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Hindawi Publishing Corporation Radiology Research and Practice Volume 2011, Article ID 201839, 4 pages doi:10.1155/2011/201839 Case Report Thoracic Radionecrosis Following Repeated Cardiac Catheterization 1 2 1 1 Borut Banic, Bernhard Meier, Andrej Banic, and Christian Weinand Department of Plastic and Reconstructive Surgery, University Hospital Inselspital, University of Bern, CH-3010 Bern, Switzerland Department of Cardiology, Bern University Hospital Inselspital, University of Bern, CH-3010 Bern, Switzerland Correspondence should be addressed to Bernhard Meier, email@example.com Received 16 September 2010; Accepted 6 November 2010 Academic Editor: Andreas H. Mahnken Copyright © 2011 Borut Banic et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Radiodermatitis is a known complication in patients having undergone radiotherapy. It usually appears 2 to 5 years after irradiation. We are reporting on a case of radiodermatitis that occurred within months after coronary dilatation and stenting. It started with painful swelling, followed by a typical appearance on the skin surface. Histological ﬁnding conﬁrmed the diagnosis. However, magnetic resonance imaging showed changes in the subcutaneous tissue extending into the ribs. A radical debridement was performed including removal of a partially necrotic 4th rib. The defect was closed with a latissimus dorsi transposition ﬂap. Our ﬁndings are compared with the literature reports. 1. Introduction 2. Case Report In the past 20 years there has been an enormous growth A 59-year-old patient presented with typical chest pain to in the number of diagnostic and interventional procedures the cardiology service in May 2002 and underwent cardiac using ﬂuoroscopy. It is known that cardiac catheterization stenting of a highly stenotic lesion in the right coronary procedures expose the patient to signiﬁcant levels of radia- artery (RCA). The catheterization procedure entailed a total tion [1, 2]. However, until now, protection guidelines against of 22 minutes of ﬂuoroscopy. Six months later the patient radiation hazards associated with cardiac catheterization presented with recurrent chest pain. Repeat angiography remain mostly on staﬀ exposure . showed an occlusion of the RCA. Recanalization was Cutaneous side eﬀects of X-rays have been observed and attempted but was not successful. Fluoroscopy time during reported on since 1899 . However, until recently little this procedure was 47 minutes. Due to persistent angina attention was paid to dermal radiation injury, following pectoris angiography was repeated 2 days later when the cardiac catheterization  for which there are no legally RCA could be recanalized and 2 stents were implanted deﬁned upper limits in Switzerland. Typical are skin lesions successfully. Fluoroscopy time was 78 minutes. The total such as ulcerations and transformation of these lesions into estimated radiation dose was well over 25 gray. squamous cell carcinoma. Speciﬁcally, threshold doses for Two months later the patient complained about a painful the development of erythema, permanent epilation, moist lesion on the right chest wall overlying the 4th rib. Physical desquamation, and necrosis are reported to be 3–10, 7–10, exam revealed a 7×8 cm poikilodermal erythema. The lesion 12–25, and 25 gray, respectively [6, 7]. When these threshold persisted in spite of treatment by dermatologists over 5 years doses for dermal injuries are surpassed, further injury of the (Figure 1). underlying tissue results. The sequelae of radiation injuries Magnetic resonance imaging (MRI) conﬁrmed the sus- due to higher doses than 25 gray are not known so far. We pected radionecrosis of the skin as well as necrosis of report on a case of transthoracic necrosis of skin and bone subcutaneous tissues (Figure 2). of a patient, who underwent cardiac catheterization with In February 2009 the patient presented to the Depart- prolonged ionization of signiﬁcantly more than 25 gray. ment of Plastic and Reconstructive Surgery in our hospital. 2 Radiology Research and Practice Figure 1: Radiodermatitis measuring 8 × 5 cm occurred within months after coronary dilatation and stenting. Rad Insel Uni Bern Geb.dat.: 1950 1950 C: 215, W: 495 Seq.: ﬂ2d1 Schnitt: 6 mm Pos.: −15.4839 TR: 93 TE: 4.76 MZ: 1 i.v. KM 1(3) HFS FOV: mm Bild-Nr: 12 Bild 12 von 34 1 02.02.2009, 12:43:57 P Figure 2: Magnetic resonance imaging (MRI) showing changes in the subcutaneous tissue extending to the ribs. Indication was set for an excision of the lesion and defect 3. Discussion coverage with a ﬂap. During the operation, next to the soft Although there has been an enormous growth of cardiac tissues, the central portion of the 4th rib was found to be catheterization procedures in the last 20 years, there are necrotic and had to be removed (Figures 3(a) and 3(b)). The no regulations that limit the radiation dose to the patient. excised tissue was sent for histopathological evaluation. The Radiodermatitis as a complication of therapeutic use of ion- resulting defect, now measuring 15×10 cm, was subsequently izing radiation such as catheter-based coronary interventions covered by a pedicled myocutaneous latissimus dorsi ﬂap is described only in a few case reports [8, 9]. Cutaneous from the right side. side eﬀects are dose dependent and can develop months or During the course of hospitalization the ﬂap healed even years after radiation exposure. The cumulative dose without complications (Figure 4). The histological results necessary to induce chronic skin changes is estimated to be conﬁrmed the radionecrosis. above10to12gray. The cardiac