Routine surveillance for diagnosis of venous thromboembolism after pleurectomy for malignant pleural mesothelioma

Abstract

Objective: The purpose of this study was to determine the incidence of venous thromboembolism and utility of a routine surveillance program in patients undergoing surgery for mesothelioma.

Methods: Patients undergoing pleurectomy from May 2016 to August 2018 were included. A standardized surveillance program to look for venous thromboembolism in this group included noninvasive studies every 7 days postoperatively or earlier if symptomatic. All patients received external pneumatic compression sleeves in addition to prophylactic heparin. If deep vein thrombosis or pulmonary embolus was discovered, heparin drip was initiated until conversion to therapeutic anticoagulation.

Results: A total of 100 patients underwent pleurectomy for mesothelioma. Seven patients were found to have preoperative deep vein thrombosis, and as such only 93 patients were included for analysis. The median age of patients at surgery was 71 years (30-85 years). During the study, 30 patients (32%) developed evidence of thrombosis; 20 patients (22%) developed only deep vein thrombosis without embolism, 3 patients (3%) developed only pulmonary embolism, and 7 patients (7%) developed both deep vein thrombosis and pulmonary embolus. Of the 27 patients who developed deep vein thrombosis, 9 (33%) were asymptomatic at the time of diagnosis, and none of these developed a pulmonary embolus or other bleeding complications. There were 2 (2%) events of major postoperative bleeding related to therapeutic anticoagulation.

Conclusions: The incidence of venous thromboembolism is high (32%) among patients undergoing surveillance after pleurectomy for mesothelioma. Up to 33% of patients with deep vein thrombosis are asymptomatic at the time of diagnosis, and the incidence of complications related to anticoagulation is low. Routine surveillance may be useful to diagnose and treat deep vein thrombosis before it progresses to symptomatic or fatal pulmonary embolus.

Keywords: mesothelioma; morbidity; pleurectomy; postoperative care; pulmonary embolism; surveillance; thoracic surgery; thromboprophylaxis; venous thromboembolism.

FIGURE 1.

Postoperative protocol for surveillance and treatment of DVT. All patients received pneumatic compression sleeves intraoperatively and postoperatively, and chemical thromboprophylaxis every 8 hours after surgery. During follow-up, if patients developed symptoms of DVTs (pain, edema, or change in temperature in the extremities), they underwent LENIS ± UENIS. If they developed hypoxia, chest pain, or increased work of breathing, they underwent a CT-PA to rule out PE. If patients remained asymptomatic, they were followed every 7 days with repeated LENIS ± UENIS. If VTE was discovered, a continuous heparin drip was initiated until patients were transitioned to a long-term therapeutic anticoagulation regimen with low-molecular-weight heparin, vitamin K antagonists, or direct oral anticoagulants that were continued for the first 3 months postoperatively. POD, Postoperative day; DVT, deep vein thrombosis; PE, pulmonary embolism; CP, chest pain; WOB, work of breathing; CT-PA, computed tomography pulmonary angiography; V/Q scan, ventilation perfusion scan; LMWH, low-molecular-weight heparin; VKA, vitamin K antagonist; DOA, direct oral anticoagulant.

FIGURE 2.

Time to postoperative diagnosis of symptomatic and asymptomatic upper- and lower-extremity DVTs. The majority of patients were diagnosed on postoperative day 7, ranging from 1 to 14 days. Nine of all DVTs (33%) occurred before day 7, which included half (6/12) of the upper-extremity DVTs. Only 3 patients with lower-extremity DVTs were symptomatic before day 7. There were 6 symptomatic patients who would have been screened on postoperative day 7 regardless of symptoms. Only 1 symptomatic patient, who would have been screened by the protocol, had a negative study on postoperative day 7. DVT, Deep vein thrombosis.

FIGURE 3.

We implemented an aggressive surveillance protocol for VTE in 93 patients undergoing pleurectomy for mesothelioma. Patients received mechanical and chemoprophylaxis perioperatively and were followed every 7 days postoperatively, or earlier if symptomatic, with upper- ± lower-extremity ultrasounds. CT-PA was used to investigate patients who developed signs or symptoms suggestive of PE. Twenty-seven patients developed DVT, 9 of whom were asymptomatic; 10 patients developed PE. Therapeutic anticoagulation was initiated in these patients. There was only a 2% incidence of bleeding events related to therapeutic anticoagulation. D/C, Discharge; CTA, computed tomography angiogram; VTE, venous thromboembolism.