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| CASE REPORT |
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| Year : 2020 | Volume
: 3
| Issue : 3 | Page : 94-96 |
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Acute limb ischemia due to tumor embolism
Thilina Gunawardena, Balasubramanium Saseekaran, Rezni Cassim, Mandika Wijeyaratne
University Vascular and Transplant Surgery Unit, National Hospital of Colombo, Colombo, Sri Lanka
| Date of Submission | 16-Jun-2020 |
| Date of Decision | 17-Jun-2020 |
| Date of Acceptance | 17-Jun-2020 |
| Date of Web Publication | 26-Aug-2020 |
Correspondence Address:
Dr. Thilina Gunawardena
12A, Arawwala Road, Pannipitiya
Sri Lanka
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/VIT.VIT_17_20
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 |
| Introduction | |  |
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 | | |
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.
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].
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.
| Discussion | | |
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 | | |
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 | | |
| 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.  |
| 2. | Prioleau PG, Katzenstein AL. Major peripheral arterial occlusion due to malignant tumor embolism: Histologic recognition and surgical management. Cancer 1978;42:2009-14. |
| 3. | Chandler C. Malignant arterial tumor embolization. J Surg Oncol 1993;52:197-202. |
| 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. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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