Eur J Cardiothorac Surg 2001;19:223-225
© 2001 Elsevier Science NL
Acute pulmonary thromboembolism complicating pneumonectomy: successful operative management
Qiang Chen,
Augustine T.M. Tang,
Geoff M. Tsang
Department of Cardiothoracic Surgery, Wessex Regional Cardiac & Thoracic Unit, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
Received 5 July 2000;
received in revised form 8 November 2000;
accepted 4 December 2000.
Corresponding author. Tel.: +44-23-8077-7222; fax: +44-23-8079-8508
e-mail: gustmtang{at}aol.com
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Abstract
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Pulmonary thromboembolism after pneumonectomy carries high fatality. Here we present a case of acute embolism to the left pulmonary artery with thrombus in the right atrium and inferior vena cava following right pneumonectomy. Diagnosis was made clinically and radiologically before proceeding to emergency surgery. Thromboembolectomy was successfully performed on cardiopulmonary bypass and the patient was subsequently discharged home after uneventful recovery.
Key Words: Early complication • Postpneumonectomy • Embolectomy • Cardiopulmonary bypass
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1. Introduction
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Acute pulmonary thromboembolism (PTE) following pneumonectomy though uncommon is life-threatening. Improved survival depends on prompt diagnosis and rapid appropriate intervention.
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2. Case report
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A 56-year-old man presented with 3-months of coughing. Thoracic imaging demonstrated resectable tumour in the right lung and he was deemed physiologically fit for operation. Intraoperative frozen-section histology confirmed non-small cell carcinoma leading to right pneumonectomy. Pathological examination of the resected specimen confirmed adenocarcinoma of stage pT2N1. Subcutaneous heparin, stockings and early mobilization were used as perioperative thromboembolic prophylaxis. He progressed well postoperatively until day 7 when he suddenly became dyspnoeic. On examination he was clammy, normotensive and tachycardic with 94% saturation on transcutaneous pulse oximetry. Jugular venous pressure was elevated and electrocardiogram revealed sinus tachycardia with SIQIIITIII changes. Arterial blood-gas analysis showed moderate hypoxia (pO2 8.4, pCO2 4.14, pH 7.5). Acute PTE was diagnosed and urgent transoesophageal echocardiogram was arranged to exclude primary cardiac pathology. This demonstrated a mobile mass in the right atrium (RA) prolapsing through the tricuspid valve into a dilated and poorly contracting right ventricle (Fig. 1). Left ventricular function was normal. To further assess the pulmonary vasculature, a CT pulmonary angiogram was performed which showed left lower lobe consolidation with thrombus in the corresponding lobar artery. Additionally there was thrombus at the junction of inferior vena cava and RA. During investigation the patient's cardiopulmonary status deterriorated despite inotropic support. Emergency operative treatment was deemed appropriate: with a median sternotomy and institution of cardiopulmonary bypass using aortobicaval cannulation, through a longitudinal right atrial incision fresh thrombi were extracted from the right atrium and right ventricle. A separate incision was made in the main pulmonary artery extending to the left beyond the bifurcation. This enabled thromboemboli extraction from the distal pulmonary vasculature using Desjardin forceps and suction tubing. The patient subsequently required ventilatory support for 72 h but maintaining haemodynamic stability throughout. Full systemic anticoagulation was achieved immediately with heparin and substituted with warfarin during the first postoperative week. He further recovered steadily on the ward and was allowed home after 3 weeks in good functional status. After 6 months of outpatient follow-up he returned to full-time employment with no sign of recurrent disease.
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Fig. 1. (a,b) Transoesophageal echocardiogram demonstrating the presence of a thrombus (arrow) situated within the right atrium extending through the tricuspid valve.
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3. Comment
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Pulmonary thromboembolism (PTE) is a well-recognised complication following lung resection occuring in up to 5% of cases [1]. Autopsy findings suggest that central PTE is a potent cause of early postoperative fatality with mortality exceeding 80% [2]. Important predisposing factors include previous surgery, resection for bronchiogenic carcinoma, more extensive surgery (pneumonectomy), adenocarcinoma cell-type, larger primary tumour, more advanced cancer staging (stage II) and lack of thromboembolic prophylaxis [1]. The mechanism is uncertain but may involve a cytokine-induced hypercoagulable state peaking during the second postoperative week [3]. Peripheral deep venous thrombosis (DVT) is perhaps the commonest source of PTE: up to 14% of thoracic surgical patients developed postoperative DVT and 42% of patients with DVT diagnosed on radionuclide fibrinogen scanning after lung resection suffered PTE with less than 50% survival [4]. Central sources for PTE are less well recognized but include the vena cava after extended resection [5] and pulmonary artery stump in pneumonectomy [6].
Specific knowledge on PTE following pneumonectomy is largely anecdotal and suggests that it is more common and deadlier than after lesser resection. Evidence from case studies and small series indicate that survival is more likely when emboli are multiple and small [7]. Central PTE after pneumonectomy is almost uniformly fatal with rare reports of exception following acute intervention [2]. To enhance survival, diagnosis must be prompt relying on a high index of suspicion. Differentiation from other causes of acute cardiopulmonary collapse after pneumonectomy such as heart failure, right-to-left intracardiac shunt through a reopened foramen ovale and pneumonia [8] can usually be made using radionuclide ventilation/perfusion scan, helical CT scanning and echocardiography. Although pulmonary angiography remains the gold-standard test, in practice this may be excluded by rapid clinical deterioration. Indeed this limitation was evident in an earlier report of successful intervention when sudden and profound cardiopulmonary collapse precluded investigation. In both cases, the patient proceeded to surgery on clinical grounds alone [2]. Our patient remained sufficiently stable to allow for investigation and diagnostic confirmation before surgical intervention was chosen. Although operative salvage on clinical basis alone has been advocated because of the poor outlook, this would expose critically-ill patients to unnecessary surgery.
There is little systematic evidence on the effectiveness of various treatment options. Emergency pulmonary embolectomy can be life-saving if diagnosis is prompt [2]. Operation could be performed without using cardiopulmonary bypass (CPB) using inflow occlusion and normothermic circulatory arrest. We instituted CPB to facilitate thrombectomy from the RA and IVC, thus minimising further embolism. Successful thrombolysis of subtotal PTE following lung resection administered either systemically or via a pulmonary artery catheter has been reported [9,10]. However, this requires the patient to maintain cardiopulmonary stability throughout treatment and can result in massive haemorrhage. Systemic anticoagulation has also been advocated as a less risky alternative in the early postoperative setting with limited success, mainly confined to those with multiple small emboli [7].
Due to the high mortality of PTE in pneumonectomised patients, thromboembolic prophylaxis has been widely recommended including preoperative aspirin, avoidance of blood products, early mobilization and routine anticoagulation in the early postoperative period [1]. As limited evidence suggests that a proportion of patients may acquire the embolic source either pre- or intra-operatively, no prophylactic measure could offer universal protection and clinical vigilance remains our only guard against this complication [2].
In summary, acute PTE following pneumonectomy remains highly fatal. This case highlights that prompt diagnosis and rapid surgical intervention can enhance survival. Cardiopulmonary bypass facilitates removal of concomitant intracardiac thrombus. Perioperative thromboembolic prophylaxis in those undergoing pneumonectomy is strongly recommended as a preventative measure.
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Abstract
1. Introduction
