Acute limb ischemia in patients with cancer

Julian Scott, Gnanesh Atturu, Nav Shahi, Zoe Sun

Leeds Vascular Institute Leeds General Infirmary

West Yorkshire UK

• No Financial disclosures

Cancer and Thrombosis

• 1823

• Jean Baptiste Bouillard 1796 – 1881

• 1822; Hôpital Cochin, 20 year women occluded iliac veins in a patient with extensive cancer

Cancer and thrombosis

• Armond Trousseau • 1860 • “So great, in my opinion, is the

value of phlegmasia in the cancerous cachexia, that I regard this phlegmasia as a sign of the cancerous diathesis as certain as sanguinolent effusion into the serous cavities.”

• Superficial thrombophlebitis chest/arm

• Gastric /Pancreatic Cancer and Thrombosis

J Vasc Surg 2015;62:1598-606

• Danish Registry

• 1:5 patients operated on for acute limb ischaemia has a diagnosis of cancer

• 3.4% will develop cancer within 24 months

Case

Intervention

• Acute Onset • Normal pulses on the

Right ABI 1.0 • Sinus Rhythm • Combined case • Over the wire

thrombectomy • Restoration of pulses • Restarted Radiotherapy 2

days after embolectomy

Cancer Patients

• 1-8% Cumulative incidence VTE in Cancer Patients

• - 4-7 fold increased risk of venous thromboembolism

• Type of Cancer; Pancreatic/Brain > Breast and Prostate

• Stage metastatic > Local

• Cancer associated thrombosis second leading cause of death

Biomarkers

• Activation Coagulation System

• TAT, F1 and F2, D Dimer

• Tumour Cell Tissue Factor (TF) release of TF+ microvesicles

• Platelets – absolute levels > activation markers

• Leukocytes; absolute levels

Absolute rates of venous thrombosis (per 1000 person-

years) for individual calendar years between 1997 and 2006.

Jasmijn F. Timp et al. Blood 2013;122:1712-1723

Neutrophil extracellular traps (NETs)

• Release NET mechanism for bacterial killing

• Promotes thrombosis and Coagulation

Frontiers in Immunology; doi;10.3389/fimmu.2016.00373 Anna Karin Olsson and Jessica Cedervall, Uppsala.

Neutrophil extracellular traps (NETs) are tissue plasminogen activator (tPA)–resistant

scaffolds of blood clots.

Tobias A. Fuchs et al. Arterioscler Thromb Vasc Biol.

2012;32:1777-1783

Copyright © American Heart Association, Inc. All rights reserved.

Leeds Experience

• Arterial thrombosis in patients with malignancy

• Determine the outcomes – 30 day mortality and

amputation rate

• 5 year retrospective data

(01/06/10 – 31/05/15) • Proforma

– Demographics – Types of Malignancy – Treatment given – Outcomes

Leeds Experience; Results

• 69 patients (M:F 36:33) • Median age 71 (range 41 to

94) • Presentation

– Acute limb ischemia < 24 hours (65%)

• Type of cancer – Lung – 28 % (n = 20) – GI tract – 27 % (n = 19)

(stomach – 6) – Others – (n = 22)

• Metastasis – 56% (n = 39) • Chemo or Radiotherapy 70% • Cis/carboplatin (66 %) n = 16

Leeds Experience; Results

• Multiple sites >50% – Aorto-iliac (n = 21)

– Infra-inguinal (n = 23)

– Brachial (n = 4)

• Treatment – Conservative -

Anticoagulation

– Intervention – Thrombo-embolectomy, thrombolysis, Bypass

Limb Ischaemia & Malignancy

(n = 69)

Acute <24 hours 65 % (n = 45)

Intervention 55 %

(n = 25)

Mortality 24 % (n = 6)

Amputation 8 % (n = 2)

1- year mortality 80% (n= 20)

Conservative 45 % (n = 20)

mortality 55 % (n = 11)

Amputation 5 % (n = 1)

1- year mortality 90 % (n= 18)

Sub-acute 35 % (n = 24)

Intervention 21 %

(n = 5)

Mortality 20 % (n = 1)

Amputation (n = 0)

1-year mortality 80 % (n=4)

Conservative 79 % (n = 19)

Mortality 36 % (n = 7 )

Amputation 5 % (n = 1)

1- year mortality 63 % (n=12)

Leeds Experience; Conclusion

• Poor prognostic sign - High 30 day mortality

• Limb salvage is possible with conservative treatment.

• Complex management – Palliative Care

Leeds Cancer PADTeam