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Pulmonary embolism associated with upper extremity deep venous thrombosis after shoulder arthroscopy: A case report
Journal of Orthopaedic Science xxx (2017) 1e4
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Case Report
Pulmonary embolism associated with upper extremity deep venous thrombosis after shoulder arthroscopy: A case report Hisato Watanabe a, *, Yuichi Nagase b, Kazuya Tamai c, Sakae Tanaka d a
Department of Orthopaedic Surgery, Tokyo Metropolitan Bokutoh Hospital, Japan Department of Rheumatic Surgery, Tokyo Metropolitan Bokutoh Hospital, Japan c Center of Rheumatic Diseases, Dokkyo Medical University Hospital, Japan d Department of Orthopaedic Surgery, The University of Tokyo, Japan b
a r t i c l e i n f o Article history: Received 17 May 2016 Received in revised form 7 January 2017 Accepted 13 January 2017 Available online xxx
We report a case of upper extremity deep venous thrombosis (UEDVT) and subsequent symptomatic PE after the arthroscopic labrum repair in a 24-year-old man, and discuss the incidence, risk factors, and prophylaxis of UEDVT associated with arthroscopic shoulder surgery.
2. Case report
1. Introduction Deep venous thrombosis (DVT) and pulmonary embolism (PE) are a common, sometimes vital complication of musculoskeletal surgery. It is well known that the incidence of DVT or PE is lower in arthroscopic surgeries than in open surgeries, and lower in upper extremity than lower extremity surgeries. It is likely, however, that many cases may go undiagnosed as they are asymptomatic or present with indistinct symptoms [1]. When examined with ultrasound or venography, the incidence of DVT in patients undergoing arthroscopic knee surgery has been reported to be 6e18%, approximately 10e25% of which is symptomatic [2e4]. These studies indicate that the risk of venous thromboembolism (VTE) after knee arthroscopy is higher than previously believed. On the other hand, a systematic review showed the incidence of symptomatic VTE following arthroscopic shoulder surgery as 0.038% among 92,440 procedures [5]. Although some authors reported a higher incidence such as 0.3% [6] or 0.42% [7], the VTE after arthroscopic shoulder surgery seems to be uncommon compared to the arthroscopic knee surgery. However, shoulder arthroscopy is being used increasingly to perform a variety of diagnostic and therapeutic procedures, so that the number of patients who develop VTE is expected to rise.
* Corresponding author. Department Orthopaedic Surgery, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Koutohbashi, Sumida-ku, Tokyo, 1300022, Japan. E-mail address: [email protected] (H. Watanabe).
A 24-year-old Japanese male visited us complaining of three episodes of shoulder dislocation. His body weight was 110 kg and the body height was 175 cm, with the body mass index (BMI) of 35.9 kg/m2. Physical examination showed a positive anterior apprehension sign with abduction and external rotation of right shoulder, while the range-of-motions were normal. He had an anteroinferior labrum injury of right shoulder on MRI, so that an arthroscopic Bankart repair was planned. The patient had no history of smoking or medication, and reported negative personal and family history for thrombophilia. The preoperative laboratory data including complete blood count and D-dimer, electrocardiogram and chest X-ray did not reveal any abnormalities. At surgery under general anesthesia, the patient was placed in a beach-chair position without traction on the arm. Four anchors were used to reattach the avulsed labrum. Perfusion pressure was ranged from 40 to 50 mm Hg. The operation was uneventful, with minimal blood loss, except for a prolonged time of operation of 180 min and anesthesia of 210 min. During surgery, sequential compression devices were applied on the lower extremities as a routine procedure, but no other prophylaxis for DVT such as anticoagulant administration was applied. sault position with a The operated shoulder was placed in a De sling and a bandage for three weeks. Surgical incisions were clean and dry throughout the postoperative period. Edema around the surgical site was noted, but was consistent with the normal postoperative course. Six days postoperatively, the patient developed tachycardia with a heart rate of 120 beats/min, associated with decreased oxygen saturation at room air to 89%. Although a complete blood count, serum chemistries, and cardiac enzyme levels were normal, serum D-dimer level was high (82.3 mg/mL).
