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J Thorac Cardiovasc Surg 2008;135:709-710
© 2008 The American Association for Thoracic Surgery

Brief Communication

Thrombus in the left superior pulmonary vein after left upper pulmonary lobectomy

Eiki Nagaoka, MD*, Makoto Yano, PhD, Takahiko Sugano, MD, Takamichi Miyamoto, MD

Department of General Thoracic Surgery, Musashino Red Cross Hospital, Musashino, Tokyo, Japan

Received for publication October 4, 2007; accepted for publication November 21, 2007.

* Address for reprints: Eiki Nagaoka, MD, General Thoracic Surgery, Musashino Red Cross Hospital, 1-26-1 Kyonancho, Musashino, Tokyo, Japan 180-8601. (Email: ei.n{at}mm.neweb.ne.jp).

Renal infarction related to lung resection is rarely reported. We first encountered a case of renal thromboembolism midterm after lung resection. Creating a stump of pulmonary vein after major lung resection is among the few ways in which surgeons can generate a thrombus in the arterial system, which may lead to organ infarction. Infarction after lung resection, however, has rarely been reported. We present a case of renal infarction after lung resection.

Clinical Summary

A 76-year-old man underwent resection of the left upper lobe for lung cancer. Thirteen months after the operation, he sought treatment with severe right flank pain. A computed tomographic scan of the chest and abdomen, and of the pelvis with intravenous injection of contrast medium, revealed a large, wedge-shaped infarction of the left kidney (Go Figure 1). We detected a ball thrombus floating in the stump of the left superior pulmonary vein (LSPV), which we had left at the operation 13 months before. We consider this infarction of the kidney to be caused by thromboembolism.


Figure 1
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  		Figure 1. Computed tomographic scans of chest and abdomen. A, Round defect of contrast media in left superior pulmonary vein (arrow). B, Eleven months later, thrombus had disappeared. C, Large wedge-shaped defect in left kidney. D, One month after renal infarction, atrophy of left kidney was seen.

 
We admitted the patient and started anticoagulation therapy with heparin (20,000 units/d intravenously) and warfarin sodium (3 mg/d). Twelve days after the anticoagulation therapy had been started, the thrombus in the LSPV seemed to be smaller on transesophageal echocardiography than it had been on the day of admission. We stopped the heparin treatment, and with 2.5 mg warfarin per day kept the prothrombin international normalized ratio at about 2.0. Seventeen days after admission, the patient was discharged. In continuing follow-up, no new infarction has been observed.

Discussion

Abdominal organ infarction after lung surgery is rare, but it may cause serious diseases, such as renal failure, intestinal ischemia, or splenic infarction. We often ligate the stumps twice to avoid bleeding. Surgeons are not usually concerned with the size of the stumps, however, and without such concern, a thrombus may form in the stump (a blind-ended vessel) and ultimately embolize one or more organs.

There have been three case reports of abdominal organ infarction after lung surgery1,2Go and one report of lower extremity thromboembolism.3Go In the reports of abdominal infarction, the causes of infarction were not specified. In the case of lower extremity thromboembolism, thrombus was observed in the left atrium extending from the stump of the LSPV. All cases occurred after left upper lobectomy.

After this case, we examined patients who underwent lung surgery in our hospital. Through a series of 265 major lung resections in our hospital, 31 patients underwent contrast computed tomography for other reasons after the lung surgery. We carefully examined these computed tomographic scans and found another patient with a thrombus in the stump of the LSPV (Go Figure 2). We found two patients altogether, but one had dilated cardiomyopathy. His cardiac function was greatly reduced. For this reason, we excluded that patient.


Figure 2
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  		Figure 2. Computed tomographic scan of chest from another patient who had thrombus in left superior pulmonary vein (arrow).

 
The LSPV tends to be left longer than other pulmonary veins for anatomic reasons. This may have been the cause of thrombosis in both our cases, as both thrombi were in the LSPV.

We warn that although the occurrence is very low, thrombus may be formed in the LSPV, and some organs may be infarcted. It is therefore necessary to ligate the pulmonary vein as short as possible.

References

  1. Oura H, Hirose M, Aikawa H. Abdominal organ infarction encountered immediately after surgery of primary lung cancer. Kyobu Geka 2005;58:137-142.[Medline]
  2. Borrego Hernando J, Fernández Fernández E, Galbis San Juan F. Escudero Barrilero A. [Renal infarction following pulmonary surgery in a 13-year-old boy.]. [Article in Spanish] Arch Esp Urol 1994;47:1019-1021.[Medline]
  3. Seki M, Endo M, Kidani M, Kobayashi H, Sato H, Noto T. [A rare case of left atrial thrombus after left upper pulmonary lobectomy.]. [Article in Japanese] Nippon Kyobu Geka Gakkai Zasshi 1989;37:1371-1375.[Medline]



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