大血管部位严重放射性溃疡的治疗策略

曹彤瑜; 杜伟力; 于东宁; 张颖; 蒋徽豪; 胡云刚; 沈余明

doi:10.3760/cma.j.cn501225-20240521-00191

大血管部位严重放射性溃疡的治疗策略

doi: 10.3760/cma.j.cn501225-20240521-00191

首都医科大学附属北京积水潭医院烧伤整形与创面修复科,北京　　100035

基金项目:

国家重点研发计划 2022YFC2403004, 2018YFA0703104

详细信息

通讯作者:
沈余明,Email：shenyuming1963@163.com

计量
- 文章访问数: 737
- HTML全文浏览量: 65
- PDF下载量: 18
- 被引次数: 0
出版历程
- 收稿日期: 2024-05-21

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

Department of Burns and Plastic Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing 100035, China

Funds:

National Key Research and Development Program of China 2022YFC2403004, 2018YFA0703104

More Information

Corresponding author: Shen Yuming, Email: shenyuming1963@163.com

摘要

摘要: 目的探讨大血管部位严重放射性溃疡的治疗策略。方法该研究为回顾性观察性研究。2016年1月—2023年12月,首都医科大学附属北京积水潭医院收治23例符合入选标准的放射性溃疡患者且溃疡靠近大血管,其中女18例、男5例,年龄39~77岁。溃疡分布于腋部者11例、腹股沟区域者4例、颈部者5例、锁骨下区域者3例。根据溃疡基底与大血管之间的距离,进行溃疡分型,大血管暴露于溃疡基底为血管裸露型（2例）,溃疡基底与大血管壁的距离≤1 cm为近血管型（8例）,溃疡基底与大血管壁的距离>1 cm为远血管型（13例）。经过全面的术前评估、多学科团队合作,血管裸露型和部分血管破裂风险较大的近血管型溃疡者术前放置覆膜支架,其余患者通过术前血管定位及术中谨慎操作避免损伤血管。彻底清创后采用皮瓣或肌皮瓣修复创面,清创后创面面积为6 cm×5 cm~22 cm×12 cm,皮瓣或肌皮瓣面积为14 cm×9 cm~27 cm×10 cm。记录不同部位溃疡的分型情况、具体的创面修复方式、术中创面组织标本细菌培养结果。术后随访观察皮瓣或肌皮瓣存活情况、感染或窦道复发情况及创面愈合情况。结果 11例腋部溃疡患者中溃疡为近血管型者3例、远血管型者8例,3例锁骨下溃疡患者中溃疡为近血管型者1例、远血管型者2例,采用腹直肌肌皮瓣或背阔肌肌皮瓣修复；5例颈部溃疡患者中溃疡为血管裸露型者2例、近血管型者3例,采用胸大肌肌皮瓣或颈横动脉穿支皮瓣修复；4例腹股沟溃疡患者中溃疡为近血管型者1例、远血管型者3例,采用阔筋膜张肌肌皮瓣、股前外侧皮瓣或对侧腹直肌肌皮瓣修复。术中取的创面组织标本中检出细菌主要为金黄色葡萄球菌、头状葡萄球菌、铜绿假单胞菌。术后随访1~25个月,14例患者皮瓣或肌皮瓣存活良好且创面愈合；2例患者皮瓣边缘感染经换药后愈合；7例患者因感染复发或皮瓣部分坏死致创面未愈合,其中5例患者再次行穿支皮瓣或局部皮瓣移植修复创面,2例患者创面经清创缝合后愈合。3例行支架植入术的患者创面均愈合,无感染或窦道复发。结论基于大血管和溃疡基底距离的溃疡分型策略及选择性覆膜支架植入,结合多学科团队协作与彻底清创,可安全实现大血管部位严重放射性溃疡的修复,显著降低血管损伤与感染复发风险。
- 皮肤溃疡 /
- 放射疗法 /
- 穿支皮瓣 /
- 肌皮瓣 /
- 放射性溃疡 /
- 创面修复
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.
- Skin ulcer /
- Radiotherapy /
- Perforator flap /
- Myocutaneous flap /
- Radiation-induced ulcer /
- Wound repair
曹彤瑜：酝酿和设计研究,实施手术,采集、分析/解释数据,撰写文章,获取研究经费；杜伟力：酝酿和设计研究,实施手术,对文章的知识性内容作批评性审阅；于东宁、张颖、蒋徽豪：实施手术,采集数据；胡云刚：采集、分析/解释数据,对文章的知识性内容作批评性审阅；沈余明：酝酿和设计研究,指导并实施手术,分析/解释数据,对文章的知识性内容作批评性审阅,获取研究经费