http://dx.doi.org/10.1016/j.jos.2017.01.008 0949-2658/© 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Watanabe H, et al., Pulmonary embolism associated with upper extremity deep venous thrombosis after shoulder arthroscopy: A case report, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.008
2
H. Watanabe et al. / Journal of Orthopaedic Science xxx (2017) 1e4
Enhanced CT demonstrated thrombi obstructing bilateral pulmonary arteries as well as the subclavian through basilar vein of the affected arm (Figs. 1e3). Thus, a diagnosis of PE caused by UEDVT was reached. The treatment started with oxygen therapy and intravenous heparin administration, which later was replaced by oral anticoagulant. Seven days after the start of anticoagulation therapy, the patient's symptoms improved. The anticoagulant was continued for an additional 3 months to obtain further improvement. The enhanced CT taken 6 months postoperatively still showed a small nonocclusive residual thrombus in the left pulmonary artery, but it finally diminished on a repeat enhanced CT 9 months postoperatively. The anticoagulant therapy was stopped afterwards. Additional measurements of lupus anticoagulant, anticardiolipin antibodies, and antiphospholipid antibodies proved negative. He had normal levels for antithrombin 3, protein C, protein S, and fibrinogen. The chest X-ray did not show a cervical rib, and physical examination maneuver did not indicate thoracic outlet syndrome either. Following the removal of bandage, the patient resumed physical therapy and progressed appropriately without restriction. Six months postoperatively, the active range-of-motions were 180 in flexion, 45 in external rotation, and Th12 in internal rotation posteriorly. The muscle strength with regard to supraspinatus, infraspinatus, subscapularis, and biceps was normal. He is currently doing well without post-thrombotic syndrome.
Fig. 2. Thrombus in the bilateral pulmonary artery. (arrow).
3. Discussion Takahashi reported the overall incidence of DVT after arthroscopic shoulder surgery was 10 of 175 patients (5.7%) and UEDVT was one patient (0.58%) [8]. This low incidence of UEDVT compared with lower extremity DVT may be related to several facts: 1) fewer and smaller valves are present in the veins of the upper extremity; 2) bedridden patients generally have less cessation of arm movements as compared to leg movements; 3) less hydrostatic pressure in the arms; 4) increased fibrinolytic activity in the endothelium of the upper extremity as compared to the lower extremity [9]. The thrombus in the UEDVT is located most often in the subclavian vein (18e67%), followed by axillary (5e25%) and brachial (4e11%) veins [10,11]. In the current case, the thrombosis involved the subclavian to basilar veins, which was consistent with a common occurrence. In reviewing the literature, we found 20 cases of UEDVT and/or PE as a complication of arthroscopic shoulder surgery (Table 1) [6,7,12e20]. Possible risk factors in these 20 cases included obesity
Fig. 1. (a), (b): Enhanced CT showed thrombus blocked from brachiocephalic.
Fig. 3. (a), (b): Enhanced CT showed contrast filling distal to medial cubital vein but occlusion from basilic vein by thrombus.
