Low-molecular-weight heparin for treatment of submassive pulmonary embolism after pneumonectomy

Treatment challenges in patients with early acute massive pulmonary thrombosis embolism (PTE) after lung cancer surgery: A case report

INTRODUCTION

Early acute massive pulmonary thrombosis embolism (PTE) after lung cancer surgery is one of the most fatal surgical complications. It is often accompanied by shock and hypotension, with high mortality rate. Due to surgical wounds, patients with early acute massive PTE after lung cancer surgery have a high risk of thrombolytic bleeding, which renders treatment more challenging and there is currently no standard protocol on how to safely and effectively treat these patients in the clinic.

PATIENT CONCERNS

A 66-year-old woman after video-assisted thoracoscopic surgery for lung cancer, experienced sudden severe dyspnea, shock and hypotension with high D-Dimer, changed electrocardiogram (ECG), right ventricular dilatation, severe tricuspid regurgitation, and raised pulmonary arterial pressure on ultrasonic cardiogram (UCG), thromboses found on Ultrasonography of lower extremity vein.

DIAGNOSIS

Because of her clinical manifestations and results of bedside auxiliary examinations, the patient was finally diagnosed with acute high-risk PTE after lung cancer surgery.

INTERVENTIONS

1.5 hours after onset of symptoms, thrombolysis using a continuous micropump infusion of 20,000 units/kg urokinase into the peripheral vein for 2 hours was initiated for this patient.

OUTCOMES

The patient died of massive hemorrhage after thrombolysis.

LESSONS

Treatment for patients with early acute PTE after lung cancer surgery is challenging due to a high risk of thrombolytic bleeding at the surgical site. Real-time monitoring of vital signs during thrombolysis and catheter-directed thrombolysis are recommended for these patients, in order to use the minimum drug dosage for quick curative effects and a low risk of bleeding.

[Experience of Interventional Thrombolysis Therapy for Massive Pulmonary Thrombosis Embolism after Video-assisted Thoracoscopic Surgery for Lung Cancer]

背景与目的

肺栓塞（pulmonary thrombosis embolism, PTE）是肺癌根治术围术期严重并发症之一，其中高危PTE因伴有休克、低血压具有病情进展快、死亡率高的特点。这类患者的治疗目前尚无统一标准，是胸外科医生临床工作中的难点。本文通过总结分析我院2例肺癌术后早期并发高危PTE患者的治疗过程，探讨此类病例的诊疗策略，为广大胸外科医生提供参考。

方法

分析2017年在我院接受胸腔镜肺癌根治手术术后早期并发高危PTE患者两例。1例予静脉联合肺动脉介入溶栓治疗，1例予单纯肺动脉介入溶栓治疗。总结分析两例病人治疗效果及治疗过程中出现的并发症。

结果

2例患者均为女性，年龄分别为66岁、61岁，发生PTE的时间分别为术后48 h、45 h，接受介入溶栓时间分别是发病后70 min、50 min，介入治疗时间分别是120 min、100 min，介入溶栓后引流分别是4, 690 mL、520 mL，溶栓后住院时间分别是21 d、14 d，随访6个月均无明显并发症。

结论

肺癌术后早期发生高危PTE建议尽早行肺动脉内介入溶栓治疗，相对于静脉溶栓治疗，肺动脉内介入溶栓具有给药精准、药物用量容易控制、疗效快、出血风险小等优点。

Incidence and clinical features of the incidentally found vascular stump thrombus during routine follow up after oncologic lung surgery

OBJECTIVES

We aimed to evaluate the incidence and clinical features of vascular stump thrombus after oncologic lung surgery.

METHODS

A retrospective analysis of records from our institutional database dated between 2009 and 2016 was performed. Data regarding demographics, clinical presentation, medication use, operative findings, pathology, and radiologic findings were retrieved.

RESULTS

The study cohort consisted of 648 oncologic surgeries for primary lung cancer. The incidence of thrombus in the entire population was 5.7% (37/648). Most thrombi were incidentally found on follow-up chest computed tomography scans. Univariate Cox proportional hazard analysis showed that age (p = 0.02), adjuvant therapy (p <0.001), neoadjuvant therapy (p = 0.04), left-sided surgery (p = 0.02), complex surgery greater than simple lobectomy or segmentectomy (p <0.001), advanced stages (p <0.001), non-adenocarcinoma (p = 0.003), and thoracotomy approach (p = 0.009) were associated with an increased risk of vascular stump thrombus. There were no embolic events in our cohort, except for a case of pulmonary thromboembolism. During follow-up, 43.2% (16/37) of thrombi had completely resolved, 48.6% (18/37) showed partial regression and stabilization, and 8.1% (3/37) had progressed.

CONCLUSIONS

The incidence of vascular stump thrombus in our study was not negligible. The clinical course of stump thrombus appears to be benign in most cases. Anticoagulation may be used with caution based on an individual basis depending on each patient's risk factors.

Postoperative Acute Pulmonary Embolism Following Pulmonary Resections

Postoperative acute pulmonary embolism after pulmonary resections is highly fatal complication. Many literatures have documented cancer to be the highest risk factor for acute pulmonary embolism after pulmonary resections. Early diagnosis of acute pulmonary embolism is highly recommended and computed tomographic pulmonary angiography is the gold standard in diagnosis of acute pulmonary embolism. Anticoagulants and thrombolytic therapy have shown a great success in treatment of acute pulmonary embolism. Surgical therapies (embolectomy and inferior vena cava filter replacement) proved to be lifesaving but many literatures favored medical therapy as the first choice. Prophylaxis pre and post operation is highly recommended, because there were statistical significant results in different studies which supported the use of prophylaxis in prevention of acute pulmonary embolism. Having reviewed satisfactory number of literatures, it is suggested that thoroughly preoperative assessment of patient conditions, determining their risk factors complicating to pulmonary embolism and the use of appropriate prophylaxis measures are the key options to the successful minimization or eradication of acute pulmonary embolism after lung resections.

Acute pulmonary embolism after pneumonectomy

Pulmonary embolism (PE) by occlusion of the pulmonary arterial bed may lead to acute life-threatening but potentially reversible right ventricular failure, one of the most severe complications of thoracic surgery. Still, the incidence of acute pulmonary embolism after surgery is reduced by comprehensive anticoagulant prevention, improved surgical techniques, appropriate perioperative management and early ambulation. However, there is difficulty in diagnosing PE after thoracic surgery due to the lack of specific clinical manifestations. So that optimal diagnostic strategy and management according to the clinical presentation and estimated risk of an adverse outcome is fundamental.