Perioperative Management of Case of Gynecological Malignancy with Bilateral Deep Venous Thrombosis of Lower Limbs Along with Pulmonary Embolism

doi:10.4236/ojanes.2011.11001

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Open Journal of Anesthesiology, 2011, 1, 1-4

doi:10.4236/ojanes.2011.11001 Published Online October 2011 (http://www.SciRP.org/journal/ojanes)

Perioperative Management of Case of

Gynecological Malignancy with Bilateral Deep

Venous Thrombosis of Lower Limbs Along with

Pulmonary Embolism

Mahesh K umar Ar o ra 1, Rakesh Garg2

1Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi, India; 2Department of An-

aesthesio logy and Int ensive Care, All Ind i a Institute of Medi cal Sciences, New Delh i , India.

Email: [email protected]

Received S eptember 5th, 2011; revised October 10th, 2011; accepted Oct ober 18th, 20 11.

ABSTRACT

We describe the anaesthetic management of 45 year female patient with pre-existing deep venous thrombosis (DVT)

and pulmonary embolism (PE) who was subsequently scheduled for a laparotomy. Before planning the surgical proce-

dures, adequate anticoagulation must be achieved to prevent further complications of DVT, thromboembolism, and

pulmonary embolism in particular. The risk of stopping the anticoagulation prior to surgery must be considered and

adequately discussed with the patient and surgeons. The anaesthetic plan must be selected keeping in mind the coagula-

tion status and the need of anticoagulation in the postoperative period.

Keywords: Deep Venous Thrombosis, Pulmonary Embolism, Anaesthesia, Oncology Surgery

1. Introduction

Venous thromboembolism (VTE), in the form of deep

vein thrombosis (DVT) or pulmonary embolus (PE) is

one of the concerns mostly in the postoperative period

[1]. The presence of preexisting DVT and PE in patient

scheduled for oncologic surgery carries a challenge for

anaesthesiologist. As many as 50% of patients who have

a proximal DVT develop a PE, and among those who

have a clinically significant PE, 70% have evidence of

DVT [1]. The underlying etiology for prothrombotic

tendency of malignancies is the impact that malignant

disease has on the Virchow’s triad of stasis, intimal

injury, and hypercoagulability [1]. Patients who have

mali gnancy have a si x fold i ncrease d risk o f VTE, and it

is estimated that the incidence of VTE in the cancer

population is 1 in 200 patients [1-4]. Patients who have

brain tumors and adenocarcinoma of the ovaries,

pancreas, stomach, colon, lung, prostate, and kidney have

a higher risk of VTE than those who have other

mali gnanc ie s [4-6 ]. With o ther r isk fac tor s equa l, sur ger y

for malignant disease results in a 2- to 3-fold increase in

thromboembolism compared with surgery for nonmali-

gnant conditions [1,5]. Among the all malignancies, the

gynecologic oncology patients have the highest risk of

venous thromboembolism [6]. Though postoperative

DVT and PE usually remains a concern and various

measures are mentioned in literature for its prevention

but the presence of DVT and PE preoperatively in a

patient scheduled for oncology surgery and its periopera-

tive management has not been much described in litera-

ture.

We present a case of bilateral lower limb DVT with

pulmonary embolus scheduled for laparotomy for gynae-

cology malignancy.

2. Case History

A 45-year-old female weighing 72 kg was scheduled for

laparotomy for the excision of abdominoplevic mass and

carcinoma ovary. On reviewing the history, patient had

fever for last 3 weeks, pain and swelling in both lower

limbs since last 10 days. The swelling appeared in the

foot and gradually involved the whole of the both lower

limbs in 3 - 4 days. Doppler examination of lower limb

revealed bilateral deep venous thrombosis (DVT). She

was started on inj enoxaparin 0.6 mL once daily since 4

days. Two days back she complained of breathlessness.

