Radiation-induced Skin Injury on the Upper Arm Following Cardiac Interventional Radiology: A Review and Case Report

  Abstract: Cardiac interventional radiology (IVR) has gained popularity since the late 1980s. An extensive search of literature published from 1996 to 2009 identified 78 reports regarding radiation-induced skin injuries (RISI) following cardiac IVR. The authors present a case report and a review of the relevant literature. A 59-year-old man underwent percutaneous transluminal coronary angioplasty (PTCA). The estimated cumulative skin dose was 11.8 Gy. The patient discovered erosions on the right upper arm 2 months after PTCA. The lesion did not resolve with conservative treatment, and evolved into an intractable skin ulcer. The authors surgically removed the lesion and reconstructed the defect using an anterolateral thigh (ALT) flap. Radiation-induced skin injuries following PTCA usually develop on the back, and rarely on the upper arm. Radiation ulceration commonly requires surgical intervention. Physicians should be aware of the possibility of RISI, and thus, take measures to minimize exposure of patients and staff to radiation.

Introduction

  Cardiac interventional radiology (IVR), such as percutaneous transluminal coronary angioplasty (PTCA) for ischemic heart disease, has become increasingly popular since the late 1980s, largely due to advances to reduce its invasiveness. Advances in the procedure have expanded the indications for cardiac diseases that were previously untreatable. Treatment of difficult cases needs more complex procedures under fluoroscopy, and thus, more exposure to radiation. Radiation-induced skin injuries (RISIs) after cardiac IVR have been reported in Japan and elsewhere. Lichtenstein et al¹ published the first report in 1996, and in 1998, Hayami² reported the first case in Japan. An extensive literature search revealed 78 cases,^1–45 in Japanese or English, regarding RISIs following cardiac IVR between 1996 and 2009. Radiation-induced skin injuries after cardiac IVR generally occur only after repeated procedures, and are typically located on the trunk. The authors present a rare case of a patient in whom a radiation-induced skin ulcer (RISU) developed on the right arm, after only 1 procedure, which was reconstructed with a free flap. A review of 78 RISI cases after cardiac IVR is also provided.

Case Report

  A 59-year-old man had experienced cardiac infarction. The right coronary artery (RCA) was completely occluded, and the left anterior descending artery (LAD) and left circumflex artery (LCX) showed incomplete occlusion, so PTCA was performed. The procedure was performed in another hospital, so the exact fluoroscopy time was unknown. The authors inquired and discovered that the patient had been in the fluoroscopy room for almost 3.5 hours. The radiation associated with coronary angiography (CAG) was 110 kV, 1.855 mA, and FSD = 0.4 m. The total number of frames from the right back skin was 1846. The entrance dose from the right back skin was 2.67 Gy. The radiation associated with PTCA was 110 kV, 6 mA, and FSD = 0.4 m. The maximum time of fluoroscopy from the right back skin was 1958 seconds. The maximum entrance dose from the right back skin was 9.16 Gy. The cumulative skin dose was estimated to be 11.8 Gy. The patient reported pruritus and epidermolysis within a few days after the procedure on the right side of the chest and right upper arm. A dermatologist initially treated these lesions as dermatomycosis with antimycotic agents, and the lesions improved, albeit temporarily. However, the skin lesions began to deteriorate, and the patient was referred to another dermatologist. Upon presentation to this new dermatologist, erythema, edema, and erosion were identified on the right upper arm and side of the chest, and were treated conservatively with various ointments. The lesion on the side of the chest had healed, but a pigmented area remained. The lesion on the upper arm remained as a scarred, intractable ulceration with severe pain. The patient was referred to the authors for surgical treatment since the ulcer had not responded to conservative therapy. Upon presentation to the authors’ department, an erythemic and painful skin ulceration with necrosis was noted on the extensor surface of the right upper arm (Figure 1). The patient was also limited in his ability to elevate the shoulder joint associated with sclerotic changes to the skin and subcutaneous tissue on the upper arm. Resection of the skin lesion and reconstruction with a free flap were performed. Necrosis extended to subcutaneous tissues around the atrophic skin and surface of the triceps brachii muscle. After resection of necrotic tissues on the right arm, part of the median nerve was exposed.   Reconstruction was performed using an anterolateral thigh (ALT) flap taken from the right thigh, approximately 11 cm × 15 cm in size. Branches of the lateral circumflex femoral artery and vein were anastomosed to the radial artery and cephalic vein of the antebrachial region; the flap was then transplanted (Figure 2C). Skin from the abdomen was grafted onto the flap harvest site. Ulceration extended to subcutaneous fat tissue with fibrosis and atypical granulation. Dilated blood vessels and moderately chronic inflammation were also seen in the area of dermal atrophy. Histopathological findings of the lesion were consistent with radiodermatitis (Figure 2E). Immediately after the operation, the patient appeared free of the severe pain that had developed, and was discharged from the hospital 28 days later. The patient’s ability to elevate his right shoulder joint improved. No recurrence of symptoms has been seen at 5 years’ follow up (Figure 3).