catheterization ionizing Anticoagulation had to be stopped preoperatively. After radiation exposure rate can reach 0.008–0.016 coulomb/kg the successful operation, the patient started to complain of × minute, during a short and relatively constant time [1, chest pain. Repeat angiography showed a recurrent stenosis 5]. A routine cardiac catheterization procedure exposes a within the implanted stents. The stenosis was dilated again patient to an average radiation dose of 2.5 gray whereas and 2 additional stents were implanted with a good result. percutaneous interventions result in an average dose of 6.4 Fluoroscopy time was 9 minutes. The defect coverage of gray . Our patient received a cumulative dose much higher the excised chest tissue healed well, and the patient did not than 25 Grey that led to skin changes already two months develop any further skin changes. after the last exposure. Radiology Research and Practice 3 (a) (b) Figure 3: (a) Necrotic muscle covering the rib after the removal of radiodermatitis. (b) Situs after partial removal of the 4th rib. The patient was transferred to our Department of Plastic and Reconstructive Surgery for excision of the lesion in 2008 after 5 years of continuous dermatological treatment. The tissue necrosis that was encountered intra-operatively was deeper than previously seen on the MRI. The resulting defect was closed using a latissimus dorsi myocutaneous transposition ﬂap. The patient recovered well after plastic surgery and followup showed good healing of the soft tissue over the defect. In summary we present a case of a large and deep thoracic tissue necrosis after cardiac catheterization. Its early onset less than two months after the last catheterization indicates that the radiation dose the tissues received was well above the threshold of 25 Grey. Although the patient was successfully treated with a late excision and soft tissue coverage, we suggest that an early excision within several weeks after the onset of the radiodermatitis should be performed. References  D. S. Baim and S. Paulin, “Angiography: principles under- Figure 4: Wound healed after reconstruction of the defect with a lying proper utilization of cineangiographic equipment and latissimus dorsi transposition ﬂap. contrast agents,” in Cardiac Catheterization, Angiography and Intervention,W.Grossman andD.S.Baim, Eds.,pp. 15–27, Lea and Felbiger, Philadelphia, Pa, USA, 1991. To date, 9 cases of radiation dermatitis have been  L.W.Johnson,R.J.Moore,and S. Balter,“Review of reported in the literature [4, 6, 8–12]. However, such radiation safety in the cardiac catheterization laboratory,” extensive tissue necrosis has not been reported. In most cases Catheterization and Cardiovascular Diagnosis, vol. 25, no. 3, of radiodermatitis, patients had undergone repeat cardiac pp. 186–194, 1992. catheterization procedures due to complex and anatomical  S. Balter, F. A. Heupler Jr., J. E. Goss et al., “Guidelines for challenging cases. However, most cases lack information personnel radiation monitoring in the cardiac catheterization about exposure time and resulting radiation. In our case laboratory. Laboratory Performance Standards Committee the patient underwent several catheterization procedures of the Society for Cardiac Angiography and Interventions,” in November and December 2002, the ﬁrst lasting 21, the Catheterization and Cardiovascular Diagnosis, vol. 30, no. 4, second 47, and the third 78 minutes. This totals an exposure pp. 277–279, 1993. time in 2002 of 157 minutes. Another 9 minutes were added  D. A. Lichtenstein, L. Klapholz, D. A. Vardy et al., “Chronic in 2003. The procedures had been described as diﬃcult radiodermatitis following cardiac catheterization,” Archives of because of the tortuosity of the RCA. Therefore, the most Dermatology, vol. 132, no. 6, pp. 663–667, 1996. radiointense lateral projection (longest possible intrabody  P. L. Pattee, P. C. Johns, and R. J. Chambers, “Radiation trajectory) had to be used most of the time. This also risk to patients from percutaneous transluminal coronary explained the localization of the skin lesion at the lateral angioplasty,” Journal of the American College of Cardiology, vol. entry side of the chest. 22, no. 4, pp. 1044–1051, 1993. 4 Radiology Research and Practice  G. T. Nahass, “Acute radiodermatitis after radiofrequency catheter ablation,” Journal of the American Academy of Derma- tology, vol. 36, no. 5, pp. 881–884, 1997.  J. C. Nenot, “Medical and surgical management for localized radiation injuries,” International Journal of Radiation Biology, vol. 57, no. 4, pp. 783–795, 1990.  A. Aerts, T. Decraene, J. J. van den Oord et al., “Chronic radiodermatitis following percutaneous coronary interven- tions: a report of two cases,” Journal of the European Academy of Dermatology and Venereology, vol. 17, no. 3, pp. 340–343,  L. Dehen, C. Vilmer, C. Humiliere et al., “Chronic radioder- matitis following cardiac catheterisation: a report of two cases and a brief review of the literature,” Heart,vol. 81, no.3,pp. 308–312, 1999.  H. Goldschmidt and W. K. Sherwin, “Reactions to ionizing radiation,” Journal of the American Academy of Dermatology, vol. 3, no. 6, pp. 551–579, 1980.  J. L. Schmutz, F. Granel, S. Reichert-Penetrat, N. Danchin, and A. Barbaud, “Radiodermites apres ` catheterisme cardiaque,” Presse Medicale, vol. 28, no. 39, pp. 2168–2173, 1999.  F. D. Malkinson, “Radiation injury to skin following ﬂuoro- scopically guided procedures,” Archives of Dermatology, vol. 132, no. 6, pp. 695–696, 1996. 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Published: Dec 15, 2010
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