Perioperative Management of Case of Gynecological Malignancy with Bilateral Deep Venous Thrombosis of Lower

2 Limbs Along with Pulmonary Embolism

She was referred to our institute. On examination, her

pulse rate was 92 beats per min, blood pressure of 108/82

mmHg and respiratory rate was 22/min. Investigations

revealed haemoglobin 8.4 g/dL. Her D-Dimer by quanti-

tative Immunoturbidimetry method was >20 µgFibEq/mL

(normal < 0.5). Computed tomographic angiogram revea-

led thrombus in left descending pulmonary artery with

extension into left lower lobe, infrarenal inferior vena

cavae (IVC), bilateral common iliac vein, external iliac

vein, common femoral vein, saphenofemoral vein, popli-

teal veins along with hepatomegaly and abdominopelvic

mass encasing IVC. Haematologists opinion was taken

and dose of inj enoxaparin was increased to 80 mg sc

twice a day. The risk associated with the surgery and

written infor med conse nt was t aken. I VC filt er was p laced

in the infrarenal IVC via right transjugular approach.

The dose of enoxaparin was omitted on the morning of

surgery and patient was premedicated with oral diazepam

(10 mg) and pantaprazole (40 mg). Her platelet co unts were

180 × 103/mm3, prothrombin time—13:17 (control:test),

aPTT—2 8:30 (c ontrol:test) . In the opera ting roo m, routi ne

monitors were attached. Anaesthesia was induced with

intravenous fentanyl (150 µg), propofol (140 mg) and

lungs ventilated with oxygen in isoflurane (2%). After

achieving neuromuscular blockade with atracurium (40

mg), trachea was intubated with endotracheal tube. Left

radial artery was cannulated. Ultrasound guided right IJV

was cannulated using triple lumen central venous

catheter (CVC). Anaesthesia was maintained with isoflu-

rane in oxygen and air along with infusions of fentanyl

(50 µg/hr) and atracurium (20 mg/hr). Intraoperatively

tumor mass was excised and blood loss was 1500 mL,

which was replaced with 1500 mL of voluven initially

and then with 4 units of packed RBC (after removal of

tumor mass) . Pa tient re maine d hae modyna micall y stab le.

After completion of surgery, residual neuromuscular

blockade was reversed and trachea was extubated. She

was shifter to ICU for observation. Inj enoxaparin was

restarted 6 hours later. Analgesia was provided with

intravenous morphine infusion (1 mg/hr). She remained

stable and shifted to ward on 2nd day and discharged

home on the 8th day uneventfully.

3. Discussion

A number of issues related to pre-existing DVT prior to

gynecologic surgery deserve further clarification, the

optimal duration of pharmacological treatment, and the

optimal duration/modality of prophylaxis to prevent

thromboembolism in these high-risk cancer patients. The

other concern was bleeding during the perioperative

period due to anticoagulation for treatment of DVT and

pro-coagulation associated with the malignancy. The

pathogenesis of perioperative PE is assumed to be based

on a hypercoagulable state that may occur during major

surgery and that may extend into the postoperative period

[7]. Massive PE is associated with haemodynamic

instability and high mortality (30%). So, the treatment

options include anticoagulation, thrombolysis, placement

of a vena caval filter and pulmonary embolectomy [8].

Further the thrombus extension occurs during the im-

mobility in the perioperative period. This chance of

thrombus extension and risk of further pulmonary

embolus in our patient having bilateral DVT prompted us

to insert IVC filter prophylactically. Placement of IVC

filter prior to urgent surgery in a patie nt with a DVT has

also been described earlier [5,9]. The use of vena caval

filters has expanded to include primary venous throm-

boembolism (VTE) prophylaxis in special patient popu-

lations such as major trauma patients, major surgery

patients, advanced malignancy, and neurological or neu-

rosurgical patients with paralysis or prolonged immo-

bilization. We were apprehensive about the dislodgement

of IVC filter intraoperatively as site of its placement was

as same as surgical site. Surgeons were careful enough to

avoid compression or distortion of the IVC.

