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Ann Thorac Surg 2003;76:599-601
© 2003 The Society of Thoracic Surgeons

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Case report

Pulmonary embolism after lung resection: diagnosis and treatment

^a Second Department of Surgery, Kagawa Medical University, Kagawa, Japan

Accepted for publication December 23, 2002.

^* Address reprint requests to Dr Yokomise, Kagawa Medical University, 1750-1, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
e-mail: yokomise{at}kms.ac.jp

	Abstract

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Pulmonary embolism after lung resection (PEALR) has a high mortality rate, and it is one of the most severe complications after lung resection. Early diagnosis and treatment are essential for PEALR. Here we present 3 cases of severe PEALR. In these cases, transthoracic Doppler echocardiography was useful for confirming the diagnosis of PEALR. Thrombolysis with recombinant tissue plasminogen activator (r-tPA) was used to treat the embolism, and these patients were subsequently discharged. Thus echocardiography may become a primary procedure to confirm the diagnosis of severe PEALR, and thrombolysis with second-generation r-tPA may be the preferred choice for treatment.

	Introduction

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Pulmonary embolism after lung resection (PEALR) has a high mortality rate, and it is one of the most severe complications after lung resection. Although early diagnosis and treatment are essential for PEALR, there are few reports describing strategies for management of the condition. In this report, we describe 3 patients with PEALR for whom transthoracic Doppler echocardiography was useful in confirming the diagnosis and in whom thrombolysis with recombinant tissue plasminogen activator (r-tPA) was effective. Conventional diagnostic procedures for pulmonary embolism include pulmonary angiography and a ventilation/perfusion (V/Q) scan. Thrombolysis is often contraindicated immediately after lung resection. Here we also discuss diagnosis and treatment for severe PEALR.

	Case reports

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Case 1
A 51-year-old woman was admitted with adenocarcionoma (stage IA) of the left lung, and a left lower lobectomy was performed. She was mobile from postoperative day 2. On postoperative day 5 sudden chest pain and dyspnea occurred. Arterial blood gas analysis demonstrated hypoxia, an oxygen tension (PO₂) of 56 Torr on 10 L face mask oxygen, and a carbon dioxide tension (PCO₂) of 46 Torr. The patient went into shock and resuscitation was performed. Echocardiography showed right ventricular dilatation and hypokinesis, more than 50 mm Hg of pulmonary arterial mean pressure (PAPm), and third-degree tricuspid regurgitation. The diagnosis was confirmed as pulmonary embolism (PE). It took 1 hour to confirm the diagnosis of PE after the first episode. Intravenous heparin was then started and a bolus infusion of 230 x 10⁴ IU of alteprase, r-tPA was given within 1 minute, with an additional 2,070 x 10⁴ IU administered over the next hour. Although hemorrhage from the thorax was observed to a maximum of 160 mL in 1 hour, it could be controlled by blood transfusion. The patient’s respiratory state improved 5 hours after the treatment. Although heparin was administered, aggravation of the respiratory–circulatory state was observed on postoperative day 9 and the patient was equipped with a percutaneous cardiopulmonary support system. Urokinase was administered to the patient through a Swan-Ganz catheter. Embolectomy was performed because the patient’s general state had not improved, and pulmonary angiography showed a defect in the right pulmonary artery. Mediastinitis subsequently developed; however, the patient’s condition was improved by omentopexy. The patient was discharged on postoperative day 192. Recurrence of PE did not occur for 6 years.

Case 2
A 49-year-old woman was admitted with adenocarcinoma (stage IIA) of the right lung, and a right lower lobectomy was performed. On postoperative day 1, when she stood up from the bed, sudden back pain and dyspnea occurred. Arterial blood gas analysis demonstrated hypoxia, with PO₂ of 51 Torr on 10 L face mask oxygen, and PCO₂ of 48 Torr. Echocardiography showed right ventricular dilatation and hypokinesis, more than 40 mm Hg of PAPm, and third-degree tricuspid regurgitation. Infused spinal computed tomography (CT) was performed because the PAPm was not so high; this revealed a defect in the left pulmonary artery. The diagnosis was confirmed as PE. It took 1.5 hours to confirm the diagnosis of PE after the first episode. Intravenous heparin was started and a bolus infusion of 140 x 10⁴ IU of alteprase, r-tPA was given within 1 minute, with an additional 1,260 x 10⁴ IU over the next 1 hour. Although hemorrhage from the thorax was observed to a maximum of 140 mL in 1 hour, it could be controlled by blood transfusion. The patient’s respiratory state improved 4 hours after the treatment. After that, intravenous urokinase was infused for 3 days to protect against recurrence of PE. The patient was discharged on postoperative day 28. She died of a recurrence of lung cancer 4 years later, and there was no recurrence of PE in those 4 years.

