A Hybrid Approach to Radiation-Induced Axillary Artery Hemorrhage.

Axillary artery blowout is a rare life- and limb-threatening condition. The traditional surgical approach of ligation and extra-anatomic bypass is associated with a high morbidity and mortality. We present a case report of a 65-year-old male with axillary artery hemorrhage secondary to an irradiated squamous cell cancer. We propose a staged hybrid approach for the treatment of this unusual clinical entity consisting of emergent stent grafting followed by planned elective extra-anatomic bypass, debridement, and a course of specific antimicrobial therapy.

In situ beta radiation to prevent recanalization after coil embolization of cerebral aneurysms.

BACKGROUND AND PURPOSE: Endovascular treatment of cerebral aneurysms, a minimally invasive alternative to surgery, is too often followed by recanalization and recurrences. The purpose of this work was to assess if in situ beta radiation can inhibit recanalization after coil embolization. METHODS: Radioactive platinum coils (32P-coils) were produced by ion implantation of 32P. A single-coil arterial occlusion model was used to compare angiographic and pathological results at 1 to 12 weeks after nonradioactive and 32P-coil embolization of maxillary, cervical, and vertebral arteries in 26 dogs. Coils of varying activities were used and results compared to define the minimal activity required to inhibit recanalization. Similar experiments were performed in 16 porcine maxillary and lingual and 8 rabbit axillary arteries. Results of 32P-coil embolization of bifurcation aneurysms were then compared with embolization with nonradioactive coils in 12 dogs at 3 months. RESULTS: Nonradioactive coil embolization of canine arteries led to occlusion at 1 week, followed by recanalization at 2 weeks, which persisted at 3 months in all cases. 32P-coils, ion-implanted with activities above 0.13 microCi/cm, led to persistent occlusion at 3 months in 80% of arteries. 32P-coils ion-implanted with the same activity inhibited recanalization in porcine and rabbit arteries. Bifurcation aneurysms treated with 32P-coils had better angiographic results at 3 months (P=0.006) than aneurysms treated with nonradioactive coils. Arteries occluded were filled with fibrous tissue at 3 months. Aneurysms embolized with 32P-coils showed more complete neointimal coverage of the neck, without recanalization, as compared with aneurysms treated with nonradioactive coils. CONCLUSION: In situ low-dose beta radiation inhibits recanalization after coil embolization and may improve long-term results of endovascular treatment of aneurysms.

Irradiation-induced changes in the subclavian and axillary arteries after radiotherapy for carcinoma of the breast.

Three case reports are reviewed to illustrate the possibility of treating irradiation-induced lesions of the subclavian-brachial vascular segment (aneurysm and segmental occlusions) 14, 20, and 26 years after radical mastectomy and subsequent radiotherapy. All patients had an extraanatomic vein bypass graft from the carotid to the brachial artery crossing the shoulder near the acromioclavicular joint, with the advantage that the tissue changed by radiotherapy or infected by ulceration could be circumvented. There were no postoperative complications, with adequate function of the grafts (follow-up, 17, 24, and 20 months, respectively).

[Post-irradiation axillo-subclavian arteriopathy: surgical revascularization]. / Artériopathie radique axillo-sous-clavière: revascularisation chirurgicale.

Post-irradiation axillo-subclavian arteriopathy can develop 6 months to 20 years after radiotherapy. Incidence estimated from duplex scan screening is about 30%, half of the cases having no hemodynamic significance. In our experience, asymptomatic lesions are the most common. Nevertheless, we have observed since 1978, 38 symptomatic patients including 23 with either acute ischemia (8 patients), or chronic ischemia (15 patients) requiring revascularization. We used an endovascular approach in 8 and open surgery in 15. A bypass graft was performed in 13 patients, using a vein (8 patients) rather than a prosthesis (5 patients), implanted in healthy territory, proximally or in the common carotid (11 patients) or the proximal subclavian (2 patients), and distally in the axillary artery (5 patients) or the brachial artery (8 patients). One venous bypass became occluded postoperatively. The other bypasses remained patent during follow-up of over 10 years. There of the five prosthetic bypassess gradually failed without recurrence of critical ischemia. Other revascularization procedures included endarterectomy and thrombectomy. In the long term, functional prognosis mainly depended on the frequently associated involvement of the plexus in the post-irradiation changes, which, together with the revascularization procedure, also required neurolysis in 11 patients, two omental covers and a free musculocutaneous transfer in 9 patients.

Radiotherapy-related axillary arteriopathy.

Treatment of breast cancer involves surgery, then perhaps radiation, hormonal or chemotherapy. Radiation-induced arterial injury is a well-known entity that represents a rare cause of arterial occlusion. We present the case of a 76-year old woman who complained of a severe intermittent claudication of the right upper limb. Twenty years before, she underwent a right-sided radical mastectomy followed by intense radiation therapy for several weeks. The patient was found to suffer of a radiotherapy-related axillary artery thrombosis and was successfully treated by angioplasty and stenting.

Acute upper limb ischaemia following chest wall reconstruction--a word of caution.

Irradiation arteriopathy, although rare, is a recognised entity following radiotherapy for the management of advanced cancers. It is known to manifest in varied forms and can be chronic and progressive. We present a case of an acute upper limb ischaemia following deep inferior epigastric artery perforator (DIEP) free flap reconstruction for a chest wall defect in a patient who had previously undergone radiotherapy 25 years back for carcinoma of the breast. It is envisaged that the axillary artery was thrombosed secondary to radiation arteriopathy and the collaterals that had developed were probably damaged during debridement of the irradiated unhealthy tissue prior to free flap reconstruction. A cross-limb vascular graft tunnelled under the flap restored the perfusion to the limb. We propose that the possibility of radiation arteriopathy should be considered and a preoperative arteriogram should be performed prior to planning any major surgical reconstruction in patients having undergone irradiation to major vascular beds.

Radiotherapy-related axillary artery occlusive disease: percutaneous transluminal angioplasty and stenting. Two case reports and review of the literature.

Radiotherapy-related axillary artery occlusive disease is a relatively rare condition. This complication is usually encountered in patients with breast carcinoma treated by radiotherapy and might be frequently concealed by the presence of lymphoedema. We discuss this rare complication of radiotherapy treatment for breast cancer and present two cases and their successful treatment by a modified percutaneous transluminal angioplasty and stenting technique. A review of literature on the subject is also presented.

Irradiation injury to large arteries.

Four cases of irradiation injury to large arteries are presented and the literature is reviewed. Three patterns of injury have emerged. 1. Intimal damage resulting in mural thrombosis presenting within 5 years of irradiation. 2. Fibrotic occlusion presenting within 10 years of injury. 3. A predisposition to the development of atheroma together with periarterial fibrosis associated with a latent interval of 20 or more years. The treatment of choice is a bypass procedure of the arterial lesion.

Percutaneous intervention for radiation damage to axillary arteries.

Radiation injury to subclavian and axillary arteries is a rare and late complication of radiotherapy. Until recently it has been treated almost exclusively by carotid-brachial bypass surgery. We report three cases who presented with severe upper limb ischaemia following previous axillary radiotherapy for breast carcinoma. One patient with an axillary artery occlusion failed angioplasty and required bypass surgery. A further patient with an axillary artery occlusion was successfully managed by the percutaneous placement of an arterial stent. The third patient with an isolated axillary artery stenosis responded to balloon angioplasty. All three patients remained asymptomatic. Percutaneous angioplasty and stent placement, where necessary, are appropriate first choice treatment for delayed radiation stenosis and occlusion in upper limb ischaemia.