Author + information
- Maarten J.G. Leening, MD, PhD∗ (, )
- Auke P.J.D. Weevers, MD,
- Robert-Jan M. van Geuns, MD, PhD,
- Jaap W. Deckers, MD, PhD and
- Mark-David Levin, MD, PhD
- ↵∗Department of Cardiology, Albert Schweitzer Hospital, PO Box 444, 3300 AK Dordrecht, the Netherlands
In a recent issue of the Journal, Navi et al. (1) demonstrated an increase in short-term risks for arterial thromboembolisms in patients with cancer. We would like to argue that this finding implies that arterial thromboembolisms can be the presenting symptom of an indolent cancer.
Herewith, we present the case of a 50-year-old man with stable coronary artery disease, who experienced 3 angiographically confirmed thromboses of bioresorbable scaffolds (2.5- to 3.5-mm diameter overlapping Absorb, Abbott Vascular, Abbott Park, Illinois) in his left anterior descending artery at 128, 129, and 242 days after implantation. Scaffold thromboses occurred despite treatment with a combination of aspirin, ticagrelor, and either coumarin (with an international normalized ratio in the therapeutic range at time of thrombosis) or therapeutic dose low-molecular-weight heparin. During this period of recurrent scaffold thromboses, the patient also developed multiple unprovoked deep vein thromboses, a pulmonary embolism, and a thrombus in the apex of the left ventricle. No abnormalities could be identified by extensive hematologic analysis, including lupus anticoagulant, anticardiolipin antibodies, antinuclear antibodies, β2-glycoprotein-I antibodies, protein S activity, protein C activity, antithrombin III activity, JAK2 mutations, factor II mutation, and factor V Leiden mutation. Further imaging, including abdominal computed tomography scans, raised the suspicion of a widespread metastasized cancer, the presence of which was confirmed by biopsy of a bone lesion and an esophageal tumor. Due to his deteriorating clinical condition, the patient was offered best supportive care. He died of a hemorrhagic stroke 1 month after the diagnosis of metastasized esophageal cancer was made.
Venous thromboembolism was identified as a common complication of cancer by Trousseau in 1865. Since then, the cancer-induced prothrombotic state leading to venous thromboembolism has been recognized as a well-known presenting symptom of underlying cancer (2). A similar mechanism may explain the observed increased risk of arterial thromboembolisms in patients with cancer (1). Because Absorb bioresorbable scaffolds provide a clear substrate for coronary thrombosis (3), we would like to create awareness among cardiovascular specialists for the occurrence and especially recurrence of late scaffold thrombosis as a potential presenting symptom of an underlying undiagnosed cancer.
Please note: Drs. Weevers and van Geuns have received institutional research grants and speaker fees from Abbott Vascular. Dr. Levin has received fees from Janssen, Roche, AbbVie, Celtrion, Amgen, Celgene, and Takeda, all unrelated to the content of the manuscript. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. The patient described in our case provided written consent for publication of materials relating to him.
- 2018 American College of Cardiology Foundation
- Navi B.B.,
- Reiner A.S.,
- Kamel H.,
- et al.
- Ali Z.A.,
- Serruys P.W.,
- Kimura T.,
- et al.