Abstract
Venous gangrene (VG) is defined as a clinical triad of skin necrosis and discolouration, documented evidence of venous thromboembolism (VTE) and presence of palpable or doppler- identifiable arterial pulsation. Venous gangrene is rare condition which is associated with poor prognosis in cancer patients. The pathogenesis of VG is multifactorial and could paradoxically be due to warfarin treatment. Heparin Induced Thrombocytopenia (HIT) associated venous gangrene develops when heparin therapy is discontinued and warfarin therapy initiated or continued.It has been reported that the presence of anticardiolipin antibodies appears to double the risk of thrombo-embolic events in cancer patients in comparison with those who are anticardiolipin antibody negative. The presence of anticardiolipin antibodies is therefore a warning sign for venous gangrene in cancer patients. Hypercoagulable state associated with malignancy, cancer treatment, prolonged immobilisation, surgical operations and metabolic syndrome are all associated with increased risk of VTE and VG.The current evidence suggests that cancer patients are at increased risk from recurrent venous thrombosis and venous gangrene, and LMWH provides potential promise as a safe and effective measure in the management of such patients.
Highlights
Venous gangrene (VG) is a rare condition in association with malignancy but carries a grave prognosis [1]
Hypercoagulable state associated with malignancy, cancer treatment, prolonged immobilisation, surgical operations and metabolic syndrome are all associated with increased risk of venous thromboembolism (VTE) and VG
Cytokines increase the expression of tissue factor (TF) and platelets activating factors (PAF) and decrease the expression of thrombomodulin and the endothelial cells protein C receptors
Summary
Venous gangrene (VG) is a rare condition in association with malignancy but carries a grave prognosis [1]. Cytokines increase the expression of TF and platelets activating factors (PAF) and decrease the expression of thrombomodulin and the endothelial cells protein C receptors This imbalance in procoagulant-anticoagulant pathways leads to the hypercoagulable state associated with malignancy leading to the increased risk of thrombosis in cancer patients. Stop warfarin Start LMWH or DTI is cases of proven HIT Limb elevation to decrease the swelling Good nutrition and hydration of the patient Treatment of the underlying malignancy Venous thrombectomy or intrathrombus catheter-directed thrombolysis ing and have a lower risk of heparin-induced thrombocytopenia. In cases of proven HIT alternative anticoagulation such as direct thrombin inhibitors (DTI) e.g. hirudin or argatroban can be used [36] (table 2, 3)
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