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Acute Aortic Thromboembolism after Right Middle and Lower Bilobectomy for Metastatic High-Grade Sarcoma
Poster Title: Acute Aortic Thromboembolism after Right Middle and Lower Bilobectomy for Metastatic High-Grade Sarcoma
Submitted on 08 Feb 2018
Author(s): Adil Malik, Andrew A. Serdiuk, David Thrush, Evan S. Glazer, Puya Alikhani, Arnold B. Etame, Carla C. Moodie, Joseph R. Garrett, Cheryl Goodman, Robert Koss, Livingstone S. Dore, Michael L. Steighner, Eric M. Huss, Philip J. Werner, Keming Yu, Mihaela Druta, and Eric M. Toloza
Affiliations: University of South Florida Morsani College of Medicine, Moffitt Cancer Center
This poster was presented at USF Research Day 2018
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Poster Information
Abstract: Introduction:
Aortic thromboembolism is a rare, yet devastating complication in cancer patients, particularly in those with no prior history of atherosclerotic disease. Thrombotic events have been widely reported in cancer patients, especially within the venous system. However, arterial thrombotic events are much less common and has been estimated to have a prevalence between 1.5% and 3.1% in cancer patients.[1] Aortic thromboembolic events present an emergency, with consequences related to ischemia of the lower limbs, vital organs, or the spinal cord.

Case Presentation:
We present a case of acute aortic thromboembolism following right middle and lower bilobectomy for metastatic high-grade sarcoma from the anterior thigh. Postoperatively, the patient complained of bilateral lower extremity paresthesia and paraplegia while recovering in the post-anesthesia care unit, but had normal pedal pulses bilaterally initially, prompting suspicion of a spinal cord injury, which was ruled out by thoracolumbar MRI (Fig. 1). Following an episode of malignant hypertension, with systolic blood pressures of 230-240 mmHg treated with esmolol and then nicardipine, and loss of pedal pulses, a CT angiogram (Fig. 2) revealed abdominal aortobiiliac thrombotic occlusion, proximal superior mesenteric artery dissection with distal occlusion, and renal and splenic infarction. Despite initiation of intravenous heparin drip, the patient’s overall status declined following complications of emergency aortobiiliac thromboembolectomy, as additional embolic events and ischemic bowel subsequently developed. The post-operative course was further complicated by cerebellar infarctions, and the patient expired on post-operative day 3.

Lower limb ischemia secondary to aortic occlusion presents with paresthesia and paraplegia, obscuring a clear diagnosis of vascular versus neurological etiology. Factors encouraging thrombosis in cancer patients include cancer-induced hypercoagulability, anti-phospholipid syndrome, blood transfusions, and chemotherapy regimens. Neurology consult alone may result in diagnostic delay and irreversible end-organ ischemic injury, adding to the already poor outcomes of arterial thromboembolism in cancer patients. Lower extremity pulses should be assessed, although distal pulses may remain intact and vascular symptoms may appear hours after onset. CT angiogram is used to quickly determine location and significance of arterial occlusion. Thromboembolectomy or anticoagulation may be used to manage thromboembolic events.

Arterial thromboembolism has been underreported in cancer patients and presents a poor prognosis. Several etiologic factors have been proposed that may contribute to arterial occlusion in cancer patients. Appropriate diagnostic and therapeutic measurements should be taken to diagnose vascular origin and avoid time-sensitive ischemic complications.
Summary: This is a presentation of a case of acute aortic thromboembolism following right middle and lower bilobectomy for metastatic high-grade sarcoma fro the anterior thigh. It discusses significance of arterial thromboembolic events in cancer patients and challenges faced by physicians. Post-operative ca is extremely important, and this report highlights one of many complications that are encountered in this patient population.
References: 1. Sanon, S. et al. Vasc Med 16:119–130, 2011.
2. Javid, M. et al. Eur J Vasc Endovasc Surg 35:84–87, 2008.
3. McClain, R. et al. AA Case Rep 1:64–66, 2013.
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