Discussion

  A RISI is one potential iatrogenic side effect after cardiac IVR. RISIs are well known for their deterministic effects and have threshold doses. For single, short-term exposures, the threshold dose appears to be ~ 3 Gy for temporary epilation, 6–8 Gy for erythema, and ≥ 15 Gy for moist desquamation, erosion, ulceration, and necrosis.3 Additionally, injuries can be classified according to the time of occurrence into acute and chronic radiodermatitis. Acute radiodermatitis generally develops ~ 2 days after a single radiation exposure and is considered to have a threshold dose of approximately 10–12 Gy⁴; although, a threshold of 3 Gy has been described in other reports.^3,5 Chronic radiodermatitis may be assumed to result from cumulative x-ray exposure rather than a single exposure. The latency period between the first procedure performed and the onset of noticeable chronic cutaneous changes varies from 2 to 10 years.¹ The cumulative dose necessary to induce chronic skin changes has been estimated to be about 10 Gy in the case of a single exposure⁶ and 35–40 Gy⁶ or > 10–12 Gy¹ in the case of fractionated exposure.   The absorbed dose rate in the skin from a direct fluoroscopic x-ray beam is typically between 0.02 and 0.05 Gy/min, depending on the mode in which the fluoroscopic equipment is operated and the size of the patient.⁷ Mizutani⁸ reported the average skin exposure dose during CAG as 1.1 Gy per procedure. Cascade et al⁹ reported that PTCA exposes the patient to 3.4 times more radiation than CAG. These doses are roughly equivalent to several hundred or thousand doses of simple roentgenography.   The number of cardiac IVR in Japan in 2000 was approximately 700,000,⁴⁶ and there were 7 case reports of RISIs in 2001. This suggests that the incidence of IVR procedures was 1 per 100,000; however, it was very difficult to determine the actual number of cases. There are probably many missing cases, and thus an increased incidence of RISIs.   Procedure for cardiac IVR caused RISI. Seventy-eight cases of RISI directly related to cardiac IVR were reviewed (Table 1, Figure 4). The type of procedure for IVR was almost always CAG and PTCA. Two patients underwent CAG alone^10–12 but the remaining 73 patients had additional PTCA. Many patients underwent several procedures on separate days. Ten patients received additional stent placements, and 3 patients had catheter ablation for arrhythmia. The latent period between the initial procedure and onset of radiodermatitis varied from a few days after the procedure to 168 months. Both acute and chronic radiodermatitis were included among the cases. Clinical reports included many cases with temporary dermatitis involving skin ulcerations appearing immediately after IVR. Thus, patients should be followed closely if an itching sensation or erythema develops after cardiac IVR.   Cascade et al⁹ reported radiation exposure in patients using an improved dosimetry system. The other researchers did not report the direct exposure dose, but made estimations. In the present case, the direct exposure dose was not measured, but was retrospectively calculated as 11.8 Gy based on the equipment and duration of the procedure.   Typical RISI lesion. The typical RISI lesion is located on the trunk (eg, side of the chest, scapular area, or back), predominantly on the right side. When the heart position is considered as the isocenter, the left back skin from a right anterior oblique view is closer to the x-ray tube than the right back skin in the left anterior oblique view.¹³ Placement of x-ray beams during PTCA is limited to 6 directions, depending on the site of the occluded coronary artery.¹⁴ Sites susceptible to RISI following PTCA tend to develop on the right or left back and the right side of the chest, corresponding to these general directions.^15,16 In the present case, although erythema and erosion developed on the right side of the chest, the main lesion involved the right upper arm. In the past, 2 cases of RISI on the right upper arm after cardiac catheter ablation were described by Takekoshi et al¹⁷ and Hashimoto et al¹⁸; Dandurand et al¹⁹ and Maruyama et al²⁰ reported 2 cases after PTCA. The present case is the fifth case of RISI on the right upper arm after cardiac IVR, and the third case after PTCA. Maruyama et al²⁰ considered that when PCTA was performed for occlusion of the RCA, the x-ray tube reached the point closest to the skin at the extensor surface of the right upper arm, as the bed was narrow for that patient (body mass index [BMI] = 28). The patient in the authors’ case was not as obese (BMI = 25), but a similar situation to that described by Maruyama et al²⁰ was considered to have occurred, given that the same area of RCA was occluded.   