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Echo Rounds

Answer/Explanation

Vladislav Melnyk, MD; Travis Schisler, MD; Kathrivel Subramaniam, MD MPH; Dennis Phillips, DO; University of Pittsburgh Medical Center, Pittsburgh, PA

Deep vein thrombosis with pulmonary embolism is the diagnosis (question 1, choice 3). Presence of echo density with noncompressible lumen of the femoral vein is diagnostic of thrombosis. TEE evidence of clots in the pulmonary artery supports the diagnosis. This report also stresses the importance of ultrasound guided vascular cannulations. Point-of-care ultrasound is an invaluable tool that can lead to quick perioperative DVT diagnosis and help guide clinical decisions.

Inoperative diagnosis of PE and DVT present a challenge. Although pulmonary thrombectomy can be performed at the time of lung transplantation, DVT is associated with diminished survival1 and may lead to another PE with lung infarction in the newly implanted lung.2 The findings were discussed with transplant surgeons and pulmonologists and a joint decision was made to cancel the procedure. The patient received IVC filter and was started warfarin therapy with Heparin Bridge. Deep venous thrombosis and PE resolved and the patient was allocated another graft after 5 weeks of therapy.

References

  1. Evans CF, Iacono AT, Sanchez PG, et al. Venous thromboembolic complications of lung transplantation: a contemporary single-institution review. Ann Thorac Surg. 2015;100(6):2033-2039. doi:10.1016/j.athoracsur.2015.05.095.
  2. Krivokuca I, van de Graaf EA, van Kessel DA, van den Bosch JM, Grutters JC,
    Kwakkel-van Erp JM. Pulmonary embolism and pulmonary infarction after lung transplantation. Clin Appl Thromb Hemost. 2011;17(4):421-424. doi:10.1177/1076029610371474.