1
|
Pernod G, Cohen A, Mismetti P, Sanchez O, Mahé I. [Translation into French and republication of: "Cancer-related arterial thromboembolic events"]. Rev Med Interne 2024:S0248-8663(24)00703-3. [PMID: 39097502 DOI: 10.1016/j.revmed.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 08/05/2024]
Abstract
Cancer is associated with a hypercoagulable state and is a well-known independent risk factor for venous thromboembolism, whereas the association between cancer and arterial thromboembolism is less well established. Arterial thromboembolism, primarily defined as myocardial infarction or stroke is significantly more frequent in patients with cancer, independently of vascular risk factors and associated with a three-fold increase in the risk of mortality. Patients with brain cancer, lung cancer, colorectal cancer and pancreatic cancer have the highest relative risk of developing arterial thromboembolism. Antithrombotic treatments should be used with caution due to the increased risk of haemorrhage, as specified in current practice guidelines.
Collapse
Affiliation(s)
- Gilles Pernod
- Service de médecine vasculaire, CHU de Grenoble, université Grenoble-Alpes, Grenoble, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - Ariel Cohen
- Service de cardiologie, hôpital Saint-Antoine, hôpital Tenon, Assistance publique-Hôpitaux de Paris, Sorbonne université, Paris, France; Inserm, UMRS 1166, unité de recherche sur les maladies cardiovasculaires et métaboliques, Institut hospitalo-universitaire, Institut de cardiométabolisme et nutrition (ICAN), Sorbonne université, 75013 Paris, France
| | - Patrick Mismetti
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine vasculaire et thérapeutique, hôpital Nord, CHU de Saint-Étienne, Saint-Étienne, France
| | - Olivier Sanchez
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France; Inserm UMR S1140, innovations thérapeutiques en hémostase, université Paris Cité, Paris, France
| | - Isabelle Mahé
- F-CRIN INNOVTE network, Saint-Étienne, France; Inserm UMR S1140, innovations thérapeutiques en hémostase, université Paris Cité, Paris, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France
| |
Collapse
|
2
|
Jessen ML, Eiberg J, Sillesen H, Lawaetz M. Cancer should not contravene the revascularization of chronic limb-threatening ischaemia. Vascular 2024; 32:330-336. [PMID: 36274575 DOI: 10.1177/17085381221135657] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
OBJECTIVES This study aimed to examine the frequency of cancer among patients with chronic limb-threatening ischaemia (CLTI) due to peripheral artery disease (PAD) and to determine how active cancer affected outcomes after open or endovascular revascularization. In addition, we aimed to investigate all-cause mortality and cause of death in the PAD population. DESIGN Observational single-centre cohort study based on a retrospective analysis of prospectively entered registry data. MATERIALS All consecutive patients treated for CLTI due to PAD at a single university centre between the 1st of January 2011 and the 31st of December 2015 were included. Data from the Danish Vascular Registry (Karbase) regarding demographics, surgical procedure, and complications were linked with data from the Danish Cancer Registry and Cause of Death Registry. METHODS The primary endpoint was major amputation-free survival. Secondary endpoints were postoperative complications within 30 days, cancer-free survival, all-cause mortality and cause of death in the cohort. Major amputation-free survival, cancer-free survival and mortality were described with Kaplan-Meier (KM) survival estimates. RESULTS We included 920 patients, of which 116 (13%) were in the active cancer group at the time of revascularization. There was no difference in amputation-free survival between those with cancer (86.8% 1-year KM estimate) and those without cancer (85.2% 1-year KM estimate) (p = 0.50). Likewise, we found no difference in 30-day postoperative complication rate. The risk of developing cancer in the included CLTI cohort was similar to the age-matched background population (6.1% vs 6.4%) (p = 0.69). All-cause mortality was higher in CLTI patients with cancer, mainly due to cancer, compared with CLTI patients without cancer who mainly died from cardiovascular disease. Three-year KM survival estimates were 48.3% (95% CI 40.0%-58.3%) and 64.4% (95% CI 61.2%-67.8%) (p = 0.014) for cancer and non-cancer patients, respectively. CONCLUSIONS Although cancer in patients with CLTI is related to higher medium- to long-term mortality, active cancer per se should not contravene revascularization, as postoperative complications and risk of amputation are not overrepresented.
Collapse
Affiliation(s)
- Majken L Jessen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Jonas Eiberg
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen, Denmark
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Martin Lawaetz
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
3
|
Pernod G, Cohen A, Mismetti P, Sanchez O, Mahé I. Cancer-related arterial thromboembolic events. Arch Cardiovasc Dis 2024; 117:101-113. [PMID: 38057257 DOI: 10.1016/j.acvd.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/08/2023]
Abstract
Cancer is associated with a hypercoagulable state and is a well-known independent risk factor for venous thromboembolism, whereas the association between cancer and arterial thromboembolism is less well established. Arterial thromboembolism, primarily defined as myocardial infarction or stroke is significantly more frequent in patients with cancer, independently of vascular risk factors and associated with a three-fold increase in the risk of mortality. Patients with brain cancer, lung cancer, colorectal cancer and pancreatic cancer have the highest relative risk of developing arterial thromboembolism. Antithrombotic treatments should be used with caution due to the increased risk of haemorrhage, as specified in current practice guidelines.
Collapse
Affiliation(s)
- Gilles Pernod
- Service de Médecine Vasculaire, Université Grenoble-Alpes, Grenoble, France; F-CRIN INNOVTE network, Saint-Etienne, France.
| | - Ariel Cohen
- Service de cardiologie, hôpital Saint-Antoine, hôpital Tenon, Assistance publique-Hôpitaux de Paris, Sorbonne université, Paris, France; Unité INSERM UMRS 1166 Unité de recherche sur les maladies cardiovasculaires et métaboliques, Institut Hospitalo-Universitaire, Institut de Cardiométabolisme et Nutrition (ICAN), 75013, Sorbonne Université, Paris, France
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, CHU Saint-Etienne, Hôpital Nord, Saint-Etienne, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Olivier Sanchez
- Service de pneumologie et de soins intensifs, AP-HP, hôpital européen Georges-Pompidou, Paris, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Isabelle Mahé
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France; F-CRIN INNOVTE network, Saint-Etienne, France
| |
Collapse
|
4
|
Hussain SMA. Tumor embolism and acute arterial occlusion: A systematic review. Surg Open Sci 2022; 10:216-222. [PMID: 36389271 PMCID: PMC9664516 DOI: 10.1016/j.sopen.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/18/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
Objective To determine common etiologies, presentations, management strategies and outcomes in patients with tumor embolism causing acute arterial occlusion. Study design This is a systematic review of published case reports on tumor embolism. Search strategy All published cases of tumor embolism in the MEDLINE and EMBASE databases were reviewed. The search terminologies were (Tumor Embolism), (Ischemia), (Occlusion) and (Infarction). Inclusion and exclusion criteria All published reports of tumor embolism were included. Studies regarding venous thromboembolism and cancer-associated thromboembolism without tumor embolization were excluded. The cases included numbered 42. Outcome measures These included the frequencies of different primary tumor types, clinical presentations, anatomical sites of embolization, types of intervention and outcomes including number of deaths and successful discharges. Results Lung cancer and Atrial Myxoma each accounted for 14 out of 42 cases (33%). There were 11 cases (26.9%) of stroke and 9 cases (21.4%) of myocardial infarction and limb ischemia. Femoral thrombo-embolectomy was performed in all 9 cases of limb ischemia and Primary coronary intervention was performed in 7 out of 9 (77.8%) cases of myocardial infarction. There were 14 inpatient deaths (33.3%) and 19 patients were successfully discharged (45.2%). Conclusion Lung cancer and atrial myxoma were the most common sources for tumor embolism. Acute stroke was the most common presentation. This is treated with antiplatelets or anticoagulation as well as chemotherapy and resection of primary tumor. Early revascularisation can prevent severe complications such as death, paralysis, heart failure and limb loss in selected cases of tumor embolism. Key message Histopathological examination of embolic tissue can demonstrate tumor tissue and alert the clinician to a cancer elsewhere. This is most likely to be lung cancer or atrial myxoma. Early revascularisation in selected cases of acute tumor embolism can prevent severe complications and these patients should not be automatically palliated due to their underlying neoplasm.