(9 cases), diabetes mellitus (4 cases), smoking habit (2 cases), mutation of genes resulting in increased coagulation (2 cases), anticardiolipin antibodies (1 case), protein C deficiency (1 case), and venous compression by a tumor (1 case). Surgery related risk factors included prolonged operation time [7,16], lateral decubitus position of the patient [7,16]), arm traction [21,16], and immobilization in the plaster cast or sling [17]. One report pointed out that fluid-induced soft-tissue swelling can be a cause of venous compression [13]. In our patient, the operation time was prolonged to 3 h. Although few studies clearly showed that the longer operation time increases the risk of perioperative VTE, prolonged operation time may affect the clotting cascade or result in the release of thrombogenic factors [22]. Additionally prolonged operation time may lead to increase use of perfusate resulted in fluid-induced soft tissue swelling. Furthermore, it is very probable in our patient with the BMI of 35.9 that postoperative immobilization of the swollen sault position could have increased the tissue presarm in the De sure of the arm and impeded venous flow accordingly. In the clinical setting, it is important to notice signs of DVT as early as possible. Constans proposed a simple scoring system to assess the clinical probability of UEDVT using four items, i.e., venous material (presence of central venous catheter or
Please cite this article in press as: Watanabe H, et al., Pulmonary embolism associated with upper extremity deep venous thrombosis after shoulder arthroscopy: A case report, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.008
Authors
Patients
Location of UEDVT
Interval to onset
Symptoms
PE
Operation
Position
Traction
Anesthesia
Ope time
Postoperative sling
Risk factor
Burkhart
32M
Basilic and innominate veins
PO3 days
As debridement
Lateral decubitus
N
NR
65 min
NR
Large mediastinal mass for Hodgkin's disease
Polzhofer
48M
Cephalic vein
PO7 days
þ
ASD
Lateral decubitus
3 kg
G
NR
NR
Obesity (BMI 36.8 kg/m2), DM
Creighton
43M
Brachial, medial antecubital and distal cephalic veins
PO7 days
þ
As labrum repair
Beach chair
N
B
60 min
NR
NR
Kuremsky
71M
Basilic vein
PO3 weeks
ARCR
Lateral decubitus
N
B
NR
NR
Obesity (BMI 32 kg/m2)
46F
Subclavian and axillary veins
PO6 weeks
N
B
NR
NR
Protein C deficiency
Subclavian vein Basilic and humeral veins
PO4 weeks PO4 days
Lateral decubitus Beach chair
N N
B B
NR 80 min
NR NR
66M
Humeral, cephalic, and basilic veins
PO6 days
Pain and swelling at the medial arm
ARCR pancapsular plication AS capsular repair AS labrum repair ARCR ARCR
Lateral decubitus
18M 30M
Pain, swelling and tenderness from the elbow to the axilla Anxiety, severe dyspnea, hypertension and tachycardia Pain and swelling POD14 shortness of breath Redness, swelling, induration and pain Pain from the neck to the hand NR Pain and swelling
Beach chair
N
B
80 min
NR
21M
Humeral and basilic veins
PO3 weeks
Pain and swelling
þ
AS capsuloplasty
Lateral decubitus
4 kg
G
45 min
þ
54M
Innominate, subclavian and distal axillary veins
PO3 weeks
ARCR
Lateral decubitus
4 kg
B
50 min
þ
Hariri
25M
Junction of the brachial and axillary veins
PO10 days
þ
AS capsuloplasty
Lateral decubitus
3 kg
G
150 min
þ
Smoking
Manaqibwala
58M
PO11 days
2e3 kg
GþB
NR
þ
Obesity (BMI 26.5 kg/m2)
PO11 days
ASD distal clavicle exc. ASD distal clavicle exc.
