Tumor embolism and acute arterial occlusion: A systematic review

Abstract

Objective

To determine common etiologies, presentations, management strategies and outcomes in patients with tumor embolism causing acute arterial occlusion.

Study design

This is a systematic review of published case reports on tumor embolism.

Search strategy

All published cases of tumor embolism in the MEDLINE and EMBASE databases were reviewed. The search terminologies were (Tumor Embolism), (Ischemia), (Occlusion) and (Infarction).

Inclusion and exclusion criteria

All published reports of tumor embolism were included. Studies regarding venous thromboembolism and cancer-associated thromboembolism without tumor embolization were excluded. The cases included numbered 42.

Outcome measures

These included the frequencies of different primary tumor types, clinical presentations, anatomical sites of embolization, types of intervention and outcomes including number of deaths and successful discharges.

Results

Lung cancer and Atrial Myxoma each accounted for 14 out of 42 cases (33%). There were 11 cases (26.9%) of stroke and 9 cases (21.4%) of myocardial infarction and limb ischemia. Femoral thrombo-embolectomy was performed in all 9 cases of limb ischemia and Primary coronary intervention was performed in 7 out of 9 (77.8%) cases of myocardial infarction. There were 14 inpatient deaths (33.3%) and 19 patients were successfully discharged (45.2%).

Conclusion

Lung cancer and atrial myxoma were the most common sources for tumor embolism. Acute stroke was the most common presentation. This is treated with antiplatelets or anticoagulation as well as chemotherapy and resection of primary tumor. Early revascularisation can prevent severe complications such as death, paralysis, heart failure and limb loss in selected cases of tumor embolism.

Key message

Histopathological examination of embolic tissue can demonstrate tumor tissue and alert the clinician to a cancer elsewhere. This is most likely to be lung cancer or atrial myxoma. Early revascularisation in selected cases of acute tumor embolism can prevent severe complications and these patients should not be automatically palliated due to their underlying neoplasm.

Introduction

Acute tumor embolism is a rare phenomenon with one review showing this to be a cause of arterial embolization in only 0.34% of cases [1]. Tumor embolization involves the translocation of tumor cells from a primary neoplastic source to various arterial sites resulting in occlusion and secondary complications due to ischemia. It has been known to affect blood vessels supplying the brain, heart, lung, intestine, and limbs causing the associated complications of stroke, myocardial infarction, pulmonary embolism, mesenteric infarction, and limb loss [2].

The underlying cause is generally a large and disseminated primary tumor. The risk factors for tumor embolization include type of primary malignancy, stage of tumor, tumor base size, irregular surface, and primary anatomical location [3].Common mechanisms of embolization include tumor fragmentation resulting from direct invasion of tumor into the bloodstream or surgical manipulation [4].The definitive diagnosis of tumor embolus is pathological with histological evidence of cancer cells seen in the embolus specimen [5].Radiological evidence of a primary malignancy with a separate arterial occlusion may also raise suspicion of tumor embolus.

As the patient often has a poor prognosis due their underlying malignancy, it is not always clear whether surgical intervention is indicated in these cases [6]. As this is a rare condition, the evidence base is still evolving and there are no large cohort studies or guidelines available to the responsible clinician to guide management. This makes it difficult to check the appropriateness of an intervention and provide optimal patient-centred care.

Therefore, we have performed a systematic review of published case reports of arterial tumor embolism. Ultimately, this will help to facilitate a more consistent and evidence-based approach to the care of these patients. This will also help clinicians to recognize unusual presentations of malignancy.

Materials and methods

Ethical review

Ethical review is not required for this study as this is a secondary analysis of existing research literature and does not contain patient identifiable data.

Study aims

We sought to systematically review all cases of arterial tumor embolism to obtain information on tumor source, clinical presentation, management, and outcomes.

Study design

This is a systematic review of case reports on acute tumor embolism. The study has been undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines 2020.

Inclusion and exclusion criteria

All published case reports of arterial tumor embolism were included. Studies pertaining to venous thromboembolism and cancer-associated arterial thromboembolism without tumor embolization were excluded.

Data search

An electronic search was made of the MEDLINE and EMBASE medical databases in May 2021. The search terminology included the terms (Tumor Embolism) AND (Ischemia), (Occlusion) and (Infarction). This yielded 100 potential studies for review. The studies identified by the search strategy were consecutively and manually reviewed by a single reviewer. There were 42 case reports meeting the inclusion criteria.

