Acute myocardial infarction and arterial embolism in a patient with newly diagnosed renal mass: management dilemmas! A case report

• Published in: BMC urology Vol. 21; no. 1; p. 111
• Main Authors: Martin, Benedikt, Greinacher, Andreas, Bülow, Robin, Hammer, Fabian, Hoene, Andreas, Burchardt, Martin, Zimmermann, Uwe
• Format: Journal Article
• Language: English
• Published: England BioMed Central Ltd 18.08.2021; BioMed Central; BMC
• Subjects: Acute arterial thrombotic emboli; Acute Coronary Syndrome - complications; Acute coronary syndromes; Aggregation; Angioplasty; Anticoagulants; Anticoagulants (Medicine); Anticoagulants - therapeutic use; Antiplatelet therapy; Arteries; Aspirin; Blood platelets; Blood tests; Blood vessels; Cancer; Cancer therapies; Carcinoma, Renal Cell - complications; Carcinoma, Renal Cell - diagnosis; Carcinoma, Renal Cell - surgery; Cardiology; Care and treatment; Case Report; Clear cell renal cell carcinoma; Clopidogrel; Drug dosages; Drug Therapy, Combination; Drug-Eluting Stents; Embolism; Health aspects; Heart attack; Heart attacks; Hematology; Hemostasis; Heparin; Humans; Hypertension; Implants; Incidental Findings; Kidney cancer; Kidney Neoplasms - complications; Kidney Neoplasms - diagnosis; Kidney Neoplasms - surgery; Kidneys; Laparoscopy; Male; Medical imaging; Middle Aged; Molecular weight; Myocardial infarction; Myocardial Infarction - etiology; Myocardial Infarction - surgery; Nephrectomy; Occlusion; Paraneoplastic syndrome; Paraneoplastic Syndromes - complications; Pathology; Patients; Percutaneous Coronary Intervention - methods; Platelet Aggregation Inhibitors - therapeutic use; Renal cell carcinoma; Stents; Surgery; Thrombectomy; Thrombocytopenia; Thromboembolism; Thromboembolism - drug therapy; Thromboembolism - etiology; Thromboembolism - surgery; Thrombosis; Transluminal angioplasty; Tumors; Urology; Veins & arteries; Clear cell renal cell carcinoma; Paraneoplastic syndrome; Acute arterial thrombotic emboli
• ISSN: 1471-2490; 1471-2490
• DOI: 10.1186/s12894-021-00870-z

Cancer is often associated with a hypercoagulable state and new thrombosis is often the first clinical manifestation of cancer. Surgical treatment of the primary tumor is crucial since it provides the only curative approach in most cases, but management of patients is highly complex, especially in the presence of new antiplatelet drugs and/or anticoagulants. Paraneoplastic syndromes (PNS) represent a frequent complication of renal cell carcinomas (RCC) and include different hematological symptoms in patients, whilst occlusion of arterial blood vessels displays a rare form of PNS accompanying renal tumors. We report the case of a 62-year old man who was initially hospitalized due to acute coronary syndrome. He subsequently underwent coronary angioplasty treatment including multiple stenting and treatment with ticagrelor and aspirin. Post-interventional, acute arterial thrombotic emboli of several limb arteries required thrombectomy. By computer tomography we identified a renal lesion suspicious for an RCC and suspected a PNS as underlying cause of the thrombotic complications. Triple anticoagulant therapy was maintained with therapeutic dose low molecular weight heparin (LMWH), aspirin, and clopidogrel, by which we replaced ticagrelor. Surgery was postponed for 4 weeks. We paused LMWH, aspirin and clopidogrel only at the day of surgery and perioperatively restored hemostasis by transfusion of two platelet concentrates. Laparoscopic nephrectomy was uneventful. Pathology confirmed a clear cell RCC. The patient fully recovered whilst slowly reducing anticoagulation dose. A multidisciplinary team approach of experts in urology, cardiology and hemostasis was key in managing this patient since a personalized thrombosis consult was needed to minimize the risk of reinfarction due to in-stent thrombosis. We report a therapeutic protocol that may be helpful for the management of similar cases. Furthermore, the finding of thrombotic arterial occlusions in larger blood vessels represents a novel complication of PNS in RCC and adds to the varied possible manifestations of this clinical chameleon.