Treatment of RISI. Many cases of radiodermatitis have been treated conservatively, but cases that become ulcerated are treated surgically when a positive response is not achieved with conservative therapy. Treatment for 57 cases was described in the literature the authors reviewed. Nine cases were untreated, 14 cases received ointment treatments, 1 case underwent hyperbaric oxygen therapy, 8 cases had resection and reefing, 14 cases had skin grafting, 6 cases had local skin flaps, and 3 cases had skin grafting combined with local skin flap or muscle flap. Two cases, including the present case, received free flaps. In 4 cases that developed on the upper arm, treatment was not mentioned in 1 case and the remaining 3 were treated using ointment treatment, skin grafting, and free flap, respectively.   Lesions occurring on the upper arm require reconstruction of the flap, not skin grafting, and are dependent upon the depth of invasion (eg, exposure of nerve and bone) and a defect size that is too large to reef. The pedicle flap (eg, latissimus dorsi musculocutaneous flap) is a possible option, but both the upper arm and the donor site of the flap could conceivably be irradiated at the same time during cardiac IVR. Harvesting a free flap from unirradiated skin could prove to be useful. The authors considered that a large defect and exposure of nerves after debridement warrants reconstruction using a skin flap rather than skin grafting. Reconstruction using an ATL flap, and not a latissimus dorsi musculocutaneous flap, was performed in the present case since radiation damage to the donor site was strongly suspected based on the erythema of the right chest. The authors selected the ALT flap for several reasons: unirradiated area; need for a large flap; minimization of donor sacrifice; and similarity of appearance between skin of the upper arm and thigh. Additionally, the condition of anastomotic vessels is an important element for successful treatment. The vessels were anastomosed at an unirradiated region of forearm and obtained excellent results. Hashimoto et al18 also performed reconstruction with a free ALT flap for a RISU on the upper arm after cardiac ablation. They used an ALT flap combined with a rectus femoris musculocutaneous flap. When a defect is large, an ALT flap could become a composite flap; that is, reconstruction with a free ALT flap is useful for cases with larger, deeper ulcers.   Diagnosis of RISI. Hirata et al¹⁶ reported that the diagnosis of RISI was relatively easy based on medical history and exposed sites. However, in the present literature review, only 15 of 32 cases were diagnosed with RISI upon initial examination. The remaining 17 cases were misdiagnosed as herpes zoster, fixed drug eruption, localized scleroderma, decubitus ulcer, or trichophytosis. A RISI is easily suspected when appropriate history is taken. However, in the reported cases, many patients had forgotten about contact with radioactive materials or exposure to possible sources of radiation. Thus, a patient’s history might be unreliable when attempting to formulate an appropriate treatment plan. Sharing patient information among departments and other medical facilities is important. Additionally, 26 of 78 patients underwent skin biopsy. Miyagawa et al²¹ reported intractable ulcers appearing after skin biopsy. As this procedure may result in a nonhealing ulcer, biopsy is not recommended and should be limited to cases where malignancy is strongly suspected.

Conclusion

  The incidence of lifestyle diseases appears to be increasing annually, and cardiac IVR is gaining popularity as a less-invasive treatment. Medical staff and physicians performing IVR should be aware of the possibility of RISI, and consequently, make efforts to minimize the exposure dose to patients and staff.

Acknowledgment

  The authors thank Toshio Demitsu, MD, PhD, for his efforts and support in managing this case.

References

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