Acute limb ischemia in patients with cancerpast.mac-conference.com/xconfig/upload/files/$02-Fr_J....
Transcript of Acute limb ischemia in patients with cancerpast.mac-conference.com/xconfig/upload/files/$02-Fr_J....
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Acute limb ischemia in patients with cancer
Julian Scott, Gnanesh Atturu, Nav Shahi, Zoe Sun
Leeds Vascular Institute Leeds General Infirmary
West Yorkshire UK
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• No Financial disclosures
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Cancer and Thrombosis
• 1823
• Jean Baptiste Bouillard 1796 – 1881
• 1822; Hôpital Cochin, 20 year women occluded iliac veins in a patient with extensive cancer
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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
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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
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Case
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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
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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
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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
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Neutrophil extracellular traps (NETs)
• Release NET mechanism for bacterial killing
• Promotes thrombosis and Coagulation
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Frontiers in Immunology; doi;10.3389/fimmu.2016.00373 Anna Karin Olsson and Jessica Cedervall, Uppsala.
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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.
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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
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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
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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
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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)
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Leeds Experience; Conclusion
• Poor prognostic sign - High 30 day mortality
• Limb salvage is possible with conservative treatment.
• Complex management – Palliative Care
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Leeds Cancer PADTeam