Collapse
Affiliation(s)
- Syed Mohammad Asim Hussain
- Department of Vascular Surgery, Frimley Park Hospital, Portsmouth Rd, Frimley, Camberley GU16 7UJ, United Kingdom
| |
Collapse
|
5
|
González Rodríguez P, Gisbert SMM, Chiriboga Granja JI, Medina MC, Palonés FJG. Anaplastic thyroid tumor as an embolic source of metastasis. J Vasc Surg Cases Innov Tech 2022; 8:386-389. [PMID: 35936021 PMCID: PMC9352510 DOI: 10.1016/j.jvscit.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/12/2022] [Indexed: 11/24/2022] Open
Abstract
Tumor-based arterial thromboembolism in patients with cancer is a poorly described concept that lacks evidence for surgical indications owing to its unusual occurrence. The study and understanding of this condition’s etiology is, however, essential because it could constitute the initial presentation or determine the prognosis of oncologic disease. In the present report, we have described the case of a 77-year-old female patient with multiple cerebral, splenic, and upper limb arterial embolic episodes. Embolectomy for acute upper limb ischemia revealed the histopathologic diagnosis of an anaplastic thyroid tumor.
Collapse
|
6
|
Villemur B, Roux C, Poggi JN, Elias A, Le Hello C. Is it justified to search for cancer in patients with peripheral arterial disease? JOURNAL DE MEDECINE VASCULAIRE 2022; 47:133-140. [PMID: 36055682 DOI: 10.1016/j.jdmv.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 07/19/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Cancer is the leading cause of death in European countries, ahead of cardiovascular diseases. Cancer is also the most common co-morbidity among patients hospitalized for the management of cardiovascular diseases. Through an overview, we searched for the frequency and types of cancer associated with peripheral arterial disease (PAD) in order to address the relevance of cancer screening in patients with PAD. METHODS We searched in PubMed database from 1996 to 2020 for retrospective and prospective cohort or cross-sectional or randomized studies evaluating the frequency of all types of cancer in patients with PAD excluding patients with aneurysmal disease. The keywords used were: peripheral arterial disease, arterial thrombosis, acute leg ischemia, critical leg ischemia, chronic leg ischemia, intermittent claudication, malignant tumor, cancer. RESULTS Based on published studies, the frequency of cancer in patients with PAD varied widely from 3.8 to 30.4% depending on study design, population, method used to screen for cancer and study period. In medical records database and registers,cancer prevalence varied from 3,8% to 22,4% in 4 retrospective studies of patients with acute limb ischemia and from 10.5 to 30.4% in 3 prospective studies of patients with acute limb ischemia, critical ischemia or intermittent claudication. In 3 retrospective analyses from 2 population-based cohorts and health insurance claims data, incidence of cancer in patients with intermittent claudication, acute limb ischemia or peripheral arterial disease varied from 8% to 11.7%. The frequency of cancer in PAD patients appeared higher than in the general population. Tobacco-dependent cancers seemed to be the most common cancers in PAD. Cancers were also more frequent in case of anemia, amputation and iterative bypass thrombosis in few studies. CONCLUSION Although there is no recommendation for cancer screening in patients with PAD, the high prevalence of cancer raises the question of screening patients at high risk such as those with acute or critical limb ischemia and especially in case of severe tobacco use, anemia, amputation and iterative bypass thrombosis. These results call for further studies with larger sample size and long term follow-up.
Collapse
Affiliation(s)
- B Villemur
- Unité et consultations de médecine vasculaire, CH Toulon, La Seyne sur mer, France.
| | - C Roux
- Clinique d'Alembert, Grenoble, France
| | - J-N Poggi
- Unité et consultations de médecine vasculaire, CH Toulon, La Seyne sur mer, France
| | - A Elias
- Unité et consultations de médecine vasculaire, CH Toulon, La Seyne sur mer, France
| | - C Le Hello
- CHU Saint-Étienne, Saint-Étienne, France
| |
Collapse
|
7
|
Jain A, Reddy A, Murugesan R, Dutta S, Kumbhar U, Savlania A, Vaka SK. Outcomes of Patients With Acute Limb Ischemia in Patients With COVID-19: A Systemic Review and Meta-Analysis. Cureus 2022; 14:e27370. [PMID: 36046311 PMCID: PMC9418627 DOI: 10.7759/cureus.27370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 11/05/2022] Open
Abstract
A systemic review and meta-analysis of perioperative outcomes of acute limb ischemia (ALI) in patients with and without coronavirus disease-2019 (COVID-19) to determine the outcomes of ALI and compare the outcomes in patients with and without COVID-19 infection. A literature search of the Medline, Science Direct and Cochrane Library was performed from inception to July 15, 2021. Studies involving ALI in patients with COVID-19 were searched through three electronic databases. The endpoints include limb salvage, re-thrombosis, and mortality, and these outcomes were compared between patients with and without COVID-19 infection and type of management. The primary outcome was early limb salvage (till the patient was discharged from the hospital). The other outcomes assessed were re-thrombosis and mortality. These outcomes were compared between patients with and without COVID-19 infection and the type of management. Pooled estimates were presented as odds ratios (ORs) using a random or fixed effect model based on the results of the chi-square test and calculation of I2. Comparing the ALI outcomes in patients with and without COVID-19 infection, there was no significant difference in limb salvage rate (OR=0.26, 95% CI:0.02-3.09), but there was a significantly higher re-thrombosis (OR=2.65, 95% CI:1.34-5.23) and mortality rate (OR=4.71, 95% CI:1.11-19.99) in patients with COVID-19 infection. On comparing outcomes based on management, intervention group, and anticoagulant alone group, no significant difference was noted concerning limb salvage (OR=1.40, 95% CI:0.27-7.13) and mortality rates (OR=0.2, 95% CI:0.04-1.07). This meta-analysis demonstrates a higher re-thrombosis and mortality in ALI patients with COVID-19 infection when compared to patients without COVID-19 but with similar limb salvage.
