Postoperative Arterial Thromboembolism Causing Acute Limb Ischemia and Amputation Following Gynecologic Oncology Malignancy Surgery: Presentation of Two Cases

Abstract

This case report presents two rare cases and aims to highlight arterial thromboembolism (ATE) as a rare but potentially devastating complication following gynecologic oncology surgery. Chronic kidney disease (CKD) has been demonstrated to heighten susceptibility to thrombotic events through a variety of mechanisms, including endothelial dysfunction, uremia-associated platelet activation, impaired fibrinolysis, and systemic inflammation. In addition, other systemic and perioperative risk factors-including advanced age, malignancy-associated hypercoagulability, smoking history, hypertension, atherosclerosis, sepsis, and perioperative hemodynamic instability-may also contribute to the development of arterial thromboembolism. This report presents two rare cases of early postoperative ATE leading to acute limb ischemia, amputation, and death in patients with advanced ovarian malignancy and concomitant CKD.
In the first instance, a 51-year-old female patient was diagnosed with end-stage CKD and required long-term dialysis. She subsequently underwent a surgical procedure for high-grade serous ovarian carcinoma. Severe postoperative ATE manifested on postoperative day 1, rapidly progressing to extensive ischemia. Despite escalating treatment from prophylactic to therapeutic anticoagulation and vasodilator therapy, the patient's condition continued to deteriorate, ultimately resulting in the need for amputation. The patient succumbed on postoperative day 35 due to complications from sepsis and multi-organ failure. In the second case, a 71-year-old woman with advanced-stage CKD (non-dialysis-dependent) underwent primary cytoreductive surgery for ovarian mucinous carcinoma. Bilateral lower-extremity arterial thrombosis developed on postoperative day 2, with absent distal perfusion. Despite aggressive anticoagulation and prostacyclin therapy, thigh-level amputation was necessary, and the patient succumbed on postoperative day 18 due to multi-organ failure.
These cases suggest that CKD may increase susceptibility to postoperative arterial thromboembolism and may be an important predisposing factor rather than an independent causal risk factor. ATE development in this setting is likely multifactorial and should not be interpreted as a direct cause-effect relationship based on two cases. In this high-risk population, ATE may progress rapidly and remain refractory to medical therapy. Early postoperative peripheral perfusion monitoring and multidisciplinary management are essential.