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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 94-96

Acute limb ischemia due to tumor embolism


University Vascular and Transplant Surgery Unit, National Hospital of Colombo, Colombo, Sri Lanka

Date of Submission16-Jun-2020
Date of Decision17-Jun-2020
Date of Acceptance17-Jun-2020
Date of Web Publication26-Aug-2020

Correspondence Address:
Dr. Thilina Gunawardena
12A, Arawwala Road, Pannipitiya
Sri Lanka
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/VIT.VIT_17_20

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  Abstract 


Acute limb ischemia (ALI) is a surgical emergency that should be promptly recognized and treated. Tumor embolism is a rare cause for acute arterial occlusion and ALI. It has been reported with atrial myxomas and primary/secondary tumors of the lung. Here, we present a case report of bilateral lower limb ischemia due to acute occlusion of the aorta by a tumor embolus originating from a disseminated soft tissue sarcoma.

Keywords: Acute limb ischemia, embolectomy, tumor embolism


How to cite this article:
Gunawardena T, Saseekaran B, Cassim R, Wijeyaratne M. Acute limb ischemia due to tumor embolism. Vasc Invest Ther 2020;3:94-6

How to cite this URL:
Gunawardena T, Saseekaran B, Cassim R, Wijeyaratne M. Acute limb ischemia due to tumor embolism. Vasc Invest Ther [serial online] 2020 [cited 2020 Oct 22];3:94-6. Available from: https://www.vitonline.org/text.asp?2020/3/3/94/293524




  Introduction Top


Acute limb ischemia (ALI) caused by arterial tumor embolism is extremely rare.[1] In this case report, we describe a patient who presented with acute ischemia of the bilateral lower limbs, due to a saddle embolus from a disseminated soft tissue sarcoma.


  Case Report Top


A 24-year-old female patient presented to the emergency treatment unit at the National Hospital of Sri Lanka with sudden-onset bilateral lower limb weakness and numbness for 1½ h duration. Four years back, she was diagnosed to have a synovial cell sarcoma of the left thigh when investigated for a painless, progressively enlarging thigh lump. At that time, ultrasound-guided biopsy of the lump was complicated by accidental puncture of the superficial femoral artery, which led to a large pseudoaneurysm. It was surgically repaired, the tumor was excised with adequate margins, and adjuvant radiotherapy was given. A whole-body positron emission tomography computed tomography (CT) scan done 2 years after this treatment was negative for local recurrence and metastasis, and up to this admission, she had been asymptomatic.

On this admission, she had a regular heart rate of 96 beats/min, and blood pressure was 130/90 mmHg. Lower limb pulses were not palpable from the femoral downward, and the legs were cold. The sensation was impaired over the bilateral feet, but motor function was intact. Our clinical diagnosis was Rutherford Grade IIA acute bilateral lower limb ischemia due to a saddle embolus.

The patient was taken to the theater, and bilateral femoral artery embolectomies were done using Fogarty balloon catheters. Soon after the procedure, there was restoration of bilateral foot pulses. The retrieved embolic material was sent for histology [Figure 1]. The patient was started on anticoagulation with subcutaneous enoxaparin 1 mg/kg twice daily dose and warfarin 5 mg daily dose.
Figure 1: Retrieved embolic material during embolectomy

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The patient's chest X-ray which was done postoperatively revealed an opacity in the right lower zone, which was suggestive of a metastatic deposit [Figure 2]. The transthoracic echocardiogram and ultrasound scan of the abdomen were normal. She had an allergic history to iodinated contrast material, so a magnetic resonance imaging scan of the chest, abdomen, and pelvis was planned to assess the tumor spread. The histology of the embolic material was compatible with a sarcoma [Figure 3].
Figure 2: Chest X-ray with pulmonary metastasis

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Figure 3: Histology of the embolus (H and E stain)

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However, while on enoxaparin and 6 mg of warfarin with an international normalized ratio of 1.7, the patient's conscious level suddenly deteriorated. An urgent noncontrast CT scan of the brain revealed hemorrhage into metastatic deposits in the bilateral cerebral hemispheres.[Figure 4]. While awaiting emergency decompressive craniotomy, the patient deteriorated and passed away.
Figure 4: Noncontrast computed tomography of the brain

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  Discussion Top


Acute arterial occlusion due to tumor embolism is rare and infrequently reported. It is known to occur with left atrial myxomas, primary and secondary tumors of the lungs, primary tumors of the aorta, and direct aortic invasion by tumor.[1],[2] Rarely, paradoxical arterial embolism of the tumor may occur in a patient with a patent foramen ovale.[3]

Primary lung cancers and secondary lung deposits have a propensity to invade the pulmonary veins. These may get dislodged during handling of the lung hilum during surgical resection or as a spontaneous event. In our patient, we suspect that secondary deposits of the sarcoma seen in the right lower lobe of the lung may have infiltrated the pulmonary veins and its spontaneous dislodgment led to peripheral embolization.

Emboli arising from atrial myxomas are often small and tend to cause cerebral emboli.[2],[3] In contrast, emboli from the lung primaries or secondaries tend to be larger, and they usually lodge at branching points of larger arteries, such as the aorta and common femoral, popliteal, and brachial arteries. The lower extremity arteries appear to be more commonly affected compared to the upper extremity.[2] Tumor emboli occluding the superior mesenteric artery and coronary arteries have been reported.[4]

ALI is a vascular surgical emergency, and limb salvage depends on early diagnosis and prompt treatment. For tumor embolism, embolectomy remains the mainstay of treatment. Anticoagulation is recommended by some authors to prevent distal propagation of the thrombus.[3],[4] However, evidence or proper guidelines on the need, duration, or means of post-tumor embolism anticoagulation does not exist. In our patient, anticoagulation precipitated fatal bleeding into previously undiagnosed cerebral metastatic deposits which ultimately led to her demise.

Acute arterial occlusion due to tumor embolism is associated with poor overall prognosis, and patients ultimately succumb due to the disseminated malignancy. However, when the site of arterial occlusion is accessible to embolectomy, it should almost always be attempted and good success rates have been reported in the literature.[3]


  Conclusions Top


ALI due to tumor embolism is rare. Once diagnosed and the limb viable, embolectomy should be attempted and it is usually successful resulting in restoration of limb perfusion. However, the prognosis of these patients is poor with maximum expected survival calculated in months.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lioudaki S, Kontopodis N, Palioudakis S, Koutsopoulos AV, Drositis I, Ioannou CV. Acute aortic occlusion due to tumor embolism in a patient with lung malignancy. SAGE Open Med Case Rep 2017;5:2050313X17720627.  Back to cited text no. 1
    
2.
Prioleau PG, Katzenstein AL. Major peripheral arterial occlusion due to malignant tumor embolism: Histologic recognition and surgical management. Cancer 1978;42:2009-14.  Back to cited text no. 2
    
3.
Chandler C. Malignant arterial tumor embolization. J Surg Oncol 1993;52:197-202.  Back to cited text no. 3
    
4.
Togo S, Yamaoka T, Morita K, Iwasa K, Aoyagi Y, Oshiro Y, et al. Acute lower limb ischemia and intestinal necrosis due to arterial tumor embolism from advanced lung cancer: A case report and literature review. Surg Case Rep 2018;4:42.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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