We started the low molecular weig ht heparin (LMWH)

—enoxaparin in our patient as LMWH like enoxaparin,

dalteparin, tinzaparin are considered the initial treatment

of choice, and may be preferable for patients with cancer

[1,5,10,11]. LMWHs are as effective as unfractionated

heparin (UFH) for reducing DVT recurrence, thrombus

extension and risk of death due to PE. For acute VTE

treatment, limitations of UFH include an unpredictable

anticoagulant response with the need for frequent

monitoring, a relatively narrow therapeutic window, and

the potential for severe toxicity, especially heparin-

induced thrombocytopenia (HIT) [12]. Importantly, trials

of UFH in PE show that many patients are subtherapeutic

or supratherapeutic while receiving UFH. In contrast,

LMWHs provide a more targeted approach to procoag-

ulant complex inhibition, predictable pharmacokinetic

and pharmacodynamic characteristics, and no need for

anticoagulant monitoring [12]. LMWH is the preferred

approach for the initial 5 to 10 days of anticoagulant

treatment of the cancer patient with established VTE

[2,13]. LMWHs are typically given subcutaneous in a

standard weight-based dose (eg, enoxaparin 1.5 mg/kg sc

once/day or 1 mg/kg sc twice a day or dalteparin 200

units/kg sc once a day). LMWH is considered to be

effective for DVT management in patients with cancer.

Thrombolytic therapy of DVT is generally reserved for

patients who have limb-threatening thrombosis, symp-

toms for less than a week and low risk of bleeding. Abso-

lute indications for thrombolytic therapy are a massive

Perioperative Management of Case of Gynecological Malignancy with Bilateral Deep Venous Thrombosis of Lower 3

Limbs Along with Pulmonary Embolism

iliofemoral DVT, especially in the case of phlegmasia

cerulea dolens, and a pulmonary embolism that is accom-

panied by hemodynamic instability. Our patient had a

history of DVT for 3 weeks and was stable hemody-

namically, so we avoided thrombolysis when the patient

presented to us and started her on enpxaparin. Never-

theless, thrombolytics have not been shown to decrease

mor t a l i t y in t hese pat ients.

The quantitative rapid ELISA, with a sensitivity of

95%, in general has shown the most clinically useful

values among the various D-dimer assays [13]. An

abnormal D-dimer indicates the need for further testing if

PE is suspected. The imaging modalities includes con-

trast enhanced multidetector computerized tomography

pulmonary angiography (CT angiography) and CT

venous phase imaging of the proximal leg veins (CT

venography). The gold standard for the diagnosis of PE

is Contrast pulmonary arteriography. In the presence of

breathlessness, we suspected PE and since D-Dimers

were raised, we confirmed the presence of PE with CT

angiography.

The patients with PE, the gas-exchange abnormalities

related to various variables including the size and

character of the embolic material, the extent of the

occlusion, the underlying cardiopulmonary status and the

length of time since embolization [13]. Hypoxemia has

been attributed to an increase in alveolar dead space,

right-to-left shunting, ventilation/perfusion inequality, and

a low mixed venous oxygen level. Classic triad of PE

dyspnea, chest pain and hemoptysis is seen in 20% of

patients. Our patient had only breathlessness and preope-

rative ABG was within normal limits. This may probably

be because of thromb osis only in one segment of l ung.

So, we conclude, great vigilance is required in the

management of a patient with bilateral lower limb deep

venous thrombosis with pulmonary embolism. Measures

for prevention of further pulmonary embolism should be

undertaken prior to urgent oncology surgery. Before

planning the surgical procedures, adequate anticoagula-

tion must be achieved to prevent further complication of

DVT, thromboembolism, and pulmonary embolism. The

risk of stopping the anticoagulation prior to surgery must

be considered and adequately discussed with the patient

and surgeons. The anaesthetic plan must be selected

keeping in mind the coagulation status and the need of

anticoagulation in the postoperative period.

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Perioperative Management of Case of Gynecological Malignancy with Bilateral Deep Venous Thrombosis of Lower

Limbs Along with Pulmonary Embolism

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