Lateral decubitus
46M
Middle upper arm to antecubital fossa Brachial and basilic veins
Lateral decubitus
2e3 kg
GþB
NR
þ
Obesity (BMI 35.9 kg/m2)
43M
Basilic and brachial veins
PO12 days
57M
Basilic and brachial veins
PO11 days
66F
Brachial vein
PO5 days
Delos
68M
Axillary, brachial and basilic veins
PO6 days
Kim
45F
NR
PO1 day
Pain, swelling and redness of the axillary region Basilar-thoracic pain associated with bloody sputum Pain and swelling at the medial elbow Swelling and tenderness extending down the volar forearm Tenderness at the medial elbow Swelling and tenderness at the medial elbow Tenderness around the elbow Swelling and tenderness at the medial elbow Cardiac arrest
Obesity (BMI 25 kg/m2) Antiphospholipid antibody syndrome Mutation of the 1691 A gene C677T gene for the methylenetetrahydrofolate reductase enzyme Heterozygous mutation for the gene cording for methylenetetrahydrofolate reductase (MTHFR-C677T) NR
Brislin Takahashi
NR 69F
NR Subclavian vein
PO1 month PO4 weeks
NR Asymptomatic
Bongiovanni
Garofalo
þ
ARCR
Lateral decubitus
2e3 kg
GþB
NR
þ
Obesity (BMI 27.1 kg/m2)
ARCR
Lateral decubitus
2e3 kg
GþB
NR
þ
Obesity (BMI 28 kg/m2), DM, smoking
ARCR
Lateral decubitus
2e3 kg
GþB
NR
þ
Obesity (BMI 26.8 kg/m2)
ARCR
Beach chair
N
B
NR
þ
Pacemaker, DM
þ
ARCR
Beach chair
N
G
360 min
NR
þ
ARCR Patch graft
NR Beach chair
NR NR
NR G
NR NR
NR NR
Prolonged ope time, DM, Obesity (BMI 27.9 kg/m2) NR Hypertension
H. Watanabe et al. / Journal of Orthopaedic Science xxx (2017) 1e4
Please cite this article in press as: Watanabe H, et al., Pulmonary embolism associated with upper extremity deep venous thrombosis after shoulder arthroscopy: A case report, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.008
Table 1 20 cases of UEDVT and/or PE as a complication of arthroscopic shoulder surgery.
M: Male F: Female NR: No record PO: Postoperative AS: Arthroscopic ASD: Arthroscopic subacromial decompression. ARCR: Arthroscopic rotator cuff repair N: None G: General anesthesia. B: Brachial plexus block DM: Diabetes Mellitus.
3
4
H. Watanabe et al. / Journal of Orthopaedic Science xxx (2017) 1e4
pacemaker), localized pain, unilateral pitting edema, and other diagnosis at least as plausible as UEDVT [23]. This scoring system would be useful in defining patients with high clinical probability of UEDVT particularly when ultrasound is negative, in which case patients should be further investigated by enhanced CT. However, these four items may possibly be indistinct from postoperative local changes. In addition, since one-third of patients with UEDVT are asymptomatic [24], a low clinical probability in this scoring system does not exclude the diagnosis of UEDVT. Actually, in reviewing the UEDVT cases reported to date, the range of symptoms varied from asymptomatic to pain and/or swelling of the arm, a prominence of superficial veins in the upper arm and chest, cyanosis of the hand, numbness and tingling of the fingers, and functional impairment. Given the wide variety of presentations, we think that UEDVT cannot be reliably diagnosed on the basis of history and physical examination alone. As was the case in our patient, D-dimer testing has been shown to have a high sensitivity and negative predictive value for both DVT and PE. Merminod showed diagnostic value of D-dimer in UEDVT, the sensitivity of 100% and the negative predictive value of 100%, in a sample of 52 consecutive patients [25]. Kleinjan et al. proposed a diagnostic algorithm for UEDVT that the combination of clinical decision score, D-dimer testing, and ultrasonography can safely and effectively exclude UEDVT [26]. Taking into account that PE could possibly develop postoperatively without preceding upper or lower extremity DVT [27,28], we should probably check D-dimer measurements before and after arthroscopic shoulder surgery, particularly when the patient has at least one risk factor for VTE such as obesity in the current case. There is no established treatment protocol for UEDVT because of the lack of cases and large-scale randomized trials. The National Institute of Clinical Excellence (NICE) does not recommend routine thromboprophylaxis for patients undergoing upper extremity surgery [29]. Similarly, no other current guidelines recommend the administration of VTE prophylaxis in shoulder arthroscopy, because of its minimal tissue invasiveness. To determine whether DVT prophylaxis after arthroscopic shoulder surgery would be beneficial, a well-designed, randomized controlled study is needed. 4. Conclusion Because of the limited number of cases, as well as the low prevalence rate, it is difficult to draw any firm conclusion on the cause, risk factors, or proper prophylaxis of UEDVT and PE. Even if the clinical symptoms are lacking, measurement of D-dimer can be of help in excluding UEDVT following arthroscopic shoulder surgery. Conflict of interest The authors declare that they have no conflict of interest. Disclaimer None. References [1] Bernardi E, Piccioli A, Marchiori A, Girolami B, Prandoni P. Upper extremity deep vein thrombosis: risk factors, diagnosis, and management. Semin Vasc Med 2001;1(1):105e10. [2] Ramos J, Perrotta C, Badariotti G, Berenstein G. Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy. Cochrane Database Syst Rev 2008 Oct 8;(4):CD005259.