Study endpoints

The outcome measures included the frequencies for type of primary malignancy, presence of invasion or metastases, site of embolization, surgical intervention and outcome following intervention.

Statistical analysis

Descriptive statistics have been used in this study. Data synthesis was done by manually determining frequencies from included studies.

Results

The studies included in this systematic review have been tabulated below (Table 1).

Table 1.

Published cases of tumor embolism.

Article	Tumor type	Invasion or metastases	Site of embolization	Management/surgical intervention	Outcome
Cheema et al. [7]	Non-small cell Lung cancer	Cardiac metastases	Infra-renal aorta and bilateral common iliac arteries	Thrombectomy	Death. Unable to be weaned
Togo et al. [8]	Squamous cell lung cancer	Left atrial invasion	Right superficial femoral artery Superior mesenteric artery	Right femoral embolectomy and balloon angioplasty (failed) Right Above-knee amputation Laparotomy and small bowel resection	Morbidity. Discharged to rehabilitation unit after 3 months
Lioudaki et al. [9]	Left upper (LUL) Lung cancer	Invasion into left superior pulmonary vein and aortic arch adventitia	Infra-renal aorta (post-op complication)	Bilateral femoral embolectomies (inadequate) Subclavian-bifemoral bypass	Death on post-operative day 5
Cinarka et al. [10]	LUL Squamous cell Lung cancer	Invasion into hilar structures	Right brachial artery	Brachial embolectomy	Discharged
De Alcantara et al. [11]	Adenocarcinoma of right lung	Invasion into pulmonary vein	Saddle embolus aortic bifurcation (post-op complication)	Bilateral femoral embolectomy	Discharged
Schreffler et al. [12]	Adenocarcinoma of lung	Invasion into left pulmonary vein and left atrium	Left external artery Right popliteal artery Left frontal lobe cortical infarct Bilateral renal infarcts Splenic infarct	Bilateral embolectomy and bilateral fasciotomies	Discharged
Morsey et al. [13]	Germ cell origin lung cancer				xxx
French et al. [14]	Lung cancer				xxx
Tsubouchi et al. [15]	Mediastinal Sarcoma	Partly infiltrated descending aorta	Bilateral renal arteries	Catheter directed thrombolysis	Discharged
Azdaki [16]	Left Atrial Myxoma		Left anterior descending coronary artery	Percutaneous coronary intervention and embolectomy	Failed revascularisation (morbidity)
Araki, S [17]	Squamous cell Esophageal cancer	Invasion into superior vena cava (had right to left shunt)	Left middle cerebral artery	Mechanical thrombo-embolectomy	Successful revascularisation. Discharged. Morbidity with stroke
Liu et al. [18]	Lung cancer	Invasion into left atrium	Coronary artery (Acute MI) Acute limb ischemia	Treatment abandoned	Death
Herbert et al. [19]	Left Atrial Myxoma		Cerebral white matter Left popliteal artery	Surgical excision	Discharged
Murugan et al. [20]	Invasive ductal Breast cancer	Liver metastases	Pulmonary artery	Thrombolysis	Death
Hattori et al. [21]	Adenocarcinoma of prostate	Haematogenous metastases	Pulmonary artery (on autopsy)		Death
Yoshikawa et al. [22]	Pleomorphic Lung cancer	Vascular invasion	Right middle cerebral artery	Mechanical embolectomy	Successful revascularisation. Morbidity due to stroke
Oyama et al. [23]	Mucoepidermoid Lung cancer	Right pulmonary vein and left atrium invasion	Distal left internal carotid artery	Mechanical thrombectomy	Successful revascularisation Death
