1. Clinical manifestation, diagnosis, and surgical treatment of chronic radiation ulcers related to percutaneous coronary intervention Biing-Luen Lee, MD. Hsu Ma, Yu-Chung Shih Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital Taipei, Taiwan

2. Case report 59-year-old man, presented with a 3x2cm central ulcerative wound with peripheral hyper-pigmentation at central back for 2 years

3. Initial diagnosis: Allergic dermatitis to unknown cardiovascular drugs/Carbuncle with secondary infection Responded poorly to topical treatment

4. Past history of coronary artery disease, single vessel disease with right coronary artery total occlusion status post percutaneous cardiac intervention twice in May (Duration: 2hrs) and July (Duration: 4hrs 34 mins), 2010 Tracing back the history, he presented with itching red papules with erosion at central back after the PCI was immediately noticed by patient

5. Complete excision of the ulcer followed by reconstruction with a rhomboid fasciocutaneous flap Immediately after operation21 months after operation

6. Introduction Chronic radiation ulcers that develop after cardiac catheterization have become common recently because of the rapid increase in the use of diagnostic and interventional cardiac catheterization procedures J Vasc Interv Radiol 2011; 22:425-429

7. The early diagnosis of chronic radiation ulcers is difficult and conclusive information on the optimal management of these ulcers is lacking, especially that for National Cancer Institute (NCI) grade 4 radiation ulcers

8. Retrospective study 10 patients with cardiac catheterization- induced NCI grade 4 chronic ulcers between January 2009 and April 2014 Database of the Department of Plastic Surgery at Taipei Veteran General Hospital Materials and Methods

9. Inclusion criteria: Ulcers that had not healed in 4 weeks and presence of full-thickness dermal necrosis associated with pain Appeared and progressed slowly after prolonged cardiac catheterization Infection, hypersensitivity, or malignancy was excluded as the cause of the ulcer Pathologically proven to be full-thickness, radiation-associated chronic ulcers

10. PatientAgeGenderCAD lesions PTA number PTA duration 163MaleRCA CTO14hr13min 260MaleRCA CTO2 4 hr 15 min 5 hr 21 min 357MaleLAD CTO14hr 459MaleRCA CTO2 2 hr 4 hr 34 min 564MaleLAD and RCA CTO2 2 hr 30 min 4 hr 680MaleRCA CTO15hr 782MaleLAD CTO14hr40min 858Male LAD, LCX-M and RCA CTO 4 2 hr 3 hr 38 min 958Male RCA-D near total occlusion 33 hr 1086MaleRCA CTO2 3 hr 20 min 4 hr 23 min Avg66.71.7214.94 mins CTO: chronic total occlusion

11. Patie nt Skin ulcer onset time Skin ulcer locations Disease onset to surgery Surgical procedures Follow-up (months) Status 10.2 months Right upper back; right axilla 6 monthsFasciocutaneous flap33Survive 25 months Right upper back 6 monthsFasciocutaneous flap20Survive 31.5 monthsCentral back 5.5 monthsDebridement and fasciocutaneous flap 40Survive 4ImmediateCentral back 24 monthsDebridement and fasciocutaneous flap 21Survive 512 months Left elbow; left lateral chest wall 3 months1. Debridement and pedicled forearm flap 2. Fasciocutaneous flap 69Survive 6ImmediateRight back 10 monthsDebridement and split- thickness skin graft 13Survive 7ImmediateRight shoulder 12 monthsPedicled parascapular flap 8Dead 86 monthsLeft upper back 4 monthsFasciocutaneous flap8Survive 96 months Right back1 monthsFasciocutaneous flap19Survive 106 months Right upper back 14 monthsFasciocutaneous flap2Survive Avg8.55 months23.3

12. Taiwan version of the modified World Health Organization Quality of Life-Short Version (WHOQOL-BREF) questionnaire Q1. How severe is the pain? Q2. How bothered are you by fatigue? Q3. To what extent are your daily activities affected? Q4. Do you have any difficulties with sleeping? Q5. How dependent are you on analgesics? Q6. How often do you have negative feelings such as blue mood, despair, anxiety, and depression?

13. The preoperative and postoperative scores and P values (Wilcoxon signed-rank test) for each question Preoperative score (mean  SD)Post-operative score (mean  SD) P value Q13.78 ± 1.3021.33 ± 0.7070.011 Q23.22 ± 1.2021.33 ± 0.5000.015 Q33.89 ± 0.9281.44 ± 0.7260.011 Q43.00 ± 1.3231.22 ± 0.4410.016 Q53.11 ± 2.0281.11 ± 0.3330.038 Q63.00 ± 1.3231.11 ± 0.3330.015

14. The diagnosis of chronic ulcers related to prolonged percutaneous coronary intervention depends on careful history taking and a highly suspicious clinical presentation Table 3. Diagnostic criteria for chronic radiation ulcer related to percutaneous coronary interventions Clinical presentation 1.Received prolonged cardiac catheterization of more than 3 hours at least once 2.Coronary artery lesions: chronic total or near-total occlusion 3.Chronic and non-healing ulceration and peripheral erythematous change over the back 4.Severe pain or discomfort Histopathological finding 1.Epidermal ulceration, dermal and hypodermal fibroses, and dermal telangiectasia Conclusion

15. For NCI grade 4 radiation ulcers, treatment of complete resection and immediate reconstruction with flaps or grafts may improve the symptoms and achieve reliable wound coverage without complications

16. Discussion Catheter Cardiovasc Interv 77(4): 546-556 Prevention

17. Post-procedural patient notification, chart documentation, communication of adverse skin effects, and patient follow-up

18. Early diagnosis Early referral (to experienced team consisting of wound-care specialists, dermatologists, and plastic surgeons) Early surgical intervention

19. Thank you for your attention! Questions or Comments