Incidental perioperative diagnosis of pulmonary thromboembolism and its successful management in a rural tertiary cancer care centre with limited resources - A case study : Indian Journal of Anaesthesia

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Incidental perioperative diagnosis of pulmonary thromboembolism and its successful management in a rural tertiary cancer care centre with limited resources - A case study

Sharma, Jagdeep; Walia, Harsimran Singh; Jaswal, Sofia; Mitra, Lalita Gouri

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Indian Journal of Anaesthesia 67(5):p 475-476, May 2023. | DOI: 10.4103/ija.ija_765_21
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Dear Editor,

We want to report a case where pulmonary thromboembolism (PTE) was incidentally found during the preoperative workup in a case of carcinoma (Ca) ovary who did not have any pulmonary symptoms. PTE is a substantial cause of morbidity and mortality in cancer patients.[1] Cancer patients have a four- to eight-fold higher risk of dying after an acute thrombotic event than patients without malignancy.[2] Anticoagulation is the cornerstone of medical therapy for both acute deep venous thrombosis (DVT) and PTE.[3] Rivaroxaban (Xarelto), an orally active, direct, reversible competitive inhibitor of factor Xa, is approved for the treatment of DVT and PTE.[4] This patient who was a diagnosed case of Ca ovary was posted for interval debulking surgery (IDS). On preanaesthetic testing, her contrast-enhanced computed tomography (CECT) thoracic scan showed an incidental finding of thrombus in the right descending pulmonary artery. She was asymptomatic and haemodynamically stable at that time. She was subsequently put on pharmacological anticoagulation. After the resolution of the PTE, she underwent surgery under general anaesthesia (GA) which was uneventful.

A 34-year-old female ASA physical status I (American Society of Anesthesiologists) presented with complaints of abdominal heaviness for 4 weeks. Her cancer antigen (CA) 125 levels were found to be 2905 units/ml and was diagnosed to have carcinoma of ovary stage III C. CECT thorax revealed PTE in the right descending pulmonary artery [Figure 1]. Given our resource limitation in a peripheral rural setup, she was counselled for referral to a higher tertiary care centre for treatment but she refused. After consultation with the primary team, a joint consensus was made to start pharmacological anticoagulation with the tablet Xarelto 15 mg BD. Alongside, her treatment for the primary disease was started. She was started on carboplatin and cisplatin-based chemotherapy. She received three cycles of chemotherapy. After three cycles of chemotherapy, a computed tomographic pulmonary angiogram (CTPA) was repeated which showed a resolving thrombus. It was planned to give one more cycle of chemotherapy and continue with the same treatment for PTE. On further review, after four cycles of chemotherapy, CTPA showed complete resolution of the PTE [Figure 2]. The patient was admitted 2 days before surgery. She underwent colour Doppler screening of all large vessels. There was no evidence of DVT. Preoperatively, the patient was put on low molecular weight heparin (LMWH) 1 mg/kg once daily. The patient got operated on under GA with thoracic epidural analgesia and routine DVT prophylaxis was maintained intraoperatively and postoperatively as per guidelines. Postoperative intensive care monitoring was done for 48 h. She stayed haemodynamically stable on further follow-up and was discharged from the ward on tablet rivaroxaban 10 mg OD and was asked to follow-up at 3 months.

Figure 1:
Pulmonary angiogram (Green arrow marking showing thrombus in right descending pulmonary artery)
Figure 2:
Pulmonary angiogram (Red arrow showing complete resolution of thrombus in right descending pulmonary artery after preoperative anticoagulation therapy)

PTE phenomenon in cancer patients is a known complication and invariably missed in asymptomatic patients. Careful clinical evaluation and imaging are a must. Discussion with the radiologist is recommended to avoid missing an important finding. Rivaroxaban-based anticoagulation therapy has shown to be quite successful in managing such patients. Rather than breaking an already overburdened higher tertiary care setup, strictly monitored preoperative treatment and optimization can help to get such high-risk surgeries successfully completed in resource-limited peripheral setups.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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3. Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, et al. Antithrombotic therapy for VTE disease:Antithrombotic therapy and Prevention of thrombosis, 9th ed:American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141:e419S–96S.
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