Mouadili et al. [24]	Left atrial Myxoma		Left femoral artery Right distal popliteal artery	Bilateral embolectomy Surgical excision	Successful revascularisation. Discharged
Peters et al. [25]	Infected left Atrial myxoma		Left anterior descending coronary artery (MI)	PCI with stents Surgical excision and mitral valve replacement	Successful revascularization. Discharged. Morbidity: major surgery
Walong et al. [26]	Cardiac Myxoma		Cerebral circulation (stroke)		Death
Matthew et al. [27]	Cardiac Myxoma		Infra-renal aorta (bilateral lower limb ischemia)	Embolectomy Surgical excision	Discharged
Gudipalli et al. [28]	Signet cell carcinoma (GI tract origin)	Bony metastases	DIC and haematuria, Digital infarction		Death
Salam et al. [29]	Urothelial carcinoma	Lung metastases involving pulmonary arteries and veins	Pulmonary artery (pulmonary hypertension)	Diagnostic VATS wedge	Death
Khreis et al. [30]	Squamous cell lung cancer	Invasion into pulmonary vein and left atrium	Right renal artery (infarct)		Discharged for palliative chemo
Latifi et al. [31]	Atrial myxoma		Splenic infarct Renal infarcts Right external and internal iliac artery, Left common femoral artery, coronary artery	Bilateral femoral embolectomy Surgical excision	Discharged
Goddard et al. [32]	Neuroendocrine lung cancer	Invasion into pulmonary vein	Basilar artery (stroke)	Endovascular embolectomy	Death
Carnevale et al. [33]	Acute myeloid leukemia		Femoral artery Tibial artery	Femoral embolectomy, common femoral endarterectomy, and patch plasty and tibial embolectomy	Discharged
Fukami et al. [34]	Sarcoma		Internal carotid artery (stroke)	Percutaneous embolectomy	Discharged
Ali et al. [35]	Atrial Myxoma		Coronary artery (Myocardial infarction)	Thrombolysis, Angio gram Surgical excision	Discharged
Senyei et al. [36]	Renal cell carcinoma	Invasion into renal vein and pulmonary artery metastases	Pulmonary artery (pulmonary hypertension)	Pulmonary thrombo-embolectomy	Discharged
Whealon et al. [37]	Hepatocellular carcinoma	Invasion into inferior vena cava	Bilateral pulmonary arteries	Surgical thrombo-embolectomy	Death
Iwashita et al. [38]	Gastric cancer		Pulmonary artery (pulmonary thrombotic angiopathy)	Veno-arterial Extra-corporeal membrane oxygenation (ECMO)	Death
Waithayawongsakul et al. [39]	Atrial Myxoma		Left circumflex (MI)	PCI and thrombectomy Surgical excision	Discharged
Ohshima et al. [40]	Squamous cell lung cancer		Abdominal aorta (bilateral renal infarcts, splenic infarcts, liver infarcts and brain infarcts)		Death
Rudkovsaia et al. [41]	Adenocarcinoma Gastro-esophageal junction	Metastases	Pulmonary arteries (pulmonary hypertension)		Death
Zizi et al. [42]	Cardiac Myxoma		Infra-renal aorta	Embolectomy	Death
Ali et al. [43]	Cardiac Myxoma		Right coronary artery (Acute MI)	PCI Surgical Excision	Discharged
Nagai et al. [44]	Anaplastic large cell lymphoma	Cardiac metastases	Right anterior tibial, Left popliteal artery		Discharged
Cannarile et al. [45]	Atrial myxoma		Coronary artery (MI)
Dimitrovic et al. [46]	Lung cancer	Invasion into left atrium	Right middle cerebral artery (stroke)		Morbidity
Selby et al. [47]	Atrial myxoma		TIA	Surgical excision	Discharged
Kheiwa et al. [48]	Myofibroblast tumor		Left main coronary artery (Acute MI)	Percutaneous coronary intervention	Discharged
Pineda et al. [49]	Left atrial myxoma containing malignant lymphoma cells		Obtuse marginal coronary branch (Acute MI)	PCI Surgical excision	Discharged

