Left superior pulmonary vein stump thrombosis and right renal infarction after left upper lobectomy: case report and literature review

Proximal ligation technique prevents thrombus formation in the pulmonary vein stump after lobectomy

PURPOSE

To assess the risk factors for thrombosis in the pulmonary vein stump (PVT) and the efficacy of proximal ligation in preventing PVT after lobectomy.

METHODS

In total, 649 surgical patients with lung cancer were retrospectively reviewed. To compare the clinical effectiveness of PV proximal ligation, the simple stapler group (290 patients) and the proximal ligation group (359 patients who underwent thread ligation at the pericardial reflection with/without a stapler) were analyzed.

RESULTS

In the simple stapler group, 12 of 290 patients (4.1%) developed PVT. Among these, 9 of 58 underwent left upper lobectomy (LUL). In contrast, 5 of the 359 patients (1.4%) in the proximal ligation group developed PVT. All five patients received LUL. The incidence of PVT in the proximal ligation group was significantly lower than that in the simple stapler group (p = 0.0295) as well as in the analysis by LUL alone (p = 0.0263). A logistic regression analysis indicated that higher BMI and LUL were associated with the development of PVT (p = 0.0031, p < 0.0001), and PV proximal ligation reduced PVT (p = 0.0055).

CONCLUSION

Proximal ligation of the PV has the potential to prevent PVT, especially after LUL.

Postoperative cerebral infarction and arrhythmia after pulmonary lobectomy in Japan: a retrospective analysis of 77,060 cases in a national clinical database

PURPOSE

To investigate the incidence of postoperative cerebral infarction after curative lobectomy, its association with the type of lobectomy, and how postoperative new-onset arrhythmia contributes to postoperative cerebral infarction.

METHODS

The subjects of this analysis were 77,060 patients who underwent curative lobectomy for lung cancer between 2016 and 2018 according to the National Clinical Database. Incidences of postoperative cerebral infarction and postoperative new-onset arrhythmia were analyzed. Moreover, mediation analysis was performed to evaluate the causal pathway between postoperative new-onset arrhythmia and postoperative cerebral infarction.

RESULTS

Postoperative cerebral infarction occurred in 110 (0.7%) patients after left upper lobectomy and in 85 (0.7%) patients after left lower lobectomy. Left upper lobectomy and left lower lobectomy were associated with a higher likelihood of postoperative cerebral infarction than right lower lobectomy. Left upper lobectomy was the strongest independent predictor of postoperative new-onset arrhythmia. However, in the mediation analysis, the odds ratio for cerebral infarction did not change after the addition of the factor of postoperative new-onset arrhythmia.

CONCLUSION

Cerebral infarction occurred significantly more often not only after left upper lobectomy, but also after left lower lobectomy. Postoperative new-onset arrhythmia was less likely to be related to cerebral infarction after left upper lobectomy.

Efficacy of direct oral anticoagulant for renal infarction due to pulmonary vein stump thrombosis after left pneumonectomy

Background

Thrombosis of the pulmonary vein stump is a common complication after a left upper lobectomy and can be a source of embolism in various organs, such as the kidneys. A renal infarction, on the other hand, is a rare and often lethal condition that is usually diagnosed postmortem. Here, we present a case of renal infarction associated with pulmonary vein stump thrombosis after a left pneumonectomy, which was treated successfully with edoxaban.

Case presentation

A 73-year-old man was diagnosed with squamous cell lung cancer (cT1miN0M0 stage IA1). Due to pneumoconiosis, extensive lymph node infiltration into the pulmonary artery was noted and necessitated an open thoracotomy. Ultimately, a left pneumonectomy was performed. Atrial fibrillation occurred on postoperative day 3, and the patient complained of left-sided abdominal pain. Contrast-enhanced computed tomography revealed a left upper pulmonary vein thrombosis and a left renal infarction. Anticoagulant therapy was immediately initiated with heparin and warfarin. On postoperative day 13, warfarin was replaced with the direct oral anticoagulant edoxaban since the patient’s compliance and drug response to warfarin were poor. On postoperative day 19, contrast-enhanced computed tomography revealed a reduction in pulmonary vein stump thrombosis and improvement in renal infarction. Subsequently, the patient was discharged. Three months post-surgery, no infarct lesions or reduced renal function was observed on imaging.

Conclusions

The direct oral anticoagulant edoxaban could be effective in preventing recurrence or exacerbation of pulmonary vein thrombosis associated with renal infarction without bleeding complications.

Splenic infarction after left upper lobectomy: a report of a case

We report the case of a 70-year-old man who developed a splenic infarction due to a thrombus in the pulmonary vein (PV) stump after left upper lobectomy (LUL). Preoperative imaging showed a mass measuring > 5 cm in the upper lobe of the left lung, and sputum cytology revealed squamous cell carcinoma. Therefore, video-assisted thoracoscopic LUL was performed. The postoperative course was uneventful but biochemical blood tests showed an increased inflammatory response. Contrast-enhanced computed tomography revealed splenic infarction and a thrombus in the left superior PV stump. Prompt treatment with anticoagulants was administered, and the patient was discharged with mild recovery. However, the patient developed cerebral infarction after discharge and died 33 days after the surgery. Splenic infarction is a rare postoperative complication, with only three reported cases, including this report. However, this condition should be considered along with PV thrombus when evaluating an increased inflammatory response after LUL.