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

Cao Tongyu; Du Weili; Yu Dongning; Zhang Ying; Jiang Huihao; Hu Yungang; Shen Yuming

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

Volume 41 Issue 5

May 2025

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Article Navigation > CHINESE JOURNAL OF BURNS AND WOUNDS > 2025 > 41(5): 432-439

Cao TY,Du WL,Yu DN,et al.Treatment strategy for severe radiation-induced ulcers near major blood vessels[J].Chin J Burns Wounds,2025,41(5):432-439.DOI: 10.3760/cma.j.cn501225-20240521-00191.

Citation:

Cao TY,Du WL,Yu DN,et al.Treatment strategy for severe radiation-induced ulcers near major blood vessels[J].Chin J Burns Wounds,2025,41(5):432-439.DOI: 10.3760/cma.j.cn501225-20240521-00191.

Citation:

Cao TY,Du WL,Yu DN,et al.Treatment strategy for severe radiation-induced ulcers near major blood vessels[J].Chin J Burns Wounds,2025,41(5):432-439.DOI: 10.3760/cma.j.cn501225-20240521-00191.

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

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

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

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Corresponding author: Shen Yuming, Email: shenyuming1963@163.com
Received Date: 2024-05-21

Abstract

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

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References(40)

References

[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.