Full text of DOI:10.1089/104240603322145247

JOURNAL OF GYNECOLOGIC SURGERY
© Mary Ann Liebert, Inc.
Acute Arterial Occlusion in a Patient with Recurrent
Cervical Cancer
DAVID GRIFFIN, M.D., Ph.D. and MITCHEL S. HOFFMAN, M.D.
ABSTRACT
Acute limb ischemia is a medical emergency and can usually be attributed to arterial throm-
bosis or embolization. An 89-year-old woman with advanced cervical cancer presented to
the emergency room complaining of several days of increasing pain in the left foot and lower
leg, along with increasing discoloration. Examination revealed a cyanotic, cool distal left
lower extremity. The patient underwent an arteriogram, which was consistent with arterial
occlusion. After discussion with the patient and her family, the decision was made to pro-
vide palliative measures only; she died on hospital day 7. The early diagnosis of acute limb
ischemia is critical in allowing the widest range of treatment options and limb salvage. A
rare case of arterial thrombosis in a patient with advanced cervical cancer is described. In
an elderly person with advanced malignancy and arterial thrombosis, treatment options are
likely to be limited. (J GYNECOL SURG 19:85)
INTRODUCTION
CUTE ARTERIAL OCCLUSION is a rare complication encountered in patients with malignancies. The diag-
nosis of acute ischemia constitutes a medical emergency and treatment decisions depend on cause, con-
dition of the limb, and the patient’s overall medical condition.
A
CASE REPORT
An 89-year-old woman with a history of advanced cervical cancer presented to the emergency room with
1–2 days of worsening left foot and lower leg pain, which had become uncontrollable with oral analgesics.
She also reported progressive discoloration of her left foot and lower leg over the preceding 12–24 hours.
The patient’s medical history was significant for stage 3B cervical cancer that was treated with radio-
therapy 6 months prior. Treatment had been complicated by ureteral obstruction, which had been managed
with antegrade ureteral stenting. The patient was subsequently diagnosed with persistent disease in the form
of lung metastasis 2 months after completing radiotherapy and entered into hospice care. She developed a
lower-extremity deep-vein thrombosis that was treated initially with low–molecular-weight heparin followed
by Coumadin® (warfarin; DuPont Pharma, Wilmington, DE). The Coumadin was discontinued 2 weeks
prior to presentation in the emergency department secondary to persistent hematuria.
Examination revealed a left foot that was extremely painful, pulseless, and cold. The skin was dusky/blue,
consistent with advanced ischemia or early gangrene. Laboratory findings were unremarkable. A vascular
Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of South Florida, Tampa
Bay, FL.
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Griffin and Hoffman
Journal of Gynecologic Surgery
surgeon was consulted and a lower-extremity arteriogram was obtained. Parenteral analgesics were admin-
istered along with low–molecular-weight heparin, producing some relief of pain. The arteriogram revealed
occlusion of the left popliteal artery with no passage of contrast to the foot (Fig. 1B). The right lower ex-
tremity arteriogram (Fig. 1A) is shown for comparison. Notably, the superficial femoral arteries had dif-
fuse atherosclerotic disease and narrowing bilaterally. The findings were reviewed with the patient and her
caregiver and various treatment options were discussed. Based on the patient’s generally debilitated condi-
tion, poor prognosis related to the underlying malignancy, and advanced ischemia of the limb, conserva-
tive comfort measures were initiated, consisting of parenteral analgesia and low–molecular-weight heparin
anticoagulation. The patient’s pain improved markedly with this treatment. She subsequently died on hos-
pital day 7.
DISCUSSION
Acute ischemia of the lower extremity is a medical emergency. The diagnosis relies on recognition of
the classic signs of ischemia, including severe pain, pallid (or more ominous, blue) skin coloration, and loss
of pulses. Other signs can include parathesia and paralysis (usually preceded by pain) and coldness of the
affected extremity. An arteriogram of the affected extremity both confirms the diagnosis and defines the
location of the occlusion.
The etiology of the occlusion is identified in approximately 90% of patients. This is most commonly an
intra-arterial thrombosis at the site of an atherosclerotic plaque.1 Other etiologies include embolization of
FIG. 1. Arteriograms showing patent right popliteal artery (A) and occluded left popliteal artery (B).

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Arterial Occlusion in Recurrent Cervical Cancer
87
thrombi or plaque and trauma. Conditions that predispose patients to thrombosis increase the risk of acute
arterial occlusion. Hypercoagulabilityin the presence of malignancy is a well-recognized phenomenon. This
hypercoagulability is typically manifested in an increased tendency to form venous thrombosis. However,
there are case reports of patients with gynecologic malignancies (ovarian and cervical) who have experi-
enced arterial thrombosis of an extremity.2–4 The ultimate outcome, especially with regard to limb salvage,
is largely dependent on the time from event to reperfusion of the limb with the amputation rate climbing
from 9% to 23% after 24 hours.1 The in hospital mortality rate can approach 25% when an acute ischemic
event occurs, which can largely be attributed to other comorbidities.1
There are multiple therapeutic modalities that have been utilized for treating acute ischemia of the ex-
tremity.1 The least invasive intervention involves systemic anticoagulation. This treatment carries the low-
est rate of successful revascularization and limb salvage unless the occlusion is minimally symptomatic and
collateral circulation exists. Interventional radiology provides several forms of treatment, including directed
thrombolysis and embolectomy. Surgical intervention is a third option and includes both vascular graft by-
pass and amputation. The decision regarding therapy must take into consideration a patient’s comorbidities
along with the site of occlusion and should be made in concert with both interventional radiology staff and
vascular surgeons. In cases when ischemia has progressed to gangrene, either at initial presentation or in
the case of failed revascularization, the treatment remains amputation of the ischemic limb. In the case de-
scribed, the patient had multiple risk factors that may have contributed to the acute ischemic event. She
was elderly and had atherosclerotic changes present in her lower extremities. The patient also had demon-
strated a hypercoagulable state with the formation of a deep-vein thrombosis. At the time of diagnosis, the
treatment options were severely limited. This was the result of a delay in presentation and the correspond-
ingly advanced ischemic changes present in the extremity.
This case illustrates a classic late presentation of acute ischemia of an extremity in a patient with ad-
vanced cervical cancer. For an elderly patient with advanced malignancy, treatment options are likely to be
limited.
REFERENCES
1. McPherson GAD, Wolfe JHN. Acute ischemia of the leg. Br Med J 1992;304:169.
2. Minjarez DA, Delorit MA, Davidson SA. Spontaneous arterial thrombosis with an advanced ovarian malignancy.
Gynecol Oncol 1997;64:176.
3. Sharma PVP, Babu SC, Shah PM, Seirafi, R, Clauss, RH. Arterial thrombosis and embolism in malignancy. J Car-
diovasc Surg. 1985;26:479.
4. Acharya G, Garick E. Arterial emboli and malignant disease. Vasc Surg 1977;11:26.
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Mitchel S. Hoffman, M.D.
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Tampa, FL 33606
E-mail:
macevedo@hsc.usf.edu