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.