the optimal management of these ulcers is lacking, especially that for National Cancer Institute (NCI) grade 4 radiation ulcers

Materials and Methods • Retrospective study • 10 patients with cardiac catheterizationinduced NCI grade 4 chronic ulcers between January 2009 and April 2014 • Database of the Department of Plastic Surgery at Taipei Veteran General Hospital

Inclusion criteria: • Ulcers that had not healed in 4 weeks and presence of full-thickness dermal necrosis associated with pain • Appeared and progressed slowly after prolonged cardiac catheterization • Infection, hypersensitivity, or malignancy was excluded as the cause of the ulcer • Pathologically proven to be full-thickness, radiation-associated chronic ulcers

Patient Age Gender CAD lesions PTA number 1 63 Male RCA CTO 1 2 60 Male RCA CTO 2 3 57 Male LAD CTO 1 4 59 Male RCA CTO 2 5 64 Male LAD and RCA CTO 2 6 80 Male RCA CTO 1 7 82 Male LAD CTO 1 8 58 Male LAD, LCX-M and RCA CTO 4 9 58 Male RCA-D near total occlusion 3 10 86 Male RCA CTO 2 Avg 66. 7 CTO: chronic total occlusion 1. 7 PTA duration 4 hr 13 min 4 hr 15 min 5 hr 21 min 4 hr 2 hr 4 hr 34 min 2 hr 30 min 4 hr 5 hr 40 min 2 hr 38 min 3 hr 20 min 4 hr 23 min 214. 94 mins

Patie nt Skin ulcer onset time Skin ulcer locations 1 0. 2 months Right upper back; right axilla 2 5 months Right upper back 3 1. 5 months Central back 4 Immediate Central back 5 12 months Left elbow; left lateral chest wall 6 Immediate Right back 7 Immediate Right shoulder 8 6 months Left upper back 9 6 months 10 6 months Avg Disease onset to surgery Surgical procedures Follow-up Status (months) 6 months Fasciocutaneous flap 33 Survive 6 months Fasciocutaneous flap 20 Survive 5. 5 months 40 Survive 21 Survive 69 Survive 13 Survive 8 Dead 4 months Debridement and fasciocutaneous flap 1. Debridement and pedicled forearm flap 2. Fasciocutaneous flap Debridement and splitthickness skin graft Pedicled parascapular flap Fasciocutaneous flap 8 Survive Right back 1 months Fasciocutaneous flap 19 Survive Right upper back 14 months Fasciocutaneous flap 2 Survive 24 months 3 months 10 months 12 months 8. 55 months 23. 3

Taiwan version of the modified World Health Organization Quality of Life-Short Version (WHOQOL-BREF) questionnaire • • • Q 1. How severe is the pain? Q 2. How bothered are you by fatigue? Q 3. To what extent are your daily activities affected? Q 4. Do you have any difficulties with sleeping? Q 5. How dependent are you on analgesics? Q 6. How often do you have negative feelings such as blue mood, despair, anxiety, and depression?

The preoperative and postoperative scores and P values (Wilcoxon signed-rank test) for each question Preoperative score (mean SD) Post-operative score (mean SD) P value Q 1 3. 78 ± 1. 302 1. 33 ± 0. 707 0. 011 Q 2 3. 22 ± 1. 202 1. 33 ± 0. 500 0. 015 Q 3 3. 89 ± 0. 928 1. 44 ± 0. 726 0. 011 Q 4 3. 00 ± 1. 323 1. 22 ± 0. 441 0. 016 Q 5 3. 11 ± 2. 028 1. 11 ± 0. 333 0. 038 Q 6 3. 00 ± 1. 323 1. 11 ± 0. 333 0. 015

Conclusion • The diagnosis of chronic ulcers related to prolonged percutaneous coronary intervention depends on careful history taking and a highly suspicious clinical presentation Table 3. Diagnostic criteria for chronic radiation ulcer related to percutaneous coronary interventions Clinical presentation 1. 2. 3. 4. Received prolonged cardiac catheterization of more than 3 hours at least once Coronary artery lesions: chronic total or near-total occlusion Chronic and non-healing ulceration and peripheral erythematous change over the back Severe pain or discomfort Histopathological finding 1. Epidermal ulceration, dermal and hypodermal fibroses, and dermal telangiectasia

• For NCI grade 4 radiation ulcers, treatment of complete resection and immediate reconstruction with flaps or grafts may improve the symptoms and achieve reliable wound coverage without complications

Prevention Discussion Catheter Cardiovasc Interv 77(4): 546 -556

Prevention • Post-procedural patient notification, chart documentation, communication of adverse skin effects, and patient follow-up

• Early diagnosis • Early referral (to experienced team consisting of wound-care specialists, dermatologists, and plastic surgeons) • Early surgical intervention

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