Collapse
Affiliation(s)
- Ankit Jain
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Abhinaya Reddy
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Rajeswari Murugesan
- Biostatistics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Souradeep Dutta
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Uday Kumbhar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Ajay Savlania
- Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Sivaranjit K Vaka
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| |
Collapse
|
8
|
Kelly A, Toale C, Moloney MA, Kavanagh EG. Outcomes of Acute Limb Ischaemia in Patients with Underlying Malignancy: A Systematic Review. EJVES Vasc Forum 2021; 54:13-20. [PMID: 34977837 PMCID: PMC8685981 DOI: 10.1016/j.ejvsvf.2021.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 09/20/2021] [Accepted: 10/28/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Previous studies have demonstrated amputation and mortality rates to be 14.3% - 30% and 11.4% - 28.9%, respectively, for all patients presenting with acute limb ischaemia (ALI). Rates of ALI are higher in patients with malignancy than in those without. Despite this, there remains uncertainty with regards to the most appropriate management for patients with cancer presenting with ALI. This is because of previously published high rates of associated morbidity and mortality in this population. The aim of this review was to summarise the available evidence reporting on outcomes of ALI in patients with underlying malignancy. METHOD A systematic review was performed in August 2020 in accordance with the PRISMA guidelines. The Medline, Scopus, Cochrane, and Embase databases were searched with the following search string ((acute limb ischaemia) OR (acute limb ischemia)) AND ((cancer) OR (malignancy)). A total of 849 papers were identified and reviewed; six studies were included. Studies were assessed for bias using the National Institute of Health/National Heart, Lung and Blood Institute Quality Assessment Tool. Data including demographics, Rutherford classification, baseline performance scores, method of revascularisation, and peri-procedural outcomes were extracted and analysed. Data were pooled based on outcomes of interest and pooled prevalence was reported with 95% confidence intervals (CI). RESULTS Six studies with 284 patients with cancer were included for analysis. The pooled overall risk of amputation was 15% (95% CI 5.9 - 26.9). The pooled 30 day mortality rate was 24% (95% CI 14.7 - 34.6). CONCLUSION Despite limitations of interstudy selection bias and some clinical heterogeneity, the included studies demonstrated acceptable short and medium term outcomes for patients with cancer undergoing revascularisation for acute limb ischaemia. This is in line with current recommendations that patients with underlying malignancy should be considered strongly for revascularisation.
Collapse
Affiliation(s)
- Aisling Kelly
- Department of Vascular & Endovascular Surgery, University Hospital Limerick, Limerick, Ireland
- National University of Ireland Galway, Galway, Ireland
| | - Conor Toale
- Department of Vascular & Endovascular Surgery, University Hospital Limerick, Limerick, Ireland
| | - Michael A. Moloney
- Department of Vascular & Endovascular Surgery, University Hospital Limerick, Limerick, Ireland
| | - Eamon G. Kavanagh
- Department of Vascular & Endovascular Surgery, University Hospital Limerick, Limerick, Ireland
| |
Collapse
|
9
|
Bryce Y, Emmanuel A, Agrusa C, Ziv E, Harnain C, Huq S, Martin ES. Acute limb ischemia in a cancer patient has high morbidity, high mortality, and atypical presentation: a tertiary cancer center's retrospective study. BMC Cancer 2021; 21:916. [PMID: 34388968 PMCID: PMC8361627 DOI: 10.1186/s12885-021-08659-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/27/2021] [Indexed: 11/10/2022] Open
Abstract
Background Acute Limb Ischemia (ALI) carries a high morbidity and mortality rate that is compounded in the cancer patient. Though it is a relatively uncommon event, it is of extremely high adverse impact and carries poor awareness among clinicians. Methods Retrospective review of electronic medical records was performed of cancer patients presenting with acute limb ischemia (ALI) to the tertiary cancer center’s urgent care center or as inpatient between January 1, 2014 and January 1, 2020. Results Out of the 29 cancer patients with ALI, 12 (41%) died within 3 month and 9 (31%) patients died within 1 months of ALI diagnosis. 65% had long term adverse outcome after ALI – 31% with death in 1 month, 2 (7%) with an amputation, 5 (17%) with lifestyle-limiting claudication, and 3 (10%) with subsequent wound ulceration or gangrene. Patients not eligible for standard of care (12 patients, 41%) (RR 2.33 95% CI [1.27–4.27], p < 0.01) and heparin administration ≥6 h from presentation (19 patients, 65%) (RR 2.81 [1.07–7.38], p = 0.04) were at increased risk of adverse outcome. Atypical/confounded presentation of ALI (13 patients, 45%) (RR 1.84 95% CI [1.03–3.29], p = 0.04), pulse exam not documented (12 patients, 41.4%) (RR 1.95 [95% CI [1.14–3.32], p = 0.01), and patients with services other than a vascular specialist initially consulted (8 patients, 27.6%) (RR 1.91 95% CI [1.27–2.87], p < 0.01) were significant risk factors for heparin administered ≥6 h from presentation. Conclusions ALI is devastating in cancer patients, with a high number presenting with atypical/confounded signs and symptoms which delays treatment. Heparin administered ≥6 h from presentation is associated with adverse outcome.
Collapse
Affiliation(s)
- Yolanda Bryce
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Amoateng Emmanuel
- City University of NY (CUNY) School of Medicine, 160 Convent Avenue, Convent Ave, New York, NY, 10031, USA
| | - Christopher Agrusa
- New York Presbyterian Hospital Weill Cornell Medical Center, 525 East 68th Street Starr 8, New York, NY, 10065, USA
| | - Etay Ziv
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Christopher Harnain
- New York Presbyterian Hospital Weill Cornell Medical Center, 525 East 68th Street Starr 8, New York, NY, 10065, USA
| | - Samantha Huq
- New York Presbyterian Hospital Weill Cornell Medical Center, 525 East 68th Street Starr 8, New York, NY, 10065, USA
| | | |
Collapse
|
10
|
Harnarayan P, Islam S, Naraynsingh V. Arterial Embolism in Malignancy: The Role of Surgery. Ther Clin Risk Manag 2021; 17:635-640. [PMID: 34177265 PMCID: PMC8219304 DOI: 10.2147/tcrm.s308026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/25/2021] [Indexed: 11/23/2022] Open
Abstract
Background Peripheral arterial embolism from malignant disease is uncommon and a rare cause of limb ischemia. In the acute setting, patients can present with severe ischemia of either the upper or lower limb, and urgent surgical intervention is often required to avoid severe debilitation and limb loss. Patients Our case series comprised three patients who presented with upper and lower limb ischemia and were found to have concomitant malignancy. All three patients were female, with a median age of 54.3 years, and none of the patients was on active chemotherapy. One presented with stage IIb uterine carcinoma, one with stage IIIb ovarian carcinoma, and the other with stage IIIb cervical carcinoma. These patients were referred for vascular management, with two being acute and the other acute on chronic. Results Of the three patients, two presented with acute limb ischemia and underwent arterial thrombectomy, one of the upper and the other the lower limb. The third patient, with acute-on-chronic upper limb ischemia, was treated conservatively with intravenous heparin followed by oral anticoagulation. All three had limb salvage and survival outcome at 1 year post-treatment. Conclusion In this small series, surgical intervention in two patients and conservative management in the other patient led to limb salvage with a reasonably good quality of life. Even though the long-term survival for patients with malignant disease is generally poor, surgical intervention can achieve limb salvage with a reasonably good quality of life.