Our initial search yielded a total of 100 studies. Out of these, 42 studies met the inclusion criteria, and these were all case reports. The remaining studies were excluded as they concerned venous thrombo-embolism or hypercoagulability due to cancer.

Tumor source

The most common causes of tumor embolism were lung cancer and cardiac myxoma. There were 14 cases out of 42, in which the source of the tumor embolus was an underlying lung cancer. All histological types of lung cancer were prevalent including squamous cell, adenocarcinoma, small-cell, germ-cell origin, pleomorphic and mucoepidermoid types. Invariably, the cancer was of an advanced stage and demonstrated either local invasion or metastatic disease in all cases. The pulmonary vein and left atrium were the most invaded structures, with this occurring in 10 out of 14 reports.

There were also 14 cases out of 42 in which the source of tumor embolus was an underlying cardiac myxoma, which most originated from the left atrium. This is a benign tumor so does not metastasise to other structures. Since, the tumor is already present in the heart, it can easily embolize and occlude the arterial supply.

A wide variety of tumor types were implicated in the remaining cases of tumor embolus. These included 2 cases of Sarcoma and 1 case each of squamous cell esophageal carcinoma, invasive ductal breast carcinoma, prostate adenocarcinoma, signet-cell carcinoma of gastro-intestinal tract origin, urothelial carcinoma. Acute myeloid leukemia, renal cell carcinoma, hepatocellular carcinoma, gastric cancer, adenocarcinoma gastro-esophageal junction, anaplastic large-cell lymphoma and myofibroblast tumor. All solid organ tumors were at an advanced stage with metastatic disease present.

Clinical presentation

The most frequent clinical presentation of tumor embolism was acute stroke resulting from occlusion of the cerebral circulation. This occurred in 11 out of 42 cases (26.2%). The arteries affected included the distal internal carotid artery, left middle cerebral artery, right middle cerebral artery, basilar artery, and lacunar arteries.

The next most common clinical presentations were acute myocardial infarction and acute lower limb ischemia occurring in 9 out of 42 cases (21.4%), each. The most frequent site of tumor embolization was a coronary artery, occurring in 9 cases (21.4%) and leading to myocardial infarction. The arterial sites included the left anterior descending coronary artery, the right coronary artery, left circumflex artery and the obtuse marginal branch.

Acute lower limb ischemia was a common presentation, but the anatomical site of embolization and occlusion was variable. There were 5 cases of embolic occlusion at the infra-renal aorta resulting in bilateral acute lower limb ischemia. Tumor embolus of the right superficial femoral artery, left superficial femoral artery, left external iliac artery, right popliteal artery, left popliteal artery and tibial artery was also described.

Another frequent clinical presentation was pulmonary thrombotic microangiopathy and pulmonary hypertension resulting from tumor embolization to the pulmonary artery. This occurred in 7 out of 42 cases (16.7%).

The remaining cases included a wide variety of clinical presentations including renal infarcts, acute mesenteric ischemia, splenic infarcts, liver infarcts, transient ischaemic attack, and acute upper limb ischemia. In some cases, tumors embolised to multiple arterial sites simultaneously.

Management

The surgical management was informed by the clinical presentation and site of tumor embolus.

The most frequent surgical procedure performed was surgical thrombo-embolectomy with access through the femoral artery. This was used to treat acute lower limb ischemia and was performed in 9 cases, with one patient undergoing bilateral calf fasciotomies. In a couple of cases, thrombo-embolectomy was insufficient, and a vascular surgery procedure was done in addition. There was 1 case of femoral endarterectomy and patch plasty and 1 case of subclavian-bifemoral bypass.

Percutaneous coronary intervention for myocardial infarction was performed in 7 out of 9 cases. Treatment was abandoned in one case and there was insufficient data in the other case. Percutaneous thrombo-embolectomy for stroke was performed in 4 out of 11 cases. Pulmonary thrombo-embolectomy for pulmonary thrombotic angiopathy and pulmonary hypertension was performed in 2 out of 7 cases. Veno-Arterial extra-corporeal membranous oxygenation was used for-cardiopulmonary support in one patient. Thrombolysis was used in 3 cases, with one case using catheter-directed thrombolysis.

There was one case of brachial embolectomy to treat acute upper limb ischemia. A laparotomy and small bowel resection were required in patient to treat acute mesenteric ischemia resulting from tumor embolism to the superior mesenteric artery.

In most patients, the underling tumor was far too advanced to be amenable to surgical management. The only exception to this was an atrial myxoma. This was surgically excised in 10 out of 14 cases, with one case of infected left atrial myxoma also necessitating a mitral valve replacement.

Outcome

The goal of management was to prevent in-hospital death, organ infarction and limb-loss through revascularisation. There were 14 out of 42 (33%) in-hospital deaths. One patient suffered limb loss requiring an above-knee amputation. 19 patients out of 42 (45.2%) were discharged from hospital following successful revascularization and one was discharged on palliative pathway.

Discussion

This systematic review has shown that a wide variety of primary malignancies have been implicated in the phenomenon of tumor embolization. The most prevalent among these are primary lung cancers, which can invade the pulmonary veins, and atrial myxomas. These tumors can spontaneously embolize as confirmed in previous studies [50].This is likely related to the proximity of these tumors to the heart which can pump tumor fragments into the systemic circulation resulting in wide dissemination and showering. Recent surgery is also an important risk factor for embolization as physical manipulation can cause tumor seeding and disruption and this has been corroborated in the literature [51]. All tumors were at an advanced stage demonstrating either invasion into a major blood vessel or metastatic disease, which were the primary mechanisms of neoplastic embolization. Notable rare tumors demonstrating this phenomenon included sarcoma, which infiltrated the descending aorta and internal carotid, and anaplastic large cell lymphoma, which metastasised to the heart.

