Thromboembolic events are relatively common in patients undergoing major thoracic surgery and are associated with high mortality. The frequency of these events may be related to the presence of pre-operative venous thrombotic disease, which is present in a relatively high proportion of patients with malignancy. We hypothesized that routine venous doppler studies would identify patients at high risk for pulmonary embolus (PE) and lead to interventions which would improve surgical outcomes.
From 1998 until 2003, routine lower extremity venous studies were performed in all patients (344) prior to undergoing major thoracic surgery. Positive studies led to IVC filter placement or fractionated heparin use peri-operatively. Negative study patients received routine post-operative prophylaxis with subcutaneous unfractionated heparin and sequential compression devices. Post-operatively, suspected DVT and/or PE were evaluated with standard imaging studies and patients with a positive scan for pulmonary embolus were anti-coagulated. The pre-operative study results, management, and surgical outcomes were reviewed utilizing our thoracic surgical database.
Of the 344 patients in the study group, 338 (98.3%) had negative pre-operative venous studies. 4 (1.2%) of these patients had pulmonary emboli demonstrated post-operatively by spiral CT. One patient (25%) in this subset died. Of the 6 patients (1.7%) with positive doppler studies pre-operatively, 4 underwent placement of an IVC filter and 2 were started on fractionated heparin therapy pre-operatively. None of these patients had indication of a post-operative pulmonary embolism. The overall incidence of pulmonary embolism was 4/344 (1.2%).CONCLUSIONS: Unsuspected DVT may be diagnosed in approximately 2% of patients presenting for major thoracic resection pre-operatively. Recognition and treatment may decrease risk for thromboembolic events in the thoracic surgical patient.
An aggressive peri-operative management strategy appears to limit the development of PE in these patients and warrants further study.
B.J. Tempesta, None.