Collapse
Affiliation(s)
- Patrick Harnarayan
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Shariful Islam
- Department of Surgery, San Fernando General & Teaching Hospitals, San Fernando, Trinidad and Tobago
| | - Vijay Naraynsingh
- Department of Surgery, Medical Associates Hospital, St. Joseph, Trinidad and Tobago
| |
Collapse
|
11
|
Govsyeyev N, Malgor RD, Hoffman C, Harroun N, Sturman E, Al-Musawi M, Malgor EA, Jacobs DL, Nehler M. A systematic review and meta-analysis of outcomes after acute limb ischemia in patients with cancer. J Vasc Surg 2021; 74:1033-1040.e1. [PMID: 33905869 DOI: 10.1016/j.jvs.2021.03.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/26/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cancer results in a hypercoagulable state that is associated with both venous and arterial thromboses. However, little is known about the effects of acute limb ischemia (ALI) in this cohort of patients. In the present systematic review and meta-analysis, we analyzed the available clinical data on cancer and its association with ALI and evaluated the outcomes in these patients after a diagnosis of ALI. METHODS Three databases, including PubMed, EMBASE, and the Cochrane Library, were queried. Studies that met the inclusion criteria were included regardless of the publication year, language, sample size, or follow-up length. All the steps of the meta-analysis were conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) and MOOSE (meta-analysis of observational studies in epidemiology) guidelines. RESULTS Seven studies from 6222 references with a total of 2899 patients were included. Of the 2899 patients, 1195 (41%) had had a diagnosis of ALI before their cancer diagnosis, and 1704 (59%) had presented with ALI after a cancer diagnosis. Nearly three quarters of ALI events were among patients with cancer of the skin and soft tissue (19%), genitourinary (18%), lung (17%), and gastrointestinal (16%) systems. ALI recurrence was similar between the two groups, and major amputation was more likely in patients with a diagnosis of ALI after a cancer diagnosis (7.4% vs 4.6%; P < .01). The incidence of mortality at 1 year was significantly greater for patients with established cancer who had presented with ALI compared with the patients who had presented with ALI before a cancer diagnosis (50.6% vs 29.9%; P < .01). After adjusting for study variability using the random effects model, the mortality at 1 year for all patients was 52.3% (95% confidence interval, 37.7%-66.5%). No significant heterogeneity (P = .73) was found between the two groups of patients, which varied by the timing of the ALI diagnosis in relation to the cancer diagnosis. CONCLUSIONS The 1-year mortality after the development of ALI in patients with cancer was >50%. For patients presenting with ALI of unclear etiology, the presence of an underlying cancer should be considered.
Collapse
Affiliation(s)
- Nicholas Govsyeyev
- Department of Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colo; CPC Clinical Research, University of Colorado, Anschutz Medical Center, Aurora, Colo
| | - Rafael D Malgor
- Department of Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colo; Division of Vascular Surgery and Endovascular Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colo.
| | - Clayton Hoffman
- Division of Vascular Surgery and Endovascular Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colo
| | - Nikolai Harroun
- Division of Vascular Surgery and Endovascular Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colo
| | - Erin Sturman
- Division of Vascular Surgery and Endovascular Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colo
| | - Mohammed Al-Musawi
- Department of Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colo
| | - Emily A Malgor
- Department of Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colo; Division of Vascular Surgery and Endovascular Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colo
| | - Donald L Jacobs
- Department of Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colo; Division of Vascular Surgery and Endovascular Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colo
| | - Mark Nehler
- Department of Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colo; CPC Clinical Research, University of Colorado, Anschutz Medical Center, Aurora, Colo; Division of Vascular Surgery and Endovascular Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colo
| |
Collapse
|
12
|
Argyriou A, Kafetzakis A, Saratzis A, Huasen B, Coscas R, Renard R, Bisdas T, Torsello G, Tsilimparis N, Calderbank T, Stavroulakis K. Revascularization Outcomes in Patients With Acute Limb Ischemia and Active Neoplastic Disease. J Endovasc Ther 2020; 28:100-106. [PMID: 32909530 DOI: 10.1177/1526602820954285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE To report the outcomes of surgical (ST), endovascular (ET), and hybrid (HT) treatment in cancer patients with acute limb ischemia (ALI). MATERIALS AND METHODS A multicenter retrospective registry collected 139 patients (mean age 72.3±12.4 years; 73 men) with ALI and active malignancy treated by ET (41, 29%), ST (70, 51%), or HT (28, 20%) in 7 European centers between July 2007 and February 2019. In 22 cases (16%) ALI was the first manifestation of the malignancy. Lung cancer was the most common diagnosis (38, 27%). The primary composite outcome was amputation-free survival (AFS). Overall survival, amputation-free time (AFT), and reintervention-free time (RFT) were also assessed. Cox regression analysis was applied to identify independent risk factors for the primary and secondary outcomes. Results are presented as the hazard ratio (HR) and 95% confidence intervals (CIs). RESULTS ET was associated with improved 12-month AFS compared with both ST (HR 2.27, 95% CI 1.20 to 4.28, p=0.002) and HT (HR 2.14, 95% CI 1.09 to 4.18, p=0.008). ST (HR 2.50, 95% CI 1.19 to 5.53, p=0.003) and HT (HR 3.10, 95% CI 1.45 to 6.65, p<0.001) were related to an increased risk for mortality compared with ET. At 12 months, the AFT was similar between the 3 groups (ET vs ST: HR 1.52, 95% CI 0.51 to 4.53, p=0.45 and ET vs HT: HR 1.21, 95% CI 0.36 to 4.11, p=0.73). The 12-month RFT also did not differ significantly between the 3 treatment options (ET vs ST: HR 1.10, 95% CI 0.49 to 2.46, p=0.79 and ET vs HT: HR 0.51, 95% CI 0.22 to 1.17, p=0.19). ST and/or HT increased the risk for the major amputation and/or death (HR 1.76, 95% CI 1.05 to 2.05, p=0.03), while Rutherford class I ischemia (HR 0.12, 95% CI 0.02 to 0.90, p=0.04) and previous vascular interventions on the index limb (HR 0.55, 95% CI 0.32 to 0.97, p=0.04) showed a protective effect. CONCLUSION In patients with ALI and active malignant disease, ET was associated with increased AFS and overall survival compared with both ST and HT, while the limb salvage and reintervention rates were comparable among the 3 groups.
