Radiation ulcer is located in where the radiation beam enters. During performing percutaneous coronary angiography, it requires different radiator angles by operating radiator to visualize different coronary arteries. Among these 9 patients, the location of radiation ulcer was in the right subscapular region in 8 cases with or without involvement of auxiliary and arm area. That area is the common site where is the radiation beam entrance site for visualizing right coronary artery. Only 1 case had lesions in his mid back.
Histopathology studies were performed in 6 cases, while the clinicians and pathologists were not aware of patients’ radiation exposure history. Although all the histopathology studies showed features compatible with radiation skin damage, including absence of adnexal structures, sclerosis of reticular dermis, and presence of atypical stellate-shaped fibroblasts (Fig. 5), only 1 case had been diagnosed correctly as radiation dermatitis. To make thing worse, skin biopsy exacerbated the preexisting radiation dermatitis.
All medical managements to these wounds failed to promote healing, including conventional wound care, hyperbaric oxygen therapy, hydrocolloid dressing, artificial biologic coverage, and conservative wound debridement. Eight patients (8/9) eventually received surgical treatments. Surgical intervention including radical wound debridement and reconstruction were arranged according to the patients’ condition. These managements eventually brought complete wound healing in each and every patients (Fig. 6), although their treatment courses often were long and complicated involving repeated excisions and wound closures.
We presented 9 patients having radiation ulcers, which were identified among the individuals who received cardiac angiographic intervention during 2012 and 2013 in our hospital. This represents the incidence of radiation ulcer is 0.34% per practice (9/2570) or 0.42% per patient (9/2124). In this study, we used strict inclusion criteria to identify the cases with radiation ulcer; that is, only patients, whose clinical photos were available for reviewing, would be included for further evaluation. However, pictures were not routinely taken for every patient in the clinic of dermatology or plastic surgery. Besides radiation ulceration following PCI usually developed a period of time (week or months) after the cardiac procedure and the initial presentation of this complication is mild. Thus some of the patients could not relate current skin problem with previous PCI procedures and might seek medical help as their conveniences, not the original hospital. Therefore, it is highly possible that our study underestimates the exact incidence of radiation ulcer. Despite of the aforementioned limitations, the incidence rate in our report is still much higher than that of any other reports before.8
Accurately measuring the radiation absorption dose at the skin entrance site is difficult. Therefore, the exact radiation exposure dose can only be estimated indirectly by using procedure time and fluoroscopy time. During the normal mode of fluoroscopy for regular coronary angiography, patient is usually exposed to a radiation dose at a rate around 0.02 to 0.05 Gy/min. In general, the mean duration of the each procedure is between 1 and 2 h, thus the cumulative radiation dose is theoretically at a maximum of 3 Gy in an individual PCI.9 However, in reality, the radiation dose associated with fluoroscopic procedures is dependent on multiple factors. For example, a higher radiation emission rate (up to 0.2 Gy/min) will occur automatically decided by computer setting when operators require higher image resolution or when the radiation needs to pass a longer distance through human body. Therefore, the actual cumulative radiation dose is usually underestimated, if we use only the procedure time (or fluoroscopy time) to calculate it.
Chronic radiation skin damages, which may not be preceded by acute radiation dermatitis, develop weeks to months after radiation exposure with refractory symptoms such as pruritus and pain. Skin ulcer can be triggered and worsening by minor trauma caused by scratching, applying topical agents or hot packing employed by patients to relieve the associated pruritus and pain. Contact dermatitis, fixed drug eruption and scleroderma are the possible clinical differential diagnoses. But the typical location on back, bizarre shape with very sharp margin, and concentrically colored distribution of the lesion are characteristic to radiation dermatitis. These features help remind clinicians to ask patients about any history of previous cardiac catheter intervention. Although the cause-and-effect relationship between radiation and the cutaneous presentation seems obvious once it is diagnosed, a timely identification of fluoroscopy-induced chronic radiation damage is often challenging. The difficulties in making the correct diagnosis are usually owing to the variable onset interval, misleading concomitant symptoms, and lack of awareness of fluoroscopy-induced radiation skin damage.
