Surgical Management Of Lower Limb Ischemia In Patients With Metastatic Cancer
Anand Brahmandam, MBBS1, Yunshan Xu2, Yanhong Deng, MPH2, Raul J. Guzman, MD1, Alan Dardik, MD, PhD1, Cassius Iyad Ochoa Chaar, MD1.
1Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA, 2Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT, USA.
Objectives: Advances in oncologic therapy have prolonged life expectancy of patients with metastatic cancer. Because of common risk factors, these patients could present with vascular conditions requiring surgery. This study aims to evaluate the surgical management and perioperative outcomes of patients with metastatic cancer treated for lower limb ischemia.
Methods: The American College of Surgeons National Surgical Quality Initiative Program (ACS-NSQIP) files (2005-2018) were reviewed. Patients with disseminated cancer undergoing surgery for lower limb ischemia were identified and compared to patients without disseminated cancer. Perioperative outcomes of patients with disseminated cancer were compared to a propensity-matched (2:1) group of patients without disseminated cancer.
Results: During the study period, there were 186,667 patients undergoing surgical treatment of lower limb ischemia, with 0.6% patients (n=1,121) having disseminated cancer. Patients with disseminated cancer were more likely to be older (>66 years=61% vs 55%; P<0.001), and undergo emergency surgery (19.3% vs 7.6%, P<0.001). Patients without cancer were more likely to have diabetes, hypertension, and dialysis dependent. Patients with disseminated cancer were more likely to be treated with primary amputation (31.2% vs 23.6%) and less likely to undergo open lower extremity revascularization (LER) (42.7% vs 47.2%) or endovascular LER (20.5% vs 23.9%) (P<0.001). After propensity matching, there was no difference in demographics, comorbidities, or type of surgery. However, patients with disseminated cancer were more likely to have >10% loss of body weight in the 6 months prior to surgery (8.9% vs 3.4%, P<0.001) and had a trend towards lower albumin (3.14 vs 3.05, P=0.06). Post-operatively, patients without disseminated cancer had a higher rate of acute renal failure (2.2% vs 0.7%; P=0.02), while patients with disseminated cancer received more blood transfusions (19.5% vs 13.8%; P=0.002). There were no significant differences in other post-operative outcomes. (Table) Interestingly, patients with disseminated cancer were significantly more likely to suffer from 30-day mortality (16.5% vs 6.7%; P<0.001).
Conclusion: Patients with disseminated cancer undergoing surgery for lower limb ischemia have significantly higher mortality compared to patients without cancer. These patients represent a small group of the ACS-NSQIP patients treated for lower limb ischemia and are more likely to undergo primary amputation.
| Outcome | No Cancer (n=1,187)n (%) | Disseminated Cancer (n=594)n (%) | P-Value |
| Mean Length of Stay in days (SD) | 10.85 (14.50) | 10.32 (12.52) | 0.43 |
| Deep Vein Thrombosis | 19 (1.60) | 14 (2.35) | 0.48 |
| Pulmonary Embolism | 8 (0.67) | 7 (1.18) | 0.27 |
| Unplanned Intubation | 45 (3.79) | 14 (2.36%) | 0.11 |
| Cardiac Arrest | 15 (1.26) | 9 (1.52) | 0.66 |
| Myocardial Infarction | 26 (2.19) | 11 (1.85) | 0.64 |
| Progressive Renal Insufficiency | 10 (0.84) | 8 (1.35) | 0.32 |
| Acute Renal Failure | 26 (2.19) | 4 (0.67) | 0.019 |
| Blood Transfusions | 164 (13.82) | 116 (19.53) | 0.002 |
| Cerebrovascular Accident with neurological deficit | 12 (1.01) | 5 (0.84) | 0.73 |
| Sepsis | 55 (4.63) | 26 (4.38) | 0.81 |
| Reoperation | 208 (17.52) | 84 (14.14) | 0.07 |
| Mortality | 72 (6.1) | 98 (16.5) | 0.001 |
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