Collapse
Affiliation(s)
- Angeliki Argyriou
- Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany
| | | | | | - Bella Huasen
- Department of Interventional Radiology, Royal Preston Hospital NHS Foundation Trust, Preston, UK
| | - Raphaël Coscas
- Department of Vascular Surgery, Ambroise Paré Hospital, Boulogne-Billancourt, France.,UFR des sciences de la santé Simone Veil, Paris-Saclay University, Paris, France
| | - Regis Renard
- Department of Vascular Surgery, Ambroise Paré Hospital, Boulogne-Billancourt, France.,UFR des sciences de la santé Simone Veil, Paris-Saclay University, Paris, France
| | - Theodosios Bisdas
- Department of Vascular and Endovascular Surgery, Medical Center Athens, Greece
| | - Giovanni Torsello
- Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximilians-University Hospital Munich, Germany
| | - Tom Calderbank
- Department of Cardiovascular Science, University of Leicester, UK
| | - Konstantinos Stavroulakis
- Department of Vascular Surgery, St Franziskus Hospital, Münster, Germany.,Department of Vascular Surgery, Ludwig-Maximilians-University Hospital Munich, Germany
| |
Collapse
|
13
|
Gamal WM, Mohamed AF, Askary ZM. The role of delayed lower limb embolectomy in patients with late ischemia. Chirurgia (Bucur) 2020. [DOI: 10.23736/s0394-9508.19.04979-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
14
|
Björck M, Earnshaw JJ, Acosta S, Bastos Gonçalves F, Cochennec F, Debus ES, Hinchliffe R, Jongkind V, Koelemay MJW, Menyhei G, Svetlikov AV, Tshomba Y, Van Den Berg JC, Esvs Guidelines Committee, de Borst GJ, Chakfé N, Kakkos SK, Koncar I, Lindholt JS, Tulamo R, Vega de Ceniga M, Vermassen F, Document Reviewers, Boyle JR, Mani K, Azuma N, Choke ETC, Cohnert TU, Fitridge RA, Forbes TL, Hamady MS, Munoz A, Müller-Hülsbeck S, Rai K. Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg 2019; 59:173-218. [PMID: 31899099 DOI: 10.1016/j.ejvs.2019.09.006] [Citation(s) in RCA: 230] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
15
|
Abstract
The introduction of targeted agents into modern cancer therapy pursued the goal of molecularly more specific, and thereby more effective and safer, therapies. Paradoxically, however, several toxicities were brought to greater attention, among these not only cardiac but also vascular toxicities. The latter reach far beyond venous thromboembolism and include a broad spectrum of presentations based on the vascular territories and pathomechanisms involved, including abnormal vascular reactivity, acute thrombosis, or accelerated atherosclerosis. This article provides an overview of the most common presentations and their management strategies.
Collapse
Affiliation(s)
- Joerg Herrmann
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA.
| |
Collapse
|
16
|
Silva FCS. O papel da ecografia vascular no manejo das complicações associadas ao acesso venoso central para hemodiálise em pacientes oncológicos: relato de dois casos e revisão da literatura. J Vasc Bras 2018; 17:257-261. [PMID: 30643514 PMCID: PMC6326130 DOI: 10.1590/1677-5449.000418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Central venous catheter implantation for hemodialysis is commonly performed in large centers and its complications are sometimes associated with insufficient training of those who perform it, but may also be related to the patient’s clinical condition. The present study reports two cases of complications related to use of a short-stay catheter for hemodialysis. In the first case, the cannula was inadvertently inserted into the left subclavian artery, causing arterial thrombosis, which was conservatively managed and good collateral perfusion was documented with vascular echography. The second case illustrates an incidental finding of Central Venous Septic Thrombosis in a patient who had used a catheter for a week, which was treated with antibiotic therapy, anticoagulation, and ultrasound control. In both cases, surgical intervention would have been high risk because of the patients' poor prognosis. Vascular ultrasonography enabled monitoring of these clinical situations and use of less aggressive treatments.
Collapse
|
17
|
Herrmann J, Yang EH, Iliescu CA, Cilingiroglu M, Charitakis K, Hakeem A, Toutouzas K, Leesar MA, Grines CL, Marmagkiolis K. Vascular Toxicities of Cancer Therapies: The Old and the New--An Evolving Avenue. Circulation 2016; 133:1272-89. [PMID: 27022039 DOI: 10.1161/circulationaha.115.018347] [Citation(s) in RCA: 200] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Since the late 1990s, there has been a steady decline in cancer-related mortality, in part related to the introduction of so-called targeted therapies. Intended to interfere with a specific molecular pathway, these therapies have, paradoxically, led to a number of effects off their intended cancer tissue or molecular targets. The latest examples are tyrosine kinase inhibitors targeting the Philadelphia Chromosome mutation product, which have been associated with progressive atherosclerosis and acute vascular events. In addition, agents designed to interfere with the vascular growth factor signaling pathway have vascular side effects ranging from hypertension to arterial events and cardiomyocyte toxicity. Interestingly, the risk of cardiotoxicity with drugs such as trastuzumab is predicted by preexisting cardiovascular risk factors and disease, posing the question of a vascular component to the pathophysiology. The effect on the coronary circulation has been the leading explanation for the cardiotoxicity of 5-fluorouracil and may be the underlying the mechanism of presentation of apical ballooning syndrome with various chemotherapeutic agents. Classical chemotherapeutic agents such as cisplatin, often used in combination with bleomycin and vinca alkaloids, can lead to vascular events including acute coronary thrombosis and may be associated with an increased long-term cardiovascular risk. This review is intended to provide an update on the evolving spectrum of vascular toxicities with cancer therapeutics, particularly as they pertain to clinical practice, and to the conceptualization of cardiovascular diseases, as well. Vascular toxicity with cancer therapy: the old and the new, an evolving avenue.
Collapse
Affiliation(s)
- Joerg Herrmann
- From Mayo Clinic, Division of Cardiovascular Diseases, Rochester, MN (J.H.); University of California at Los Angeles, Division of Cardiology, Los Angeles (E.-H.Y.); University of Texas, MD Anderson Cancer Center, Houston (C.A.I.); Arkansas Heart Hospital, Little Rock, AR and Koc University School of Medicine, Istanbul, Turkey (M.C.); University of Texas Health Science Center, Houston (K.C.); University of Arkansas for Medical Sciences, Little Rock (A.H.); Athens Medical School, Hippokration General Hospital, Greece (K.T.); University of Alabama at Birmingham (M.A.L.); Detroit Medical Center, Cardiovascular Institute, MI (C.L.G.); and Citizens Memorial Hospital, Bolivar, MO and University of Missouri, Columbia (K.M.).
| | - Eric H Yang
- From Mayo Clinic, Division of Cardiovascular Diseases, Rochester, MN (J.H.); University of California at Los Angeles, Division of Cardiology, Los Angeles (E.-H.Y.); University of Texas, MD Anderson Cancer Center, Houston (C.A.I.); Arkansas Heart Hospital, Little Rock, AR and Koc University School of Medicine, Istanbul, Turkey (M.C.); University of Texas Health Science Center, Houston (K.C.); University of Arkansas for Medical Sciences, Little Rock (A.H.); Athens Medical School, Hippokration General Hospital, Greece (K.T.); University of Alabama at Birmingham (M.A.L.); Detroit Medical Center, Cardiovascular Institute, MI (C.L.G.); and Citizens Memorial Hospital, Bolivar, MO and University of Missouri, Columbia (K.M.)