In our study, the distant sites of embolization also varied widely. The most prevalent sites included the cerebral arteries and coronary arteries. This is likely related to the small size of these vessels, the proximity of these vessels to the heart, the direct pathway to these vessels and the large proportion of total cardiac output received by the cerebral and coronary vessels relative to the rest of the body.

Another frequent site of embolization were the lower limb arteries. This is related to the tendency of a large mass of tumor tissue to lodge at sites of arterial division such as the aortic bifurcation, common femoral bifurcation, and the popliteal trifurcation as the vessel caliber suddenly decreases at these points [52]. At bifurcation sites, the local blood flow is disturbed due to recirculation eddy currents, directional change and reciprocating flow patterns which are associated with low or oscillating shear stress [53].These altered haemodynamic flow patterns can induce the activation of atherogenic and thrombogenic pathways in endothelial cells which contribute to the development of an occlusive lesion at these sites [54].

Finally, the pulmonary artery was also a frequent site of tumor embolization likely due to the frequent branches and small caliber of these vessels. In such cases, the primary malignancy was usually of gastrointestinal tract, hepatic, breast, or urological origin. These cancers can directly embolize to the pulmonary artery via the inferior vena cava, right atrium, and right ventricle. In such cases, the prognosis was poor with death occurring in 6 out of 7 patients in our study (85.7%). The specific tumors implicated in this embolization pathway included Gastric cancer, Adenocarcinoma of Gastro-esophageal junction, Hepatocellular carcinoma, Invasive ductal Breast carcinoma, Renal cell carcinoma, Urothelial carcinoma, and Adenocarcinoma of Prostate. The significance of anatomical vascular pathways to tumor embolization was particularly illustrated in a patient with a squamous cell esophageal cancer, which invaded the superior vena cava, but then embolised to the left middle cerebral artery causing a stroke, as the patient had an underlying right-to-left shunt.

It is important to differentiate the diagnosis of acute tumor embolism from the more prevalent phenomena of cancer-associated-thromboembolism as the management may differ. Tumor embolism is the physical translocation of tumor cells, cell clusters, or tumor fragments, whereas the pathophysiology of thrombo-embolism involves vessel damage, static blood flow and activation of the coagulation cascade due to the hypercoagulable state induced by cancer [55].Tumor embolism is potentially treated with surgery or chemotherapy, while venous thrombo-embolism is treated with anti-coagulation. Clinically, the two may be indistinguishable so the diagnosis is often made on histology or post-mortem analysis [56].The clinician should be cognisant of the fact that an acute embolism may be the first presentation of an undiscovered malignancy and investigate thoroughly. Conversely, a patient with a known malignancy may present with a tumor embolism, as opposed to a thrombo-embolism, precluding the use of thrombolysis. Tumor embolism should be part of the differential diagnosis of several medical and surgical specialties given the prevalence of neoplastic disease and the wide variety of malignancies implicated in this phenomenon.

It is also important to differentiate acute tumor embolism from the more common occurrence of haematogenous metastatic spread of cancer as this has implications for management and prognosis. The former involves the physical fragmentation and movement of cancer cells or pieces of tumor tissue in the bloodstream resulting in occlusion. The latter occurs at a cellular level through biochemical interactions of cancer cells with the microenvironment and vasculature to enter the bloodstream with eventual deposition in solid organs [57].

It is important to note that the risk of acute tumor embolism can be increased due to operative manipulation of tumors during surgery. This has been well described in lung cancer cases treated with pneumonectomy [58].To prevent tumor dissemination, the principle of primary venous control during oncological surgery was established [58].

Chemotherapy and radiotherapy can also increase the risk of tumor embolization through the mechanism of tumor lysis. Tumor lysis syndrome is well-described in hematological malignancies. However, the increased use of oncological cancer treatment has resulted in reports of tumor lysis syndrome in solid malignancies, which is much rarer and has a higher mortality. Recent studies in mice have shown that disseminated micro-emboli composed of debris from lysed tumor cells can cause micro-obstruction of capillary beds in various organs e.g., kidneys, lungs, brain [59].This mechanism is further supported in a case report of endometrial cancer treated with chemotherapy resulting in pulmonary tumor embolism [60].