On the other hand, radiation induced-morphea (RIM) is a possible differential diagnosis in the literature.10 RIM rarely leads to nonhealing ulceration and it potentially extends exceeding outside the radiation exposure field. It mainly appears in the female patients in the literature and has been reported that systemic sclerosis is a relative risk factor for developing an exaggerated postirradiation fibrosis. Unlike to the characters of RIM, all of our patients were male, and had severe refractory painful ulcers confined on the original radiation exposure area. And none of them had history of systemic sclerosis or any other autoimmune disease. These features favor the diagnosis of radiation ulcer. Therefore, these cases were diagnosed with radiation ulcer, not RIM.
The histological features of these lesions include epidermal atrophy, dermal sclerosis (eosinophilic homogenized sclerosis of dermal collagen), dilated superficial blood vessels, loss of adnexal structures (hair follicle and sweat duct), and increased atypical stellate-shaped fibroblasts.11,12 In most situations, the proper diagnosis of radiation skin damage can be made by combining the clinical presentations and a radiation exposure history. Skin biopsy should be reserved when histology pictures are needed for a correct diagnosis such as radiation malignancy or invasive deep infections are suspected. This is because radiation ulcers’ histological features are not characteristic, and scleroderma and lichen sclerosis may present similar pathologic findings. To make thing worse, an incision biopsy creates new wound and potentially exacerbates the preexisting damaged skin and ulcer.
Up to now, there is no consensus or guidelines for managing radiation ulcer. Generally speaking, conservative treatments may be effective for radiation dermatitis (without ulcer). These managements include appropriate skin protection and avoidance of unnecessary surgical procedures. However, once radiation ulcer occurs, surgical intervention becomes necessary to promote wound healing.13,14 In our experience, aggressive radical excision following by reconstruction with local flap is effective in treating radiation ulcers with refractory course.
To prevent this complication, minimizing the radiation dose is the cornerstone and this is possible by following current regulations and several new approaches.15–17 For example, by simply adjusting preset standard frame rates for acquisition and fluoroscopy, as well as modifications and upgrades to the newer X-ray equipment, Sawdy et al18 achieved a significant reduction (66%) of total radiation exposure to patients. This is imperative not only for the patient but also for the medical staff because backscattered radiation can accumulate up to 25% to 40% of direct radiation.19,20 On the other hand, whenever a substantial radiation dose level has been reached, the patient should be informed and appropriately educated about skin care. Regular dermatology monitoring and evaluation are necessary in these patients.15,16 This is both for surveying radiation dermatitis and radiation malignancy. Malignancies arising from chronic radiation dermatitis have been documented in other types of radiation exposure, such as radiation therapy for cancer or benign disease. Squamous cell carcinoma, basal cell carcinoma, and sarcoma are the most common types of malignancies.21,22 It was reported that 0.9% of cancers in the United States were caused by diagnostic X-rays.23 Therefore, it is sensible to speculate that the cardiac angiographic intervention might pose an even higher risk of malignancy,24 giving its higher radiation exposure.
In conclusion, radiation skin damage is an overlooked complication after wide spread application of cardiac angiographic interventions. Prolonged procedure time, accumulative multiple procedures, RCA with CTO, obesity, and diabetes are frequent characteristics among the patients of cardiac fluoroscopy induced radiation ulcer in this study. To minimize the incidence and severity of radiation skin injuries, medical attention is required before, during, and after the procedure. Postintervention regular dermatology monitoring and patient education about skin care are pivotal not only for the radiation dermatitis but also for the possible malignancy. When facing a sharply demarcated patch with or without ulcer on the back in shape of rectangle or square, physicians should be alert to the possibility of radiation dermatitis. Skin biopsy should be avoided if the clinical presentation and history of radiation exposure are typical. Radical excision with local flap is an effective treatment for recalcitrant radiation ulcers.