| | - Cezar A Iliescu
- From Mayo Clinic, Division of Cardiovascular Diseases, Rochester, MN (J.H.); University of California at Los Angeles, Division of Cardiology, Los Angeles (E.-H.Y.); University of Texas, MD Anderson Cancer Center, Houston (C.A.I.); Arkansas Heart Hospital, Little Rock, AR and Koc University School of Medicine, Istanbul, Turkey (M.C.); University of Texas Health Science Center, Houston (K.C.); University of Arkansas for Medical Sciences, Little Rock (A.H.); Athens Medical School, Hippokration General Hospital, Greece (K.T.); University of Alabama at Birmingham (M.A.L.); Detroit Medical Center, Cardiovascular Institute, MI (C.L.G.); and Citizens Memorial Hospital, Bolivar, MO and University of Missouri, Columbia (K.M.)
| | - Mehmet Cilingiroglu
- From Mayo Clinic, Division of Cardiovascular Diseases, Rochester, MN (J.H.); University of California at Los Angeles, Division of Cardiology, Los Angeles (E.-H.Y.); University of Texas, MD Anderson Cancer Center, Houston (C.A.I.); Arkansas Heart Hospital, Little Rock, AR and Koc University School of Medicine, Istanbul, Turkey (M.C.); University of Texas Health Science Center, Houston (K.C.); University of Arkansas for Medical Sciences, Little Rock (A.H.); Athens Medical School, Hippokration General Hospital, Greece (K.T.); University of Alabama at Birmingham (M.A.L.); Detroit Medical Center, Cardiovascular Institute, MI (C.L.G.); and Citizens Memorial Hospital, Bolivar, MO and University of Missouri, Columbia (K.M.)
| | - Konstantinos Charitakis
- From Mayo Clinic, Division of Cardiovascular Diseases, Rochester, MN (J.H.); University of California at Los Angeles, Division of Cardiology, Los Angeles (E.-H.Y.); University of Texas, MD Anderson Cancer Center, Houston (C.A.I.); Arkansas Heart Hospital, Little Rock, AR and Koc University School of Medicine, Istanbul, Turkey (M.C.); University of Texas Health Science Center, Houston (K.C.); University of Arkansas for Medical Sciences, Little Rock (A.H.); Athens Medical School, Hippokration General Hospital, Greece (K.T.); University of Alabama at Birmingham (M.A.L.); Detroit Medical Center, Cardiovascular Institute, MI (C.L.G.); and Citizens Memorial Hospital, Bolivar, MO and University of Missouri, Columbia (K.M.)
| | - Abdul Hakeem
- From Mayo Clinic, Division of Cardiovascular Diseases, Rochester, MN (J.H.); University of California at Los Angeles, Division of Cardiology, Los Angeles (E.-H.Y.); University of Texas, MD Anderson Cancer Center, Houston (C.A.I.); Arkansas Heart Hospital, Little Rock, AR and Koc University School of Medicine, Istanbul, Turkey (M.C.); University of Texas Health Science Center, Houston (K.C.); University of Arkansas for Medical Sciences, Little Rock (A.H.); Athens Medical School, Hippokration General Hospital, Greece (K.T.); University of Alabama at Birmingham (M.A.L.); Detroit Medical Center, Cardiovascular Institute, MI (C.L.G.); and Citizens Memorial Hospital, Bolivar, MO and University of Missouri, Columbia (K.M.)
| | - Konstantinos Toutouzas
- From Mayo Clinic, Division of Cardiovascular Diseases, Rochester, MN (J.H.); University of California at Los Angeles, Division of Cardiology, Los Angeles (E.-H.Y.); University of Texas, MD Anderson Cancer Center, Houston (C.A.I.); Arkansas Heart Hospital, Little Rock, AR and Koc University School of Medicine, Istanbul, Turkey (M.C.); University of Texas Health Science Center, Houston (K.C.); University of Arkansas for Medical Sciences, Little Rock (A.H.); Athens Medical School, Hippokration General Hospital, Greece (K.T.); University of Alabama at Birmingham (M.A.L.); Detroit Medical Center, Cardiovascular Institute, MI (C.L.G.); and Citizens Memorial Hospital, Bolivar, MO and University of Missouri, Columbia (K.M.)
| | - Massoud A Leesar
- From Mayo Clinic, Division of Cardiovascular Diseases, Rochester, MN (J.H.); University of California at Los Angeles, Division of Cardiology, Los Angeles (E.-H.Y.); University of Texas, MD Anderson Cancer Center, Houston (C.A.I.); Arkansas Heart Hospital, Little Rock, AR and Koc University School of Medicine, Istanbul, Turkey (M.C.); University of Texas Health Science Center, Houston (K.C.); University of Arkansas for Medical Sciences, Little Rock (A.H.); Athens Medical School, Hippokration General Hospital, Greece (K.T.); University of Alabama at Birmingham (M.A.L.); Detroit Medical Center, Cardiovascular Institute, MI (C.L.G.); and Citizens Memorial Hospital, Bolivar, MO and University of Missouri, Columbia (K.M.)
| | - Cindy L Grines
- From Mayo Clinic, Division of Cardiovascular Diseases, Rochester, MN (J.H.); University of California at Los Angeles, Division of Cardiology, Los Angeles (E.-H.Y.); University of Texas, MD Anderson Cancer Center, Houston (C.A.I.); Arkansas Heart Hospital, Little Rock, AR and Koc University School of Medicine, Istanbul, Turkey (M.C.); University of Texas Health Science Center, Houston (K.C.); University of Arkansas for Medical Sciences, Little Rock (A.H.); Athens Medical School, Hippokration General Hospital, Greece (K.T.); University of Alabama at Birmingham (M.A.L.); Detroit Medical Center, Cardiovascular Institute, MI (C.L.G.); and Citizens Memorial Hospital, Bolivar, MO and University of Missouri, Columbia (K.M.)
| | - Konstantinos Marmagkiolis
- From Mayo Clinic, Division of Cardiovascular Diseases, Rochester, MN (J.H.); University of California at Los Angeles, Division of Cardiology, Los Angeles (E.-H.Y.); University of Texas, MD Anderson Cancer Center, Houston (C.A.I.); Arkansas Heart Hospital, Little Rock, AR and Koc University School of Medicine, Istanbul, Turkey (M.C.); University of Texas Health Science Center, Houston (K.C.); University of Arkansas for Medical Sciences, Little Rock (A.H.); Athens Medical School, Hippokration General Hospital, Greece (K.T.); University of Alabama at Birmingham (M.A.L.); Detroit Medical Center, Cardiovascular Institute, MI (C.L.G.); and Citizens Memorial Hospital, Bolivar, MO and University of Missouri, Columbia (K.M.)
| |
Collapse
|
18
|
Chotai PN, Kasangana K, Chandra AB, Rao AS. Recurrent Arterial Thrombosis as a Presenting Feature of a Variant M3-Acute Promyelocytic Leukemia. Vasc Specialist Int 2016; 32:65-71. [PMID: 27386455 PMCID: PMC4928607 DOI: 10.5758/vsi.2016.32.2.65] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/15/2016] [Accepted: 03/28/2016] [Indexed: 11/20/2022] Open
Abstract
Acute limb ischemia (ALI) is a common vascular emergency. Hematologic malignancies are commonly associated with derangement of normal hemostasis and thrombo-hemorrhagic symptoms during the course of the disease are common. However, ALI as an initial presenting feature of acute leukemia is rare. Due to the rarity of this presentation, there is a scarcity of prospective randomized data to optimally guide the management of these patients. Current knowledge is mainly based on isolated cases. We report our experience managing a patient who presented with ALI and was found to have occult leukemia. A review of all cases with ALI as a presenting feature of acute leukemia is also presented.
