Prediction of Pulmonary Embolism Following Resection of Pulmonary Infarction: A Case Series.

PURPOSE: Pulmonary nodules suspected to be cancerous are rarely diagnosed as pulmonary infarction (PI). This study examined the clinical, radiological, and laboratory data in cases diagnosed with PI to determine their potential utility as preoperative diagnostic markers. We also assessed factors affecting the postoperative course. METHODS: A total of 603 cases of peripheral pulmonary nodules undiagnosed preoperatively were resected at Hokkaido University Hospital from 2012 to 2019. Of these, we reviewed cases with a postoperative diagnosis of PI. We investigated clinical symptoms, preoperative laboratory data, radiological characteristics, and postoperative complications. RESULTS: Four patients (0.7%) were diagnosed with PI. All patients had a smoking history. One patient received systemic steroid administration, and none had predisposing factors for thrombosis. One case showed chronologically increased nodule size. Three cases showed weak uptake of 18F-fluorodeoxyglucose. One patient with preoperative high D-dimer levels developed a massive pulmonary embolism (PE) in the postoperative chronic phase and was treated with anticoagulants. CONCLUSIONS: Preoperative diagnosis of PI is difficult, and we could not exclude lung cancer. However, if a patient diagnosed with PI has a high D-dimer level, we recommend postoperative physical examination for deep venous thrombosis. Prophylactic anticoagulation therapy should be considered to avoid fatal PE.

Vena Cava Filter Complications / Complicaciones del uso de filtros de la vena cava

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Infarction of the lingula following left upper lobe trisegmentectomy.

Anatomical segmentectomy has emerged as the procedure of choice for early-stage non-small-cell lung cancer, especially in the presence of poor cardiopulmonary reserve. The most common postoperative complications are pneumonia, persistent air leak, and rarely, vascular compromise of the remaining lobe. We report the case of a 74-year-old woman who underwent thoracotomy and left upper lobe trisegmentectomy for T1bN0Mo squamous cell carcinoma and subsequently developed infarction and hepatization of the remaining lingula. A completion left upper lobectomy was performed and the patient made a full recovery.

Extralobar pulmonary sequestration with hemorrhagic infarction in a child: preoperative imaging diagnosis and pathological correlation.

We describe a rare case of extralobar pulmonary sequestration with hemorrhagic infarction in a 10-year-old boy who presented with acute abdominal pain and fever. In our case, internal branching linear architecture, lack of enhancement in the peripheral portion of the lesion with internal hemorrhage, and vascular pedicle were well visualized on preoperative magnetic resonance imaging that led to successful preoperative diagnosis of extralobar pulmonary sequestration with hemorrhagic infarction probably due to torsion.

Strangulation of aberrant artery in extralobar pulmonary sequestration on video imaging.

We report a case of an 18-year old female patient with symptomatic extralobar pulmonary sequestration. The initial symptom was sudden-onset right lateral abdominal pain. Enhanced computed tomography showed a 5 cm in diameter, spindle-shaped mass located in the costophrenic sinus with no aberrant artery. Exploratory thoracoscopy showed a haemorrhagic mass caused by strangulation of an aberrant vessel originating from the intercostal artery. Pathological findings revealed pulmonary sequestration with haemorrhagic infarction. The strangulated aberrant artery was clearly demonstrated by video imaging.

Pulmonary infarction complicating thoracoscopic removal of congenital foregut cyst.

A 42-year old woman presented with rheumatoid arthritis, dyspnoea and a congenital foregut cyst referred by a rheumatologist for thoracic surgery. The cyst was removed by video-assisted thoracoscopic surgery. The patient developed acute haemoptysis in the immediate postoperative period, which necessitated pulmonary resection due to infracted right lower lobe. This case report highlights the complication related to an unusual anatomy of a congenital foregut cyst.

Unrepaired tetralogy of fallot with major aortopulmonary collateral arteries in an adult patient.

Tetralogy of Fallot is characterized by a ventricular septal defect, a large, overriding aorta, subpulmonic stenosis, and right ventricular hypertrophy. These lesions can be associated with abnormal development of the pulmonary vasculature. This can include peripheral pulmonic stenosis, discontinuous pulmonary arteries, anomalous pulmonary venous return, and the development of aortopulmonary collateral vessels. Aortopulmonary collateral vessels develop to supply underperfused areas of the pulmonary bed and pose a unique and challenging problem at the time of surgical repair, which involves closure of the ventricular septal defect, relief of right ventricular outflow tract obstruction, maintenance of pulmonary valve competency when possible, and establishment of laminar pulmonary blood flow to all segments of the pulmonary bed. We describe a 36-year-old man with unrepaired tetralogy of Fallot with distinctive aortopulmonary collaterals, who underwent complete surgical repair with good outcome. Two-dimensional echocardiogram, cardiac magnetic resonance imaging, and cardiac catheterization each provided vital details allowing a stepwise approach to defining his unique anatomy for surgical correction.

To avoid operating on pseudo tumoral pulmonary infarctions mimicking lung cancer.

