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J Thorac Cardiovasc Surg 2006;132:197-198
© 2006 The American Association for Thoracic Surgery
Brief Communication |
a Thoracic Surgery Unit, Perugia University, Perugia, Italy
b Department of Internal Medicine and Vascular Diseases, Perugia University, Perugia, Italy
c Department of Radiology, Perugia University, Perugia, Italy
d Thoracic Surgery Unit, Perugia University at Terni, Terni, Italy
Presented as a poster at "Chest 2004," Annual Meeting of the American College of Chest Physicians, Seattle, Wash, October 23-28, 2004.
* Address for reprints: Mark Ragusa, MD, S.C. Chirurgia Toracica, Università di Perugia, Ospedale Silvestrini, Via G. Dottori, 06156, Perugia, Italy. (Email: drfastnet{at}bigfoot.com).
Limited information is currently available on the incidence of venous thromboembolism (VTE) in patients undergoing lung surgery for cancer.
1,2
Pulmonary embolism (PE) has been found to be a frequently fatal postoperative complication, as confirmed by autopsy in 15.2% of postresectional deaths.
3
The clinical burden of PE in surgical patients is underestimated, probably because the majority of VTE remains asymptomatic or associated with aspecific symptoms. Several factors increase the thromboembolic risk in patients undergoing lung cancer surgery: intrinsic procoagulant effect of cancer, extensive surgical intervention, dependent limb position in the operating room, and vessel injury consequent to the operation.
PE in patients undergoing thoracic surgery has some peculiarities. Indeed, in thoracic surgery, in addition to the established risk factors for VTE, local factors related to surgical technique, direct vascular injury, or both could play a remarkable role.
4
The aim of this study was to assess the incidence of PE after lung surgery for cancer by using multislice computed tomographic (MSCT) scanning.
Methods
The Pulmonary Embolism in Thoracic Surgery Study was a prospective study performed to identify the incidence of PE by means of MSCT scanning after lung surgery for cancer.
MSCT scanning was performed with a 4-row computed tomogram (GE Light-Speed, 4 x 1.25); technical parameters were high speed, 2.5-mm collimation, 220 mAs, and 120 Kv. All examinations were separately reviewed by 2 different radiologists.
All patients underwent chest MSCT scanning within 7 to 15 days from the time of the operation. Diagnostic criteria for PE were as follows: (1) abrupt cutoff of vessels, often distally enlarged, in case of complete obstruction; (2) partial central vascular filling defect (known as "polo mint" or "tram lining" signs); and (3) partial eccentric vascular filling defect.
Patient data, including age, sex, history of VTE, previous major operation, chemotherapy, comorbidity, smoking habit, medications, type of lung resection, tumor size, histology, and stage, were considered potential risk factors for VTE.
Patients received pharmacologic prophylaxis for VTE with low-molecular-weight heparin, starting 12 to 24 hours after surgical intervention until discharge, at a dosage of 3000 to 4000 UI/d.
The primary outcome of the study was PE incidence. The secondary aim was to analyze the correlation between surgical technique and the occurrence of thrombus in the pulmonary arterial stumps. The study protocol was approved by the regional institutional review board. All patients provided written informed consent.
Results
Fifty patients were included in this study. The average age was 66.5 years (range, 26-90 years). Twelve were women, and 38 were men. All but 2 patients received VTE prophylaxis.
Thirty-six patients underwent lobectomy, 12 underwent pneumonectomy, and 2 underwent wedge resection. The diagnosis of cancer was confirmed in all cases except one, a patient affected by tuberculosis.
Histology showed primary lung cancer in 47 patients. Details are summarized in Table 1.
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Seven (14%) patients showed PE at MSCT scanning, 5 involving the central arteries (principal, lobar, and segmentary) and 2 involving the subsegmentary arteries. Among the 7 positive cases, 2 were in situ thrombosis of the residual vascular stump, one with direct extension to the contralateral pulmonary vasculature.
PE was bilateral in 2 patients. Two of the positive results at MSCT scanning were symptomatic, and only 1 had a clinically overt deep venous thrombosis confirmed by means of duplex scanning. Because of low diagnostic accuracy, duplex scanning was not performed in asymptomatic patients.
One patient died on postoperative day 10 of respiratory failure. The results of MSCT scanning were negative for PE. Risk factors for PE are summarized in Table 2.
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In this study the incidence of PE detected by means of MSCT scanning after lung surgery for cancer was 14%, which is higher than the 5% previously reported on the basis of lung scanning.
1
As in other series on postoperative VTE, the majority of patients were asymptomatic. However, in our study population symptoms caused by thoracotomy complicate the diagnosis of PE, therefore contributing to the underestimation of its true incidence. The clinical relevance of PE in patients undergoing thoracic surgery for cancer remains undefined.
Early diagnosis of PE is essential to establish adequate treatment to prevent recurrence.
PE in patients undergoing thoracic surgery for cancer has a multifactorial origin. Injury at the operative site might play a specific role. A long vascular stump might increase the risk of in situ thrombosis.
Other potentially harmful technical aspects are as follows: intimal dissection at the ligature sites, stenosis, and/or flow turbulence induced by excessive angulations of the vascular axis.
In conclusion, we observed a high incidence of PE in patients undergoing thoracic surgery for cancer despite prophylaxis. The intrinsic mechanisms of these findings should be further explored. Studies are required to identify the best prophylactic regimen in such a clinical setting.
References
This article has been cited by other articles:
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  M. K. Gould, D. A. Garcia, S. M. Wren, P. J. Karanicolas, J. I. Arcelus, J. A. Heit, and C. M. Samama Prevention of VTE in Nonorthopedic Surgical Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Chest, February 1, 2012; 141(2_suppl): e227S - e277S. [Abstract] [Full Text] [PDF]
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 F. Dentali, A. Malato, W. Ageno, A. Imperatori, M. Cajozzo, N. Rotolo, J. Douketis, S. Siragusa, and M. Crowther Incidence of venous thromboembolism in patients undergoing thoracotomy for lung cancer J. Thorac. Cardiovasc. Surg., March 1, 2008; 135(3): 705 - 706. [Full Text] [PDF]
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