1. Aerts A, Decraene T, van den Oord JJ, et al. Chronic radiodermatitis following percutaneous coronary interventions: a report of two cases. J Eur Acad Dermatol Venereol
2. Herz-Ruelas ME, Gomez-Flores M, Moxica-Del Angel J, et al. Ulcerated radiodermatitis induced after fluoroscopically guided stent implantation angioplasty. Case Rep Dermatol Med
3. Khouzam RN, Soufi MK, Nakhla R, et al. Outpatient percutaneous coronary intervention: has its time come? J Invasive Cardiol
4. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation
5. Brilakis E. Manual of Coronary Chronic Total Occlusion Interventions: A Step-by-Step Approach. Waltham, MA: Elsevier; 2013.
6. Fetterly KA, Lennon RJ, Bell MR, et al. Clinical determinants of radiation dose in percutaneous coronary interventional procedures: influence of patient size, procedure complexity, and performing physician. JACC Cardiovasc Interv
7. Michael TT, Karmpaliotis D, Brilakis ES, et al. Temporal trends of fluoroscopy time and contrast utilization in coronary chronic total occlusion revascularization: insights from a multicenter united states registry. Catheter Cardiovasc Interv
8. Abdelaal E, Plourde G, MacHaalany J, et al. Effectiveness of low rate fluoroscopy at reducing operator and patient radiation dose during transradial coronary angiography and interventions. JACC Cardiovasc Interv
9. Miller DL, Balter S, Noonan PT, et al. Minimizing radiation-induced skin injury in interventional radiology procedures. Radiology
10. Chan J-Y, Chu C-Y. Chronic radiodermatitis following percutaneous coronary interventions. Dermatol Sin
11. Boncher J, Bergfeld WF. Fluoroscopy-induced chronic radiation dermatitis: a report of two additional cases and a brief review of the literature. J Cutan Pathol
12. Spiker A, Zinn Z, Carter WH, et al. Fluoroscopy-induced chronic radiation dermatitis. Am J Cardiol
13. Nishimoto S, Fukuda K, Kawai K, et al. Supplementation of bone marrow aspirate-derived platelet-rich plasma for treating radiation-induced ulcer after cardiac fluoroscopic procedures: a preliminary report. Indian J Plast Surg
14. Otterburn D, Losken A. Iatrogenic fluoroscopy injury to the skin. Ann Plast Surg
15. Chambers CE, Fetterly KA, Holzer R, et al. Radiation safety program for the cardiac catheterization laboratory. Catheter Cardiovasc Interv
16. Miller DL, Balter S, Schueler BA, et al. Clinical radiation management for fluoroscopically guided interventional procedures. Radiology
17. Hirshfeld JW Jr, Balter S, Brinker JA, et al. ACCF/AHA/HRS/SCAI clinical competence statement on physician knowledge to optimize patient safety and image quality in fluoroscopically guided invasive cardiovascular procedures: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training. Circulation
18. Sawdy JM, Kempton TM, Olshove V, et al. Use of a dose-dependent follow-up protocol and mechanisms to reduce patients and staff radiation exposure in congenital and structural interventions. Catheter Cardiovasc Interv
19. Balter S, Hopewell JW, Miller DL, et al. Fluoroscopically guided interventional procedures: a review of radiation effects on patients’ skin and hair. Radiology
20. Martin CJ. Measurement of patient entrance surface dose rates for fluoroscopic X-ray units. Phys Med Biol
21. Schwartz RA, Burgess GH, Milgrom H. Breast carcinoma and basal cell epithelioma after X-ray therapy for hirsutism. Cancer
22. Miller AB, Howe GR, Sherman GJ, et al. Mortality from breast cancer after irradiation during fluoroscopic examinations in patients being treated for tuberculosis. N Engl J Med
23. de Gonzalez AB, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet
Copyright © 2015 The Authors. Published by Wolters Kluwer Health, Inc. Health, Inc. All rights reserved.
24. Hung MC, Hwang JJ. Cancer risk from medical radiation procedures for coronary artery disease: a nationwide population-based cohort study. Asian Pac J Cancer Prev