Pulmonary infarction usually appears as a hump-shaped triangular opacity with its base applied to a pleural surface. In some cases, pulmonary infarctions may appear as a pseudo tumoral opacity mimicking lung cancer. Thoracotomy could be prevented by repeating CT scan in properly selected patients.

Pulmonary infarction after repair of type B aortic dissection.

Lung infarction after intrathoracic surgery is a life-threatening complication that needs urgent intervention. Although the exact etiology is not known, pulmonary infarction may be suspected for patients presenting with consolidation of the lung after intrathoracic surgery. We report a very rare case of pulmonary infarction after successful surgical treatment of a type B aortic dissection. The pulmonary infarction was treated by intrapericardial pneumonectomy. This article discusses possible etiology and management of such patients. A high index of clinical suspicion and timely investigations may allow early detection of this unusual event and avoid fatal outcomes.

Infarction of an extralobar pulmonary sequestration in a young child: diagnosis and excision by video-assisted thoracoscopy.

A 4-year-old male presented with abdominal pain. A computed tomography scan of the abdomen was negative, but a pleural effusion and mass was noted in the lower left thorax. Video-assisted thoracoscopic surgery revealed the mass to be a rare case of extralobar pulmonary sequestration that had undergone infarction.

Transplant pneumonectomy in a patient with an acutely thrombosed allograft.

Transplant pneumonectomy is most commonly performed in the setting of retransplantation and is rare for other indications. We present a case of an elderly woman who is 3 years postoperative left, single lung transplantation with a history of emphysema that developed extensive infarction of her transplanted lung secondary to thromboembolic disease. She required an allograft pneumonectomy as treatment for this and was eventually discharged on bi-level nasal positive pressure at night and 3 L nasal cannula oxygen during the day.

Complete lobar torsion simulating hemorrhagic shock after left upper lobectomy.

Lung torsion is a rare but serious complication after thoracic operations. We describe an unusual case of left lobar torsion after video-assisted thoracoscopic upper lobectomy. The profound symptom was impending hemorrhagic shock, which masqueraded as postoperative bleeding. The differentials between these 2 entities and treatment options for lung torsion are discussed.

Extralobar pulmonary sequestration presenting as hemothorax.

Symptomatic extralobar pulmonary sequestration (EPS) is extremely rare. Herein, we report two male patients (3 and 16 years of age) with EPS presenting as hemothorax. Thoracotomic resections of the sequestrated lungs were uneventful. Pathologic examinations revealed hemothorax caused by circulatory disorders within the EPSs.

The surgical pathology of pulmonary infarcts: diagnostic confusion with granulomatous disease, vasculitis, and neoplasia.

Twenty-three cases of surgically resected pulmonary infarcts sent in consultation were reviewed to evaluate their morphology and to assess reasons for consultation. The morphology of these infarcts demonstrated that only a minority had the classical triangular shape at low magnification (26%) whereas the majority were either spherical (17%) or had a geographic pattern of necrosis (35%). The margin of the infarcted tissue often had a pseudogranulomatous appearance due to palisaded histiocytes, foam cells, or perpendicularly oriented proliferations of fibroblasts and myofibroblasts (74%) and occasional cholesterol- and hemosiderin-laden giant cells. Basophilic granular karyorrhectic necrosis was seen focally (52%) as was vascular inflammation (56%) raising the differential diagnosis of Wegener's granulomatosis or infectious granulomas. These nonclassical features combined with a low incidence of clinical hemoptysis, chest pain and pleurisy, and a primary radiographic diagnosis of 'nodule r/o malignancy' highlight the need to consider thromboembolic pulmonary infarcts in the differential diagnosis of necrotic lung nodules with a histiocytic and fibroproliferative rim.

Bilateral pneumothorax, lung cavitations, and pleural empyema in a cocaine addict.

A case of bilateral pneumothorax, lung cavitations, and pleural empyema in a cocaine user is described. The patient was treated by left tube thoracostomy and right lower lobectomy. The postoperative course was uneventful. Six months later, the patient remains asymptomatic. The pathology examination of the specimen revealed infected bronchiectasis, interstitial desquamative pneumonia, diffuse alveolar damage, subsegmental arterial thrombosis, and consequent areas of pulmonary infarction.

Pulmonary infarction associated with bronchogenic carcinoma.

Computed tomography findings of pathologically proven pulmonary infarction associated with bronchogenic carcinoma are reported for two patients. In one case, the infarction was demonstrated as a well-defined pleura-based large nodule in the peripheral portion of the same lobe of the tumor. The nodule had a smooth, convex border and a linear strand from the apex of the lesion toward the hilum. The obstruction of the subsegmental pulmonary artery due to tumor invasion was considered the cause of pulmonary infarction. In the second case, the infarction was demonstrated as a rapidly appeared, pleura-based consolidation in the same lobe of the tumor with a blurred border. Obstruction of the pulmonary vein by a tumor might have played an important role in the development of the pulmonary infarction in association with a large pulmonary artery obstruction. We conclude that pulmonary infarction should be considered as a differential diagnosis when peripheral pulmonary nodules or masses are located in the same lobe as the primary cancer.