所有作者声明不存在利益冲突

HTML全文

参考文献(40)

[1]	沈余明,胡云刚.慢性放射性溃疡的诊疗策略[J].中华烧伤与创面修复杂志,2024,40(6):501-506.DOI: 10.3760/cma.j.cn501225-20240308-00091.
[2]	夏成德,杨阳.放射性皮肤溃疡的治疗和预防策略[J].中华烧伤与创面修复杂志,2024,40(8):719-724.DOI: 10.3760/cma.j.cn501225-20240415-00134.
[3]	HuY,YuL,DuW,et al.Global hotspots and research trends of radiation-induced skin injury: a bibliometric analysis from 2004 to 2023[J].Front Oncol,2024,14:1430802.DOI: 10.3389/fonc.2024.1430802.
[4]	KameniLE,JanuszykM,BerryCE,et al.A review of radiation-induced vascular injury and clinical impact[J].Ann Plast Surg,2024,92(2):181-185.DOI: 10.1097/SAP.0000000000003723.
[5]	沈余明,沈祖尧,王乃佐,等.严重放射性溃疡的修复[J].中国修复重建外科杂志,2000,14(4):208-210.
[6]	ZhouB,LongY,LiS,et al.Reconstruction of chronic radiation-induced ulcers in the chest wall using free and pedicle flaps[J].Front Surg,2022,9:1010990.DOI: 10.3389/fsurg.2022.1010990.
[7]	李罡,张志,李叶扬,等.颈横动脉颈段皮支皮瓣修复颈部放射性溃疡的临床效果[J].中华烧伤杂志,2021,37(12):1116-1121.DOI: 10.3760/cma.j.cn501120-20200807-00371.
[8]	KhodamoradiE,Hoseini-GhahfarokhiM,AminiP,et al.Targets for protection and mitigation of radiation injury[J].Cell Mol Life Sci,2020,77(16):3129-3159.DOI: 10.1007/s00018-020-03479-x.
[9]	KhanM,WangY.Advances in the current understanding of how low-dose radiation affects the cell cycle[J].Cells,2022,11(3):356.DOI: 10.3390/cells11030356.
[10]	WangB,WeiJ,MengL,et al.Advances in pathogenic mechanisms and management of radiation-induced fibrosis[J].Biomed Pharmacother,2020,121:109560.DOI: 10.1016/j.biopha.2019.109560.
[11]	SandersJT,FreemanTF,XuY,et al.Radiation-induced DNA damage and repair effects on 3D genome organization[J].Nat Commun,2020,11(1):6178.DOI: 10.1038/s41467-020-20047-w.
[12]	ZhouYJ,TangY,LiuSJ,et al.Radiation-induced liver disease: beyond DNA damage[J].Cell Cycle,2023,22(5):506-526.DOI: 10.1080/15384101.2022.2131163.
[13]	ChenZ,WangX,GaoX,et al.Transcriptional inhibition after irradiation occurs preferentially at highly expressed genes in a manner dependent on cell cycle progression[J].Elife,2024,13:RP94001.DOI: 10.7554/eLife.94001.
[14]	YuZ,XuC,SongB,et al.Tissue fibrosis induced by radiotherapy: current understanding of the molecular mechanisms, diagnosis and therapeutic advances[J].J Transl Med,2023,21(1):708.DOI: 10.1186/s12967-023-04554-0.
[15]	HymesSR,StromEA,FifeC.Radiation dermatitis: clinical presentation, pathophysiology, and treatment 2006[J].J Am Acad Dermatol,2006,54(1):28-46.DOI: 10.1016/j.jaad.2005.08.054.