In our study, surgical procedures for acute tumor embolism that were commonly performed included femoral thrombo-embolectomy and primary percutaneous coronary intervention. This is related to the extensive experience of using these procedures for conventional thrombo-embolic disease. Percutaneous thrombo-embolectomy for stroke and pulmonary thrombo-embolectomy for pulmonary tumor embolism were performed less frequently as these patients were often moribund. The standard treatment for ischaemic stroke is thrombolysis using a tissue-plasminogen activator. Patients with stroke secondary to tumor embolism may not respond to this treatment as the obstructing embolus is composed of tumor tissue rather than a fibrin blood clot. In such cases, anti-platelet or anti-coagulation therapy may help address the hypercoagulability associated with cancer but the management should also include cytoreductive chemotherapy and surgical resection of the primary tumor to treat the neoplasm [61].

In cases where the primary tumor was an atrial myxoma, surgical excision was commonly performed as this is a benign and resectable tumor. In other cases, the primary malignancy was far too advanced and disseminated precluding the possibility of surgical intervention.

Currently, there is little research data to decide regarding the appropriateness of surgical intervention for this condition. Both conservative management and surgical intervention may be reasonable options due to equivalent long-term outcomes as prognosis is ultimately determined by the stage of malignancy. In one small case series a brachial embolectomy was performed on two patients with upper limb arterial embolism associated with malignancy whilst a third patient was managed conservatively [62].Limb salvage was achieved in all 3 cases, but long-term prognosis remained poor due to malignancy.

Our results show that the outcome of surgical intervention resulted in a successful discharge more often than an adverse outcome such as inpatient hospital death, organ infarction or limb loss. This is a noteworthy finding showing that the benefits of surgery outweigh the risks in selected cases of acute tumor embolism.

The limitation of this systematic review is that it is retrospective in nature, it only includes case reports due to the rarity of the condition, missing data in some case reports and lack of data collection regarding demographics, co-morbidities, and clinical, biochemical, radiological, and histological findings.

The strengths of the systematic review include a comprehensive search strategy encompassing two main databases, clear inclusion and exclusion criteria, manual identification of relevant studies without algorithm or automation, tabulation of individual studies with data, simple synthesis methods used such as manual determination of frequencies and the use of simple and descriptive statistics. The risk of bias was low as all included studies were given equal weight.

Early surgical intervention can potentially prevent devastating complications such as death, disabling stroke, severe heart failure, bowel infarction and limb loss. This can greatly improve the patient's quality of life in the final stages of their malignancy. Case selection will be key as terminal disease, multiple co-morbidities, marked derangements in biochemistry and physiology, and poor baseline functioning are likely to preclude surgical intervention. In such cases, palliative management will be more appropriate.

In future, it may be beneficial to determine immediate, short, and medium-term prognostic outcomes following surgical intervention in cases of acute tumor embolism. This will help inform a consistent and appropriate management strategy.

Conclusion

This systematic review confirms that primary lung cancer and atrial myxoma are the most common sources of tumor embolism. Generally, thoracic tumors embolise to the systemic circulation via the heart and major arteries whereas abdominal tumors embolize to the pulmonary circulation via the inferior vena cava. Overall, acute ischaemic stroke, resulting from embolization to the cerebral circulation, is the most common clinical presentation. In addition to anti-platelets or anticoagulation, the treatment for this should also include cytoreductive chemotherapy and surgical resection of the primary tumor.

Early surgical intervention for acute tumor embolism can prevent devastating complications such as death, paralysis, heart failure, bowel resection and limb loss and enable successful discharge in selected cases. This is most often seen with femoral thrombo-embolectomy for tumor embolism of lower limb arteries and primary percutaneous coronary intervention for tumor embolism of the coronary arteries.

Ethical approval

As this is a review article, ethical approval is not required as per international standards and the policy of Frimley Health NHS Foundation Trust.

CRediT authorship contribution statement

I, Syed Mohammad Asim Hussain, was involved in the conception, design, data collection, analysis, and write-up of this manuscript. I would also like to acknowledge the contribution of the library staff at the Pennine Acute NHS Trust, who facilitated with the data search.

Funding statement

No funds were used in the production of this manuscript.

Declaration of competing interest

The author does not have any competing interests.

Data availability statement

The studies supporting the findings of this systematic review are available with the author and have been stated and referenced in this manuscript.