MANAGEMENT OF RADIATION-INDUCED OCCLUSIVE ARTERIAL-DISEASE - A REASSESSMENT

Background. The goal of this study was to evaluate the operative hazar ds, therapeutic procedures, and late results of arterial reconstructio n for radiation-induced occlusive disease. Methods. Twenty-five patien ts were referred to our institution for radiation-induced occlusive ar terial disease, Group 1: carotid artery stenosis or occlusion was enco untered in seven patients. The nine procedures employed included percu taneous transluminal angioplasty (PTA) (n=2), carotid endarterectomy ( n=3), vein or prosthetic bypass (n=4). Group 2: four patients presenti ng with subclavian and axillary artery occlusion were treated with a c ommon carotid to brachial artery vein bypass, one after unsuccessful P TA. Group 3: Thirteen patients had aorto-iliac occlusion. Initial mana gement included medical treatment (n=1), PTA (n=2), aorto-bifemoral by pass (n=4), aortofemoral and iliofemoral bypass (n=1 each), axillofemo ral bypass (n=3), femorofemoral bypass (n=1). Group 4: One patient had femoral artery occlusion treated with PTA. Results. Group 1: One of t wo PTA was successful. Endarterectomy or bypass were successful in all cases. One late vein bypass stenosis was treated by venous patch angi oplasty, Group 2: All vein bypasses were successful. Group 3: Limb sal vage was achieved in all patients but eight required repeat operations for prosthetic sepsis (n=3), restenosis (n=3), or thrombosis (n=12). Two patients died of late sepsis. Group 4: Outcome after PTA was succe ssful. Conclusions. 1) Surgery for radiation-induced arterial lesions is difficult because of arterial, periarterial, and cutaneous sclerosi s. Some patients, however, are amenable to PTA or endarterectomy. When bypass is necessary, anastomosis should be performed in healthy arter ies, for instance, the thoracic aorta for the proximal anastomosis, or the brachial artery approached through a lateral mid-arm incision. 2) The risk of early or late graft infection is enhanced by the presence of tracheostomy, colostomy, or ureterostomy and by repeat operation f or thrombosis. PTA, endarterectomy, or vein bypass should be preferred whenever feasible. When prosthetic material is unavoidable, preventio n of infection should include the use of omentoplasty, remote bypass, antibiotic-bonded grafts or, in the case of major sepsis, allografts. 3) As restenosis remains a frequent complication, annual clinical and Duplex-scan surveillance is mandatory.