[16]	LeventhalJ,YoungMR.Radiation dermatitis: recognition, prevention, and management[J].Oncology (Williston Park),2017,31(12):885-887, 894-899.
[17]	SimmanR,BachK,AbbasF,et al.Management of radiation-induced tissue injuries: a review of current treatment strategies[J].Plast Reconstr Surg Glob Open,2023,11(6):e5043.DOI: 10.1097/GOX.0000000000005043.
[18]	MincSD,ThibaultD,MaroneL.Outcomes of carotid artery stenting in patients with radiation arteritis compared with those with atherosclerotic disease[J].J Vasc Surg,2022,75(4):1286-1292.DOI: 10.1016/j.jvs.2021.11.058.
[19]	WeiJ,MengL,HouX,et al.Radiation-induced skin reactions: mechanism and treatment[J].Cancer Manag Res,2019,11:167-177.DOI: 10.2147/CMAR.S188655.
[20]	KimJM,KimSA,KwonHJ,et al.Reconstruction of radiation-induced ulcers with free flaps using the perforating vessel as a recipient vessel[J].Microsurgery,2019,39(7):613-620.DOI: 10.1002/micr.30504.
[21]	SơnTT,ThúyTTH,DungPTV,et al.Reconstruction of the thoracic radiation-induced ulcer with the pedicled internal mammary artery fasciocutaneous flap: review of the literature and a case report[J].JPRAS Open,2023,37:102-108.DOI: 10.1016/j.jpra.2023.06.007.
[22]	杨志祥,杨文峰,孙向黎,等.颈部严重放射损伤的临床治疗[J].中华整形外科杂志,2001,17(3):146-147.DOI: 10.3760/j.issn:1009-4598.2001.03.007.
[23]	马骁,金增强,杨文峰,等.应用腹直肌皮瓣修复乳癌放疗后放射性溃疡[J].中国美容医学,2010,19(2):158-160.DOI: 10.3969/j.issn.1008-6455.2010.02.005.
[24]	杜伟力,沈余明,程琳,等.乳腺癌根治术后胸部放射性溃疡的修复策略及其临床效果[J].中华烧伤与创面修复杂志,2024,40(6):521-528.DOI: 10.3760/cma.j.cn501225-20240315-00099.
[25]	MaX,JinZ,LiG,et al.Classification of chronic radiation-induced ulcers in the chest wall after surgery in breast cancers[J].Radiat Oncol,2017,12(1):135.DOI: 10.1186/s13014-017-0876-y.
[26]	张蕴鑫,刘建龙,贾伟,等.覆膜支架在颈动脉爆裂综合征治疗中的应用1例[J/OL].中国血管外科杂志(电子版),2016,8(1):74-75[2024-05-21].https://d.wanfangdata.com.cn/periodical/Ch9QZXJpb2RpY2FsQ0hJTmV3UzIwMjUwMTE2MTYzNjE0EhF6Z3hnd2t6ejIwMTYwMTAyMRoIbWRpc3Z4cXE%3D.DOI: 10.3969/j.issn.1674-7429.2016.01.021.
[27]	GoltzJP,BastürkP,HoppeH,et al.Emergency and elective implantation of covered stent systems in iatrogenic arterial injuries[J].Rofo,2011,183(7):618-630.DOI: 10.1055/s-0029-1246077.
[28]	中华医学会整形外科学分会淋巴水肿治疗学组.乳腺癌术后上肢淋巴水肿诊治指南与规范(2021年版)[J].组织工程与重建外科杂志,2021,17(6):457-461.DOI: 10.3969/j.issn.1673-0364.2021.06.001.
[29]	CastrucciT,SciarraA,SianiA,et al.Carotid artery stenting with flow inversion cerebral protection and MicroNet-covered stent[J].J Cardiovasc Surg (Torino),2024,65(3):221-230.DOI: 10.23736/S0021-9509.24.13067-4.
