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Venous thromboembolism and Cancer

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Vascular Surgery in Oncology

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Abstract

Venous thromboembolism (VTE) is a common complication in cancer patients, being the second leading cause of death in this population. They are more likely to develop VTE, because the risk factors related to the patient, related to cancer, and related to treatment. The recognition of risk situations can assist us in conducting the VTE prophylaxis. Cancer-associated thrombosis (CAT) is associated with an increased risk of death, and its treatment is challenging due to higher rates of recurrence and bleeding compared to patients without a cancer. We describe the possibilities to be used in the treatment of CAT, including different drugs, vena cava filter, and fibrinolysis.

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  1. Department of Vascular and Endovascular Surgery, AC Camargo Cancer Center, Sao Paulo, SP, Brazil

    Guilherme Yazbek & Bruno Soriano Pignataro

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  2. Bruno Soriano Pignataro
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Editors and Affiliations

  1. Vascular and Endovascular Surgery, Hospital das Clínicas - University of São Paulo Medical School, São Paulo, São Paulo, Brazil

    Antonio Eduardo Zerati

  2. Vascular and Endovascular Surgery, AC Camargo Hospital, São Paulo, São Paulo, Brazil

    Kenji Nishinari

  3. Vascular and Endovascular Surgery, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil

    Nelson Wolosker

Editors Comments

Editors Comments

Perhaps the main event that brings cancer closer to peripheral vascular disease is venous thromboembolism (VTE). The relationship between the two has been known since the nineteenth century when Armand Trousseau (1801–1867) described the association between thrombosis and malignant disease 2 years before his death [85]. The diagnosis of cancer-associated migratory spontaneous venous thrombosis has the name of Trousseau syndrome, himself a victim of gastric cancer diagnosed after the emergence of a thrombophlebitis [85, 86].

“Je suis perdu; une phlegmatia qui vient de se déclarer cette nuit, ne me laisse aucun doute sur nature de mon mal.”

[“I am lost; a phlebitis which has declared itself this night leaves me no doubt about the nature of my illness.”] —Armand Trousseau [86]

Since then, as stated in this chapter, VTE has been the second leading cause of death in individuals with cancer, behind only the oncological disease itself. The clinical presentation of DVT ranges from the absence of symptoms to more dramatic conditions, with severe pain and pallor (phlegmasia alba dolens) or cyanosis (phlegmasia cerulea dolens). Symptoms are often vague and familiar to several other clinical conditions, especially in the individual with cancer. The clinical picture depends on which veins were affected, the degree of obstruction, and collateral circulation development. The most common signs and symptoms are pain and edema, hyperemia, prominence of superficial veins, low fever, cyanosis, pain on passive foot dorsiflexion (Homans sign), muscle swelling, cyanosis, pallor [87]. About 70% of patients with characteristic DVT symptoms do not have a confirmed diagnosis, while 50% of those with confirmed DVT do not show typical symptoms, which makes evident the need for the complementary tests described in the chapter for diagnostic confirmation [87].

As the cancer patient is frequently submitted to imaging tests, either for tumor staging or to investigate other complications, such tests may reveal the presence of venous thrombosis and/or pulmonary embolism as an incidental finding. Incidental VTE accounts for half of VTE cases associated with cancer and should be treated in the same way as the symptomatic one since its risks are comparable to those of the symptomatic VTE. A more careful investigation can reveal a sign or a symptom that the patient or his doctor may have attributed to another cause. As imaging tests for cancer staging are not necessarily standardized in the same way as those performed for VTE research, it may be necessary to continue the investigation with tests targeted explicitly for this purpose.

The need for prophylaxis in hospitalized patients for clinical treatment is well established, as well as in high-risk surgical patients. More recent studies have shown benefit in the prophylaxis of high-risk patients undergoing outpatient antineoplastic treatment.

As in non-cancer patients, treatment is based on anticoagulation, and the risk of bleeding should be considered. The dissemination of studies of efficacy and safety of direct oral anticoagulants (DOAC) in cancer patients has led to changes in guidelines of significant medical associations, as exposed in this chapter, admitting rivaroxaban use, edoxaban, and apixaban in individuals with lower hemorrhagic risk. Alternative treatments using fibrinolytic and drug-mechanical thrombectomy should be considered as an exception and evaluated very rigorously in this population.

In the patient with pulmonary embolism, the risk estimate based on classifications such as the pulmonary embolism severity index (PESI) can be used to determine long-term mortality and morbidity (Table 14.6) [88].

Table 14.6 Pulmonary embolism severity index—original and simplified versions [88]
Full size table

For patients with high-risk PTE, fibrinolytic treatment is indicated in an intensive care setting, as long as there is no contraindication, followed by full anticoagulation. In intermediate or high-risk cases, the patient is treated with full anticoagulation with unfractionated heparin or low molecular weight heparin under monitoring in an intensive care unit due to the risk of clinical deterioration. Patients classified as intermediate risk and low risk are treated with full anticoagulation, considering the hemorrhagic risk and the drug interaction for choosing the anticoagulant drug.

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Yazbek, G., Pignataro, B.S. (2022). Venous thromboembolism and Cancer. In: Zerati, A.E., Nishinari, K., Wolosker, N. (eds) Vascular Surgery in Oncology. Springer, Cham. https://doi.org/10.1007/978-3-030-97687-3_14

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