Hybrid surgical thromboembolectomy and crossover endovascular revascularization for acute lower-limb ischemia in a patient with active ovarian cancer receiving a PARP inhibitor (fuzuloparib): a case report and literature review

Acute limb ischemia (ALI) is both limb- and life-threatening, and represents a vascular emergency. Malignancy produces a systemic hypercoagulable state that predisposes to arterial as well as venous thrombosis, and poly(ADP-ribose) polymerase (PARP) inhibitors—now central to maintenance therapy in ovarian cancer—have, in aggregate randomized data, been associated with only a borderline venous signal and no clearly demonstrated independent arterial signal. We report a 60-year-old woman with active high-grade serous ovarian carcinoma maintained on oral fuzuloparib who presented with Rutherford category IIa ALI of the right lower limb on a background of chronic bilateral atherosclerosis. Angiography demonstrated occlusion of the right common iliac–external iliac–common femoral–proximal superficial femoral segment with collateral reconstitution and, after dedicated cardiac evaluation (regular sinus rhythm on ECG, no arrhythmia on perioperative telemetry, normal transthoracic echocardiography without intracardiac thrombus or vegetation, and no critical carotid stenosis), no identifiable cardioembolic source. A single-stage hybrid procedure—open common femoral thromboembolectomy followed by contralateral (crossover) endovascular treatment of a residual flow-limiting dissection with overlapping self-expanding and balloon-expandable covered stents—restored inline flow and salvaged the limb; the retrieved material was submitted for histopathology, which demonstrated bland fibrin–platelet–red-cell thrombus with lines of Zahn and negative AE1/AE3 immunostaining, excluding tumour embolism. The patient was transitioned to therapeutic anticoagulation within a multidisciplinary framework, and at 3 months the limb remained viable with palpable distal pulses. This case illustrates cancer-associated arterial thrombosis superimposed on atherosclerosis—on a background that also included PARP-inhibitor exposure, whose independent contribution remains speculative—highlights a hybrid open–endovascular strategy for definitive single-setting revascularization, and underscores the importance of excluding a cardioembolic source and confirming thrombus nature histologically, while individualizing long-term anticoagulation that is necessarily extrapolated from cancer-associated venous thromboembolism evidence, with attention to drug–drug interactions, thrombocytopenia and bleeding risk.