[30]	HakimeA,KhouryE,HamegA,et al.Polytetrafluoroethylene-covered nitinol stent graft for treatment of carotid artery blowout syndrome in head and neck cancer patients[J].Laryngoscope,2013,123(7):1670-1675.DOI: 10.1002/lary.24006.
[31]	VenturiniM,MarraP,ColomboM,et al.Endovascular treatment of visceral artery aneurysms and pseudoaneurysms in 100 patients: covered stenting vs transcatheter embolization[J].J Endovasc Ther,2017,24(5):709-717.DOI: 10.1177/1526602817717715.
[32]	MaedaK,KobayashiT,EmuraS,et al.Medium-term outcomes of treatment with a VIABAHN VBX covered stent for aortoiliac occlusive lesions in patients with peripheral artery disease[J].Ann Vasc Surg,2024,105:201-208.DOI: 10.1016/j.avsg.2023.12.097.
[33]	KatsanosK,SpiliopoulosS,KarunanithyN,et al.Bayesian network meta-analysis of nitinol stents, covered stents, drug-eluting stents, and drug-coated balloons in the femoropopliteal artery[J].J Vasc Surg,2014,59(4):1123-1133.e8.DOI: 10.1016/j.jvs.2014.01.041.
[34]	ReedWP,SpenceRJ.Vertical rectus abdominis musculocutaneous flap for chest wall reconstruction after irradiation[J].South Med J,1987,80(3):287-291.DOI: 10.1097/00007611-198703000-00003.
[35]	赵奎背阔肌、腹直肌肌皮瓣修复乳腺癌术后胸壁放射性溃疡的临床疗效对比分析南宁广西医科大学2019 赵奎.背阔肌、腹直肌肌皮瓣修复乳腺癌术后胸壁放射性溃疡的临床疗效对比分析[D].南宁:广西医科大学 ,2019.
[36]	TukiainenE.Chest wall reconstruction after oncological resections[J].Scand J Surg,2013,102(1):9-13.DOI: 10.1177/145749691310200103.
[37]	王欣.带蒂腹直肌肌皮瓣修复胸壁深度放射性溃疡[J].组织工程与重建外科杂志,2020,16(4):295-297.DOI: 10.3969/j.issn.1673-0364.2020.04.008.
[38]	LiuY,LiuP,SongY,et al.A heparin-rosuvastatin-loaded P(LLA-CL) nanofiber-covered stent inhibits inflammatory smooth-muscle cell viability to reduce in-stent stenosis and thrombosis[J].J Nanobiotechnology,2021,19(1):123.DOI: 10.1186/s12951-021-00867-8.
[39]	CasanaR,TolvaV,OderoAJr,et al.Safety and efficacy of the new micromesh-covered stent CGuard in patients undergoing carotid artery stenting: early experience from a single centre[J].Eur J Vasc Endovasc Surg,2017,54(6):681-687.DOI: 10.1016/j.ejvs.2017.09.015.
[40]	LairdJR,LojaM,ZellerT,et al.iCAST balloon-expandable covered stent for iliac artery lesions: 3-year results from the iCARUS multicenter study[J].J Vasc Interv Radiol,2019,30(6):822-829.e4.DOI: 10.1016/j.jvir.2018.12.707.

下载: 全尺寸图片幻灯片

图 1 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

下载: 全尺寸图片幻灯片

图 2 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

下载: 全尺寸图片幻灯片