Arterial occlusive disease complicating radiation therapy of cervical cancer

Risk of critical limb ischemia in long-term uterine cancer survivors: A population-based study

BACKGROUND

The risk of critical limb ischemia (CLI) which causes ischemic pain or ischemic loss in the arteries of the lower extremities in long-term uterine cancer (UC) survivors remains unclear, especially in Asian patients, who are younger at the diagnosis of UC than their Western counterparts.

AIM

To conduct a nationwide population-based study to assess the risk of CLI in UC long-term survivors.

METHODS

UC survivors, defined as those who survived for longer than 5 years after the diagnosis, were identified and matched at a 1:4 ratio with normal controls. Stratified Cox models were used to assess the risk of CLI.

RESULTS

From 2000 to 2005, 1889 UC survivors who received surgery alone or surgery combined with radiotherapy (RT) were classified into younger (onset age < 50 years, n = 894) and older (onset age ≥ 50 years, n = 995) groups. While compared with normal controls, the younger patients with diabetes, hypertension, and receiving hormone replacement therapy (HRT) were more likely to develop CLI. In contrast, the risk of CLI was associated with adjuvant RT, obesity, hypertension, and HRT in the older group. Among the UC survivors, those who were diagnosed at an advanced age (> 65 years, aHR = 2.48, P = 0.011), had hypertension (aHR = 2.18, P = 0.008) or received HRT (aHR = 3.52, P = 0.020) were at a higher risk of CLI.

CONCLUSION

In this nationwide study, we found that the risk factors associated with CLI were similar in both cohorts except for adjuvant RT that was negligible in the younger group, but positive in the older group. Among the survivors, hypertension, advanced age, and HRT were more hazardous than RT. Secondary prevention should include CLI as a late complication in UC survivorship programs.

Innominate to contralateral brachial artery bypass via ministernotomy with anatomic tunneling for critical ischemia of the left upper extremity

OBJECTIVES

Scarring from prior bypass surgery and irradiation may compromise revascularization options in critical ischemia due to underlying occlusive disease. Occlusive disease of the axillo-brachial artery is particularly difficult to revascularize under such hostile conditions.

METHOD

We present a case of a 58-year-old woman presenting with a painful, pulseless, and cool left upper extremity. The patient had a known history of left upper extremity occlusive disease which was managed by subclavian-axillary artery stenting with re-occlusion and subsequent extra-anatomic left carotid-to-proximal brachial artery prosthetic bypass, which was complicated by stroke. The patient had a history of left mastectomy, axillary node dissection, and external beam radiation therapy. When considering revascularization options, the combination of post-radiation changes and scarring of the conventional operative zones for revascularization posed a high risk for complications. We describe a novel approach for such revascularization, where the inflow source was the terminal brachiocephalic artery, outflow to the upper left brachial artery, with anatomic intrathoracic-to-axillary tunneling through the thoracic outlet after verifying the lack of dynamic extrinsic compression at that level.

RESULT

The procedure resulted in resolution of the symptoms and the patient continued to do well 2 years later.

CONCLUSION

This case shows that anatomic tunneling through the thoracic outlet can be a viable option for upper extremity revascularization when hostile conditions preclude other anatomic tunneling routes or extra-anatomic options.

Hematological Malignancies and Arterial Thromboembolism

Established guidelines exist for prevention and treatment of venous thromboembolism in hematological malignancies, but none for arterial thromboembolism. However, arterial and venous thromboembolism share the same provoking features—including altered procoagulant factors and defective fibrinolytic system. The morbidity for arterial thromboembolism is increasing in hematological malignancies, with the advent of immunomodulatory and targeted therapy. However, survival rate for hematological malignancy is improving. Consequently, as patients with hematological malignancies live longer, comorbidities including diabetes, hypertension and dyslipidemia, may accentuate arterial thrombosis. Thus far, the scientific literature on prophylaxis and treatment for arterial thromboembolism in hematological malignancies is limited. This review highlights the pathogenesis, incidence and clinical features of arterial thromboembolism in hematological malignancies.

Endovascular treatment for the control of active vaginal bleeding from uterine cervical cancer treated with radiotherapy

Background Endovascular treatment has become a significant therapeutic option for the management of intractable bleeding in gynecologic malignancies. However, the endovascular treatment types were almost never mentioned when active bleeding from different arteries was identified. Purpose To present angiographic details and evaluate clinical efficacy of endovascular treatments to control active vaginal bleeding in uterine cervical cancer patients treated with radiotherapy. Material and Methods In this retrospective study, six, consecutive cervical cancer patients treated with radiotherapy who underwent endovascular treatment for active vaginal bleeding were included. Angiographic findings, endovascular treatment details, and clinical outcomes were obtained. Results Ten endovascular procedures were technically successful, in which bleeding arteries were the internal iliac artery/its branches (n = 5), external iliac artery (EIA) (n = 3), uterine artery (n = 1), and superior rectal artery (n = 1), and bleeding manifested as contrast extravasation (n = 6), pseudoaneurysm (n = 1), or both (n = 3). Three of the four repeated procedures showed different bleeding sites from the primary ones. Stent graft was inserted to preserve the patency of the bleeding EIA in two patients. For another EIA rupture, both proximal and distal embolization were performed, followed by femoral-to-femoral bypass to preserve blood flow. Bleeding control within one month was achieved in 80% (8/10). One minor complication, mild transient pelvic pain, occurred in one patient. Conclusions Various endovascular treatment was feasible and effective to control active vaginal bleeding from cervical cancer. Repeated procedures showed commonly different bleeding foci and stent graft insertion was effective for preserving the patency of the large bleeding artery.