Collapse
Affiliation(s)
- Pranit N Chotai
- Division of Vascular Surgery, Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA; Division of Pediatric Surgery, Department of Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kalenda Kasangana
- Division of Vascular Surgery, Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Abhinav B Chandra
- Division of Hematology and Oncology, Department of Internal Medicine, Maimonides Medical Center, Brooklyn, NY, USA; Division of Hematology and Oncology, Yuma Regional Cancer Center, Yuma, AZ, USA
| | - Atul S Rao
- Division of Vascular Surgery, Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| |
Collapse
|
19
|
Risk Factors for Long-Term Mortality and Amputation after Open and Endovascular Treatment of Acute Limb Ischemia. Ann Vasc Surg 2015; 30:82-92. [PMID: 26560838 DOI: 10.1016/j.avsg.2015.10.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 10/01/2015] [Accepted: 10/27/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Acute limb ischemia (ALI) is a highly morbid and fatal vascular emergency with little known about contemporary, long-term patient outcomes. The goal was to determine predictors of long-term mortality and amputation after open and endovascular treatment of ALI. METHODS A retrospective review of ALI patients at a single institution from 2005 to 2011 was performed to determine the impact of revascularization technique on 5-year mortality and amputation. For each main outcome 2 multivariable models were developed; the first adjusted for preoperative clinical presentation and procedure type, the second also adjusted for postoperative adverse events (AEs). RESULTS A total of 445 limbs in 411 patients were treated for ALI. Interventions included surgical thrombectomy (48%), emergent bypass (18%), and endovascular revascularization (34%). Mean age was 68 ± 15 years, 54% were male, and 23% had cancer. Most patients presented with Rutherford classification IIa (54%) or IIb (39%). The etiology of ALI included embolism (27%), in situ thrombosis (28%), thrombosed bypass grafts (32%), and thrombosed stents (13%). Patients treated with open procedures had significantly more advanced ischemia and higher rates of postoperative respiratory failure, whereas patients undergoing endovascular interventions had higher rates of technical failure. Rates of postprocedural bleeding and cardiac events were similar between both treatments. Excluding Rutherford class III patients (n = 12), overall 5-year mortality was 54% (stratified by treatment, 65% for thrombectomy, 63% for bypass, and 36% for endovascular, P < 0.001); 5-year amputation was 28% (stratified by treatment, 18% for thrombectomy, 27% for bypass, and 17% for endovascular, P = 0.042). Adjusting for comorbidities, patient presentation, AEs, and treatment method, the risk of mortality increased with age (hazard ratio [HR] = 1.04, P < 0.001), female gender (HR = 1.50, P = 0.031), cancer (HR = 2.19, P < 0.001), fasciotomy (HR = 1.69, P = 0.204) in situ thrombosis or embolic etiology (HR = 1.73, P = 0.007), cardiac AEs (HR = 2.25, P < 0.001), respiratory failure (HR = 2.72, P < 0.001), renal failure (HR = 4.70, P < 0.001), and hemorrhagic events (HR = 2.25, P = 0.003). Risk of amputation increased with advanced ischemia (Rutherford IIb compared with IIa, HR = 2.57, P < 0.001), thrombosed bypass etiology (HR = 3.53, P = 0.002), open revascularization (OR; HR = 1.95, P = 0.022), and technical failure of primary intervention (HR = 6.01, P < 0.001). CONCLUSIONS After the treatment of ALI, long-term mortality and amputation rates were greater in patients treated with open techniques; OR patients presented with a higher number of comorbidities and advanced ischemia, while also experiencing a higher rate of major postoperative complications. Overall, mortality rates remained high and were most strongly associated with baseline comorbidities, acuity of presentation, and perioperative AEs, particularly respiratory failure. Comparatively, amputation risk was most highly associated with advanced ischemia, thrombosed bypass, and failure of the initial revascularization procedure.
Collapse
|
20
|
Nicolajsen CW, Dickenson MH, Budtz-Lilly J, Eldrup N. Frequency of cancer in patients operated on for acute peripheral arterial thrombosis and the impact on prognosis. J Vasc Surg 2015; 62:1598-606. [PMID: 26384760 DOI: 10.1016/j.jvs.2015.06.223] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 06/24/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Little is known about acute peripheral arterial thrombosis in patients with concomitant cancer. Small studies suggest that revascularization in this patient group is associated with thrombosis and increased risk of amputation and death. We investigated the frequency of cancer in patients operated on for acute peripheral arterial thrombosis and the long-term risk of amputation, mortality, myocardial infarction, and stroke in a national cohort. METHODS This was a prospective case/noncase study comprising all Danish citizens undergoing vascular surgery for acute arterial thrombosis from 1986 to 2012 with up to 26 years of follow-up. RESULTS A total of 7840 patients were treated surgically for acute arterial thrombosis; 2384 (30.4%) were previously diagnosed with cancer or developed cancer during the observation period. Risk of amputation was not significantly different in patients with or without cancer, except in patients with cancer diagnosed <24 months before acute limb ischemia (hazard ratio, 2.0). Mortality was significantly greater in all patients having or developing cancer within 24 months after surgery (hazard ratio, 1.2-2.2). The frequencies of myocardial infarction and stroke were similar to those among patients without cancer. CONCLUSIONS One of five patients operated on for acute limb ischemia has a diagnosis of cancer, and a further 3.4% will develop cancer within 24 months. The data further show that patients with acute limb ischemia and concomitant cancer can be successfully revascularized and that the majority of these patients preserve their limb. Cancer should therefore not contravene interventional treatment.
