Invited Commentary

Abstract

Dr Ohtaka and his colleagues [1Ohtaka K. Hida Y. Kaga K. et al.Thrombosis in the pulmonary vein stump after left upper lobectomy as a possible cause of cerebral infarction.Ann Thorac Surg. 2013; 95: 1924-1929Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar] have documented a study that is both insightful and provocative. Thrombosis in the stump of the superior pulmonary vein after left upper lobectomy introducing a potential cause of embolic morbidity to vital organs, including the brain, heart, kidney, and intestines, is not widely recognized. It is doubtful that many thoracic surgeons have appreciated the association of a postlobectomy systemic embolus with a thrombus from the pulmonary vein stump. Reflecting on a career in academic thoracic surgery, I do not recall this complication being discussed in our morbidity and mortality conferences. Using contrast-enhanced chest computed tomography (CT), retrospectively interpreted to check for thrombus in the pulmonary vein stump, the authors have now effectively clarified the frequency, risk factors, and probable cause of this complication: using three-dimensional CT images, the left superior pulmonary vein stump was determined to be significantly longer than the left inferior, right superior, and right inferior vein stumps. The rationale that length contributed to thrombus formation is compelling. The true incidence of thrombus in the stump of the left superior pulmonary vein is surely underestimated. The authors detected a thrombus in the pulmonary vein stump in 3.6% of all patients and in 13.5% of left upper lobectomy patients. It is reasonable to assume that the systematic application of postresection contrast medium–enhanced chest CT, at an early interval, will significantly increase the frequency of detection. Finally, univariant analyses revealed that left upper lobectomy and operative time were notable risk factors for the presence of thrombus. Importantly, the authors recommend routine contrast medium–enhanced CT of the chest for all patients after left upper lobectomy to help identify patients with a high risk for thromboembolism. Their study represents a significant contribution to our appreciation and understanding of the inherent pathology of postresection pulmonary vein thrombus and provides a specific clinical implementation: the institution of postoperative anticoagulant therapy. The routine election of intrapericardial division of the left superior pulmonary in an effort to shorten the stump would be challenging, problematic, and premature at this time. However, a multicenter clinical study founded on the use of contrast medium–enhanced chest CT would be timely. Thrombosis in the Pulmonary Vein Stump After Left Upper Lobectomy as a Possible Cause of Cerebral InfarctionThe Annals of Thoracic SurgeryVol. 95Issue 6PreviewThrombus in the stump of the pulmonary vein (PV) is not a well-known complication after lung resection, and it has the potential to cause embolism to vital organs. To clarify the frequency, risk factors, and cause of this complication, a retrospective clinical study of patients who underwent lobectomy was performed. Full-Text PDF