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Post-Lobectomy Pulmonary Artery Stump Thrombosis: How Dangerous Is It?

Pulmonary embolism (PE) can present with a wide spectrum of clinical symptoms that can overlap considerably with other cardiovascular diseases. To avoid PE related morbidity and mortality, it is vital to identify this disease accurately and in a timely fashion. Several clinical criteria have been developed to standardize the diagnostic approach for patients with suspected PE. Computed tomographic pulmonary angiogram has significantly improved the detection of pulmonary embolism and is considered the imaging modality of choice to diagnose this disease. However, there are several potential pitfalls associated with this modality which can make diagnosis of PE challenging. In this review, we will discuss various pitfalls routinely encountered in the diagnostic work up of patients with suspected PE, approaches to mitigate these pitfalls and incidental pulmonary embolism.

The ACR Incidental Findings Committee presents recommendations for managing incidentally detected mediastinal and cardiovascular findings found on CT. The Chest Subcommittee was composed of thoracic radiologists who developed the provided guidance. These recommendations represent a combination of current published evidence and expert opinion and were finalized by informal iterative consensus. The recommendations address the most commonly encountered mediastinal and cardiovascular incidental findings and are not intended to be a comprehensive review of all incidental findings associated with these compartments. Our goal is to improve the quality of care by providing guidance on how to manage incidentally detected thoracic findings.

To determine the prevalence of arterial stump thrombosis (AST) after pulmonary resection surgery for lung cancer and to describe subsequent radiological follow-up and treatment.

Observational, descriptive study of AST detected by computerized tomography angiography (CT) using intravenous contrast. Clinical and radiological variables were compared and a survival analysis using Kaplan–Meier curves was performed after dividing patients into 3 groups: patients with AST, patients with pulmonary embolism (PE), and patients without AST or PE.

Nine cases of AST were detected after a total of 473 surgeries (1.9%), 6 of them in right-sided surgeries (67% of AST cases). Median time to detection after surgery was 11.3 months (interquartile range 2.7–42.2 months), and range 67.5 months (1.4–69.0 months). Statistically significant differences were found only in the number of CTs performed in AST patients compared to those without AST or PE, and in tumor recurrence in PE patients compared to the other 2 groups. No differences were found in baseline or oncological characteristics, nor in the survival analysis.

In this series, AST prevalence was low and tended to occur in right-sided surgeries. Detection over time was variable, and unrelated to risk factors previous to surgery, histopathology, and tumor stage or recurrence. AST had no impact on patient survival.

Determinar la prevalencia de trombosis de muñón arterial (TMA) en cirugías de resección pulmonar por carcinoma broncogénico, y describir su evolución radiológica y tratamiento.

Estudio observacional y retrospectivo de casos de TMA detectados mediante angiotomografías con contraste intravenoso (TAC). La comparación de variables clínicas, radiológicas, y el análisis de supervivencia mediante curvas de Kaplan-Meier, se realizó planteando 3 grupos: pacientes con TMA, pacientes con tromboembolismo pulmonar (TEP) y pacientes sin TMA ni TEP.

Se detectaron 9 TMA en 473 cirugías (1,9%), 6 de ellas en el lado derecho (67% de las TMA), con una mediana de tiempo de detección desde la cirugía de 11,3 meses (rango intercuartílico 2,7-42,2 meses). Salvo el número de TAC en pacientes con TMA comparados con el grupo sin TEP ni TMA, y la recidiva tumoral en pacientes con TEP en comparación con los restantes 2 grupos, no se encontraron diferencias estadísticamente significativas en las características basales ni en las oncológicas. Igualmente no se encontraron diferencias en el análisis de supervivencia.

En nuestra serie, la TMA fue una patología infrecuente que tendió a localizarse en las cirugías del lado derecho, y cuya detección a lo largo del tiempo fue variable. No se asoció a factores de riesgo previos a la cirugía ni tuvo predisposición en relación con la estirpe histológica, estadificación oncológica o recidiva tumoral.

To determine the prevalence of delayed postoperative venous thromboembolism (VTE) in patients undergoing oncologic lung resections, despite adherence to current in-hospital VTE prophylaxis guidelines.

Patients undergoing lung resection for malignancy in 2 tertiary-care centers were recruited between June 2013 and December 2014. All patients received guideline-based VTE prophylaxis until hospital discharge. Patients underwent computed tomography chest angiography with pulmonary embolism (PE) protocol and bilateral lower extremity venous Doppler ultrasonography at 30 ± 5 days after surgery to determine the incidence of postoperative VTE. Univariate analysis was used to compare the VTE and non-VTE groups.

A total of 157 patients were included, 45.9% were men with a mean age of 66.7 years. VTE prevalence was 12.1% with a total of 19 VTE events, including 14 PEs (8.9%), 3 deep venous thromboses (DVTs) (1.9%), 1 combined PE/DVT, and 1 massive left atrial thrombus originating from the pulmonary vein stump after pulmonary lobectomy. PE events occurred in the operated lung 64% of the time and 4 patients (21.1%) were symptomatic at diagnosis. The 30-day mortality rate of VTE events was 5.2%, with 1 patient who died secondary to massive in situ ipsilateral PE following readmission to the hospital. Univariate analysis did not demonstrate significant differences between the VTE and non-VTE populations with regard to baseline characteristics.

Despite adherence to in-hospital standard prophylaxis guidelines, VTE events are frequent, often asymptomatic, and with associated significant morbidity and mortality. More research into the potential role of predischarge screening and extended prophylaxis is warranted.

We present a 67 year old male patient who underwent VATS right upper lobectomy with en bloc chest wall resection and right lower lobe superior segmentectomy for atypical Ewing Sarcoma. Serial chest CT scan done more than two years after the initial resection showed a new filling defect in the right upper pulmonary artery stump. A repeat chest CT scan after three months of oral anticoagulation showed complete resolution of the filling defect.