Collapse
Affiliation(s)
| | - Maja Holch Dickenson
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Jacob Budtz-Lilly
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Nikolaj Eldrup
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark; Danish Vascular Registry, Aarhus University Hospital, Aarhus, Denmark.
| |
Collapse
|
21
|
Bennett KM, Scarborough JE, Shortell CK, Cox MW. Outcomes of surgical revascularization for lower extremity arterial thromboembolism in patients with advanced malignancy. J Vasc Surg 2014; 60:987-92. [PMID: 24909107 DOI: 10.1016/j.jvs.2014.04.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 04/22/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The objective of this study was to describe the outcomes of surgical revascularization for lower extremity arterial thromboembolism in patients with advanced malignancy. METHODS The 2005-2011 American College of Surgeons National Surgical Quality Improvement Program database was used for this study. Preoperative characteristics and postoperative outcomes of patients with known advanced malignancy who underwent surgical revascularization for lower extremity arterial thromboembolic disease were assessed and compared with those of patients without known advanced malignancy. Parsimonious multivariate logistic regression analysis was used to determine the independent association between advanced malignancy and 30-day postoperative mortality and morbidity after adjustment for demographic characteristics, acute and chronic comorbid disease burden, history of peripheral arterial disease, functional and nutritional status, acuity of presentation, and procedure type. RESULTS The study included 136 patients with advanced malignancy who underwent surgical revascularization for lower extremity arterial thromboembolism for analysis (65% thromboembolectomy, 26% thromboendarterectomy, and 22% bypass grafting). The 30-day mortality and morbidity rates in these patients were 30.2% and 38.2%, respectively. Compared with patients without advanced malignancy, patients with advanced malignancy had a significantly greater risk of postoperative death (adjusted odds ratio, 5.92; 95% confidence interval, 3.69-9.52; P < .001) but not morbidity (adjusted odds ratio, 1.28; 95% confidence interval, 0.87-1.87; P = .21). CONCLUSIONS Our study is the largest to date to describe the outcomes of patients with advanced malignancy who undergo surgical revascularization for arterial thromboembolism of the lower extremities. Such patients suffer high rates of early postoperative mortality and morbidity, especially when emergency operation is required. Early involvement of palliative care specialists is warranted in these patients to ensure that the decision to pursue surgical revascularization is aligned with their goals of care.
Collapse
Affiliation(s)
- Kyla M Bennett
- Department of Surgery, Duke University Medical Center, Durham, NC.
| | | | | | - Mitchell W Cox
- Department of Surgery, Duke University Medical Center, Durham, NC
| |
Collapse
|
22
|
Prisco D, D'Elios MM, Cenci C, Ciucciarelli L, Tamburini C. Cardiovascular oncology: a new discipline inside internal medicine? Intern Emerg Med 2014; 9:359-64. [PMID: 24643640 DOI: 10.1007/s11739-014-1064-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 02/20/2014] [Indexed: 12/21/2022]
Abstract
Cardiovascular disease and cancer incidence and prevalence have risen over the past few decades to become the leading causes of death. On the one hand, cancer patients will be treated with cardiotoxic chemotherapies; on the other, cardiovascular patients will receive a new diagnosis of cancer and will have to face treatments that may worsen their disease. Moreover, venous thromboembolism can commonly complicate the natural course of patients with cancer in an apparently spontaneous manner or can be triggered by a clinical event such as surgery, invasive procedures, a course of chemotherapy or radiotherapy and is known to be the second cause of death in these patients who also may need to be treated for pre-existing medical conditions or comorbidities. Thus, we introduce the concept of cardiovascular oncology (in the place of cardiooncology) to underline that the problems in this field are not limited to cardiotoxicity of chemotherapies and to the interaction between cardiologists and oncologists, and we focus on the role of the Internist, the only health care giver able to face the multiple problems that cancer patients may undergo.
Collapse
Affiliation(s)
- Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence and SOD Patologia Medica, AOU Careggi, Florence, Italy,
| | | | | | | | | |
Collapse
|
23
|
Silverberg D, Yalon T, Reinitz ER, Yakubovitch D, Segev T, Halak M. Acute limb ischemia in cancer patients: aggressive treatment is justified. Vascular 2014; 23:55-61. [PMID: 24848499 DOI: 10.1177/1708538114537048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The outcome of cancer patients with acute limb ischemia (ALI) is not well defined. The purpose of this study is to report our experience treating patients with active malignancy who developed ALI and compare their outcome with non-cancer patients. METHODS A retrospective review of patients treated for ALI between 2009 and 2012 with ALI. We identified those patients who suffered from ALI and compared the outcome of those with active malignancy to those without malignancy. RESULTS Of 147 patients treated for ALI (122 lower extremity, 25 upper extremity), 24 (16%) were cancer patients. Mean follow-up was 9.8 months for the malignancy group and 13.4 months for the control. Perioperative mortality rates were similar among cancer and non-cancer patients (20% vs. 16%, respectively, NS). Freedom from major amputation at 30 months was similar (95% vs. 89%, NS). Long-term survival rates of cancer patients were significantly lower compared to non-cancer patients (45% vs. 77% respectively, P<0.05). CONCLUSIONS Treatment of ALI among cancer patients can be achieved with perioperative mortality and limb salvage rates comparable to non-cancer patients. Aggressive treatment is justified when treating cancer patients with ALI.
Collapse
Affiliation(s)
- Daniel Silverberg
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Affiliated to the Tel Aviv University Sackler School of Medicine, Tel Hashomer, Israel
| | - Tal Yalon
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Affiliated to the Tel Aviv University Sackler School of Medicine, Tel Hashomer, Israel
| | - Emanuel R Reinitz
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Affiliated to the Tel Aviv University Sackler School of Medicine, Tel Hashomer, Israel
| | - Dmitry Yakubovitch
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Affiliated to the Tel Aviv University Sackler School of Medicine, Tel Hashomer, Israel
| | - Tal Segev
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Affiliated to the Tel Aviv University Sackler School of Medicine, Tel Hashomer, Israel
| | - Moshe Halak
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Affiliated to the Tel Aviv University Sackler School of Medicine, Tel Hashomer, Israel
| |
Collapse
|
24
|
Mouhayar E, Tayar J, Fasulo M, Aoun R, Massey M, Abi-Aad S, Iliescu C, Ahrar K, Huynh T. Outcome of acute limb ischemia in cancer patients. Vasc Med 2014; 19:112-117. [DOI: 10.1177/1358863x14523063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The optimal management strategy for acute limb ischemia (ALI) in patients with a concomitant malignancy is not well established. A very high mortality rate (83–100%) at 1 year has been reported in those who are treated surgically. Accordingly, a conservative management approach has been suggested as the main therapeutic modality. Our aim was to evaluate the survival outcomes of cancer patients treated for ALI at our cancer center. Cancer patients treated for ALI at the MD Anderson Cancer Center from 2001 to 2011 were included in this study. Overall survival and amputation-free survival rates were calculated. A total of 74 cancer patients with concomitant ALI were included in the study. Surgery was the most common therapy (36 patients; 49%). Percutaneous catheter-based interventions were used in 21 patients (28%). Eighteen patients (24%) received anticoagulation therapy only, and six patients (8%) received no therapy. The 30-day, 6-month, and 1-year overall survival rates were 80% (95% confidence interval [CI], 69% to 87%), 59% (95% CI, 47% to 69%), and 48% (95% CI, 36% to 59%), respectively. Eight patients (11%) underwent amputation. The 1-year amputation-free survival rate was 47% (95% CI, 35% to 58%). In conclusion, we did not find an invasive approach for the treatment of ALI in cancer patients to be associated with the very high mortality rates previously reported. In our opinion, the indications for surgery or catheter-based intervention in these patients should not differ from patients without cancer.
Collapse
Affiliation(s)
- Elie Mouhayar
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean Tayar
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark Fasulo
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Reem Aoun
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mona Massey
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Simon Abi-Aad
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cezar Iliescu
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kamran Ahrar
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tam Huynh
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|