Acute Limb Ischemia as Presentation of Occult Hepatocellular Carcinoma

Abstract

It is well known that patients with malignancy are at higher risk for venous thrombosis. However, the risk of arterial thrombosis is not well established and more recently it is being recognized as a serious complication of cancer. A 62 year old male with history of prior cocaine abuse and 25 pack year tobacco use who presented with acute worsening left leg pain associated with distal numbness and tingling up to the left knee. Vitals were unremarkable and physical exam was notable for cool left lower extremity below knee and non—palpable pulses without motor or sensory deficits. CT angiogram of lower extremities showed occlusion of left common, external iliac and superficial femoral arteries for which patient was taken urgently for left leg open thrombectomy and angioplasty with stent placement. Lower extremity CT angiogram showed the incidental findings of a large hypervascular liver mass measuring 9 x 8 x 7cm with several small hypervascular nodules and a 1.2 cm hypervascular focus in the gallbladder. MRI of the abdomen—pelvis showed 10 x 10 cm heterogeneous hypervascular hepatic mass compatible with hepatocellular carcinoma (HCC) with mass effect on the right hepatic vein. Laboratory tests revealed positive hepatitis C (HCV) antibody, HCV viral load of 32,865 and genotype 1A. Hepatitis B serology and alpha—fetoprotein were normal. Further chart review revealed that the patient was diagnosed with HCV in 2009 at an outside hospital and had not received confirmatory testing or treatment as the patient refused. He underwent transarterial chemoembolization and subsequent right hepatectomy with multiple in—hospital complications including acute cholecystitis, spontaneous bacterial peritonitis requiring a prolonged antibiotic course. Traditionally, cancer has been associated with increased risk of venous thromboembolism given alteration in clotting factors. However, cancer is not a well—established independent risk factor for arterial thromboembolism and patients with malignancy do not routinely receive therapies to prevent complications such as MI and stroke. Few cases of spontaneous arterial thrombosis with no iatrogenic or atherosclerotic cause in cancer patients have been reported in literature and are associated with poor prognosis. More studies need to be conducted to determine whether patients would benefit from anti—platelet or anti—coagulation in prevention of arterial thrombosis in order to improve long—term survival outcomes.