Interact CardioVasc Thorac Surg 2009;8:563-564. doi:10.1510/icvts.2008.189415
© 2009 European Association of Cardio-Thoracic Surgery
Negative results - Vascular thoracic |
Embolism of the pulmonary artery stump after right pneumonectomy
Christophoros Kotoulas* and
Stefanos Lachanis
Department of Cardiothoracic Surgery and Radiology, 401 General Military Hospital of Athens, Greece
Received 27 July 2008;
received in revised form 12 January 2009;
accepted 13 January 2009
*Corresponding author. Kifissias Ave 38, GR-11526, Athens, Greece. Tel.: +30 210 7782220; fax: +30 210 7772329.
E-mail address: info{at}kotoulas.com (C. Kotoulas).
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Abstract
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We report a case of a 53-year-old male who presented with thoracodynia three months after right pneumonectomy. Chest CT-scan demonstrated thrombus at the pulmonary artery stump without any other abnormal finding. He was treated successfully with acenocoumarol. We present this case analyzing the possible causes and discussing the treatment.
Key Words: Pneumonectomy; Pulmonary embolism; Anticoagulant treatment
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1. Introduction
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Although pulmonary embolism occurs in 20% of the cases postoperatively after major lung resections, only a few cases have been reported with isolated embolism of the pulmonary artery stump after pneumonectomy [1]. We present such a rare case, analyzing the possible causes and discussing the treatment.
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2. Case report
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A 53-year-old male presented with a large lesion in the right lung. Bronchoscopy showed total occlusion of the right intermedius bronchus due to a non-small cell lung cancer. Further investigation with computed tomography (CT-scan) and bone-scan showed that the lesion invaded the pleura, without mediastinal lymphatic spreading or distant metastasis. He underwent an uncomplicated right extrapericardial pneumonectomy using automatic staplers and mediastinal lymph node dissection. The pathology report showed a 10.5x9.5x8 cm, poorly differentiated, squamous-cell carcinoma, which invaded the parietal pleura (T3N1M0 – stage IIIa). His recovery was uneventful. He followed adjuvant chemotherapy. Three months later he presented with thoracodynia. Chest CT-scan showed thrombus at the right pulmonary artery stump without any other abnormal finding (Fig. 1). Ultrasound of the lower limbs showed no evidence of thrombosis, while echocardiogram showed no pathologic findings from the heart. He received acenocoumarol and three months later, his CT-scan had no evidence of the thrombus (Fig. 2). Today, five years later, he is still on anticoagulant medication, while his follow-up showed no recurrence or distant metastasis.
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Fig. 2. Chest CT-scan, in comparison (a and b three months later), shows no thrombus at the right pulmonary artery stump.
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3. Discussion
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Crafoord reported the first cases of pulmonary artery stump thrombosis in 1938 [2]. Many years later, in 1966, Chuang et al. described two cases of pulmonary artery stump thromboembolism during the first postoperative days [3]. Both reports were based on autopsy findings. Nowadays, although with the systemic use of anticoagulants, it has been reported that the incidence of perioperative thromboembolism after major lung resection is 20% [1]. Moreover, the postoperative use of CT-scan revealed that the overall incidence is higher than this, as 12% of the patients develop subclinical bronchial stump thrombosis [4].
It is not clear, even at autopsy, if it represents old organized pulmonary emboli or thrombi formed in situ [5]. The Virchow's triad of pathogenesis of thrombosis describes the reasons of the bronchial stump thrombosis. So, it usually happens on the right, as the right bronchial stump is longer than the left one, which results in turbulence in the main trunk and stasis of blood in the stump [6]. Furthermore, I ik et al. showed that thrombus formation in the pulmonary artery is more likely to occur following the closure of the stump with the transfixation ligature technique compared with the continuous ligature technique as a result of the damage to the intimal surface [7]. Finally, the hypercoagulable state of the blood in patients with malignant disease is well known [8]. Gouin-Thibault et al. support the theory that thromboembolism is related with high incidence of hidden cancer or unknown cancer [9].
It is remarkable that our patient had an uneventful postoperative period after the right pneumonectomy. It seems that the stump thrombosis was the result of the pulmonary artery ligation; although an automatic stapler was used for it, and he received adjuvant chemotherapy, as the patient was disease-free (he is still alive five years later) and that further investigation did not reveal any other related reason.
Although the treatment in such cases is not well described, we treated him successfully with acenocoumarol. However, the subclinical appearance of pulmonary artery thrombosis does not support the prophylactic treatment with coumarins in all pneumonectomy cases. The final result in our case supports our hypothesis for the benign natural history of it.
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References
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- Ziomek S, Read R, Tobler H, Harrell J Jr, Gocio J, Fink L, Ranval T, Ferris E, Harshfield D, McFarland D. Thromboembolism in patients undergoing thoracotomy. Ann Thorac Surg 1993;56:223–226.[Abstract]
- Crafoord C. On the technique of pneumonectomy in man: critical survey of experimental and clinical development and report of authors material and techniques. Acta Chir Scand 1938;81S:1–142.
- Chuang T, Dooling J, Connolly J, Shefts L. Pulmonary embolization from vascular stump thrombosis following pneumonectomy. Ann Thorac Surg 1966;2:290–298.[Medline]
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- Edwards R, Rickles F, Moritz T, Henderson W, Zacharski L, Forman W, Cornell C, Forcier R, O'Donnell J, Headley E. Abnormalities of blood coagulation tests in patients with cancer. Am J Clin Pathol 1987;88:596–602.[Medline]
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Abstract
1. Introduction