A Case of Right Pulmonary Vein Thrombosis after Left Upper Lobectomy-Juniper publishers
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Introduction
Pulmonary vein thrombosis (PVT) is a challenging and
life threatening medical condition which requires early diagnosis and
appropriate management. PVT presents with nonspecific symptoms of chest
pain, dyspnea, cough or hemoptysis and hence may mimic other syndromes,
such as acute coronary syndrome or pulmonary embolism at initial
presentation. PVT can have detrimental consequences, including right
heart failure, peripheral embolism, and stroke. Common risk factors
include recent history of lung transplantation, lobectomy especially
left upper lung lobe resection, and malignancy. Whereas, less common
risk factors include atrial fibrillation, chest wall trauma, sickle cell
disease. Management of PVT is dependent upon the underlying risk
factors and potential etiology, but remains a medical emergency. While
PVT is usually seen in left pulmonary vein, we report a rare case of
right sided PVT in a 49-year-old male diagnosed with right pulmonary
vein thrombosis twelve days after left upper lung lobe resection.
A 49-year-old gentleman with a history of type 2
diabetes mellitus, cirrhosis secondary to chronic hepatitis B, stage T2a
squamous cell lung cancer undergoing left upper lobe lung lobectomy
through video assisted thoracoscopic surgery (VATS) presented to the
emergency room twelve days after the procedure with complaint of acute
onset chest pain. The pain was pressure like, substernal, radiating to
left arm and neck, 8/10 in intensity, non-pleuritic, non-positional, was
noted to start at rest with no alleviating factors. Associated features
included a mild headache, lightheadedness and dyspnea. Patient denied
any trauma, prior history of similar complaints, diaphoresis,
palpitations, orthopnea, paroxysmal nocturnal dyspnea, leg swelling,
recent upper respiratory infection, fever, chills or any other medical
conditions. In particular, the patient had no prior history of
thromboembolic disease, atrial fibrillation or sickle cell disease. He
was an active smoker with twenty pack year smoking history. On
presentation to the hospital, he was hemodynamically stable with no
signs of tachycardia or respiratory distress.
Initial work showed negative troponin (less than
0.03ng/ ml), EKG revealed normal sinus rhythm with no signs ST-T wave
changes or Q waves on the EKG. A CT angiogram of the chest was performed
which revealed 1 cm thrombus in the stump of right pulmonary vein.
Transthoracic echocardiography was then performed but did not reveal any
signs of wall motion abnormality, right heart failure, tricuspid
regurgitation or atrial thrombus. Patient was started on anticoagulation
with Enoxaparin considering his history of underlying malignancy. His
chest pain improved, with pain control and he was discharged with close
follow up care with his oncologist.
Patients undergoing partial or complete lung lobe
resection are prone to develop pulmonary vein thrombosis. Left superior
pulmonary vein is the most common site of thrombosis owing to its long
course and propensity of stasis; although patient reported in this case
was found to have a clot in the right pulmonary vein stump. Following
lobectomy, the risk of pulmonary vein thrombosis is 3.6% which increases
to 13.6% in those undergoing left upper lobectomy [1,2]. In 2 studies on PVT, 7 out of 193 and 5 out of 151 patients undergoing lobectomy developed left PVT [3].
In the case reported here, the patient
developed right pulmonary vein thrombosis after left upper lobectomy.
Right PVT after undergoing left upper lobectomy has not yet been
reported in the literature. Management of PVT mainly depends upon the
underlying etiology. In patients with PVT secondary to cancer,
anticoagulation along with underlying management of malignancy is done
as in the patient reported by the authors.
There is insufficient evidence to suggest the routine
use of post-procedure prophylactic anticoagulation or routine imaging
and echocardiography in patients undergoing lung transplant or
lobectomy. Considering that the symptoms of PVT are often subtle and may
have lethal consequences such as massive hemoptysis, cerebral
infraction, renal infarction or systemic embolization [1,4];
routine diagnostic testing in high risk patients might not be
unreasonable especially in patients with left upper lobectomy, though
its utilization requires further evaluation. CT angiography of the chest
is required to diagnose pulmonary vein thrombosis thrombosis along with
a high level of suspicion in at risk patients. Anticoagulation is
indicated in patients with PVT[4].
Further studies focusing on PVT may help us understand the disease in
detail, optimize the management and prevent the high morbidity and
mortality associated with this condition.
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