Case 3
A 65-year-old man was admitted with adenocarcionoma (stage IB) of the left lung, and a left upper lobectomy was performed. Major preoperative complications were hypertrophic cardiomyopathy and atrial fibrillation. Subcutaneous heparin (5,000 U twice daily) was started for thromboembolic prophylaxis on the day of operation. Three hours after the operation sudden chest pain and dyspnea occurred. Arterial blood gas analysis demonstrated hypoxia, PO₂ of 45 Torr on 10 L face mask oxygen and PCO₂ of 41 Torr. The patient went into shock and resuscitation was performed. Echocardiography showed right ventricular dilatation and hypokinesis, more than 45 mm Hg of PAPm, and third-degree tricuspid regurgitation. The diagnosis was confirmed as PE. It took 30 minutes to confirm the diagnosis of PE after the first episode. A bolus infusion of 160 x 10⁴ IU of monteplase, r-tPA was given within 3 minutes. The patient’s respiratory state showed improvement 4 hours after the treatment. However, massive hemorrhage up to 1000 mL in 1 hour was observed, and thoracotomy was performed in an attempt to achieve hemostasis. Low–molecular weight heparin was administered for 3 days. Empyema subsequently occurred; however, the patient’s condition improved after drainage and injection of antibiotics. The patient was discharged on postoperative day 118. There was no recurrence of PE for 1.5 years.

	Comment

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Among the patients who receive lung resection for lung cancer, PE causes 15% to 20% of postoperative deaths [1, 2]. One report demonstrated that the mortality rate from PE after lung resection is 92.6% [2]. Several reports have suggested a low prevalence of PE and deep venous thrombosis in Asian individuals [3]. In Japan, perioperative thromboembolic prophylaxis is not so common in lung resection. Compression stockings, early mobilization, and subcutaneous heparin were used as prophylaxis for all high-risk patients (such as those with obesity or arrhythmia), following our treatment of case 2. However, PEAPR occurred in case 3 despite these measures. It is thought that PEALR will occur with a fixed probability because prediction and prevention are difficult [2, 4]. Early diagnosis and treatment are deemed to be essential for PEALR.

Direct evidence for PE can be provided by pulmonary angiography or a V/Q scan [5]. However, these diagnostic techniques cannot be performed promptly at the bedside. Echocardiography, either alone or combined with a clinical examination and electrocardiography, satisfactorily predicts acute pulmonary embolism with a sensitivity of 96% and a specificity of 83% [6]. Echocardiography is a convenient and safe imaging technique that may provide critical information on the physiologic effect of PE on right ventricular function [7]. This technique is suitable especially for severe PEALR, as in the cases presented here. Infused spiral CT might be useful when diagnosis cannot be confirmed by echocardiography. It has been reported that spiral CT is routinely used as an accurate method to diagnose PE in many institutions, and spiral CT could safely replace pulmonary angiography [8, 9]. In cases 1 and 3, spiral CT could not be performed because of the unstable status of each patient. In case 2, spiral CT was performed and the pulmonary emboli could be detected. We consider that echocardiography is an optimal initial selective procedure for confirming diagnosis of severe PEALR, and spiral CT is a useful second selective procedure, which should be used if possible.

Thrombolysis for postoperative PE may not be performed due to the risk of hemorrhage. However, recently a few reports of thrombolysis in which r-tPA was used to treat severe PEALR have also appeared [10, 11]. Thrombolysis seems not to be inferior to embolectomy, which is associated with a high mortality rate. In our cases, the patients might not have been saved without thrombolysis. In circumstances in which severe PE is refractory to conventional therapy (anticoagulation), is lobar or segmental in location, or is associated with hemodynamic instability, thrombolitic drugs may be indicated [12]. The second-generation r-tPA (alteplase) is fibrin selective. The half-life of this agent in plasma is very short (4 to 8 minutes); therefore, accelerated infusion is required. The third-generation r-tPA (reteplase, monteplase) has a prolonged half-life in plasma (14 to 23 minutes) and bolus infusion is suitable. However, the third-generation r-tPA also carries a high risk of hemorrhage [13]. In cases 1 and 2, although hemorrhage occurred after alteplase administration, it was controllable by blood transfusion. In case 3, the hemorrhage caused by the monteplase was not controllable and thoracotomy was performed. We thus consider that the second-generation r-tPA is the first-choice thrombolytic agent to manage severe PEALR.

We conclude that echocardiography was useful for confirming the diagnosis of PEALR, and thrombolysis with second-generation r-tPA may be a preferred first treatment choice in the case of severe PEALR.

	References

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