[3] Demers C, Marcoux S, Ginsberg JS, Laroche F, Cloutier R, Poulin J. Incidence of venographically proved deep vein thrombosis after knee arthroscopy. Arch Intern Med 1998 Jan 12;158(1):47e50. [4] Sun Y, Chen D, Xu Z, Shi D, Dai J, Qin J, Jiang Q. Incidence of symptomatic and asymptomatic venous thromboembolism after elective knee arthroscopic surgery: a retrospective study with routinely applied venography. Arthroscopy 2014 Jul;30(7):818e22. [5] Dattani R, Smith CD, Patel VR. The venous thromboembolic complications of shoulder and elbow surgery: a systematic review. Bone Jt J 2013 Jan;95-B(1): 70e4. [6] Bongiovanni SL, Ranalletta M, Guala A, Maignon GD. Case reports: heritable thrombophilia associated with deep venous thrombosis after shoulder arthroscopy. Clin Orthop Relat Res 2009 Aug;467(8):2196e9. [7] Kuremsky MA, Cain Jr EL, Fleischli JE. Thromboembolic phenomena after arthroscopic shoulder surgery. Arthroscopy 2011 Dec;27(12):1614e9. [8] Takahashi H, Yamamoto N, Nagamoto H, Sano H, Tanaka M, Itoi E. Venous thromboembolism after elective shoulder surgery: a prospective cohort study of 175 patients. J Shoulder Elb Surg 2014 May;23(5):605e12. [9] Saseedharan S, Bhargava S. Upper extremity deep vein thrombosis. Int J Crit Illn Sci 2012 Jan;2(1):21e6. [10] Hill SL, Berry RE. Subclavian vein thrombosis: a continuing challenge. Surgery 1990 Jul;108(1):1e9. [11] Marinella MA, Kathula SK, Markert RJ. Spectrum of upper-extremity deep venous thrombosis in a community teaching hospital. Heart Lung 2000 MarApr;29(2):113e7. [12] Burkhart SS. Deep venous thrombosis after shoulder arthroscopy. Arthroscopy 1990;6(1):61e3. [13] Polzhofer GK, Petersen W, Hassenpflug J. Thromboembolic complication after arthroscopic shoulder surgery. Arthroscopy 2003 Nov;19(9):E129e32. [14] Creighton RA, Cole BJ. Upper extremity deep venous thrombosis after shoulder arthroscopy: a case report. J Shoulder Elb Surg 2007 Jan-Feb;16(1):e20e2. [15] Garofalo R, Notarnicola A, Moretti L, Moretti B, Marini S, Castagna A. Deep vein thromboembolism after arthroscopy of the shoulder: two case reports and a review of the literature. BMC Musculoskelet Disord 2010 Apr;11(65):1e8. [16] Hariri A, Nourissat G, Dumontier C, Doursounian L. Pulmonary embolism following thrombosis of the brachial vein after shoulder arthroscopy. A case report. Orthop Traumatol Surg Res 2009 Sep;95(5):377e9. [17] Manaqibwala MI, Ghobrial IE, Curtis AS. Upper extremity thrombosis presenting as medial elbow pain after shoulder arthroscopy. Case Rep Orthop 2014;2014:653146. [18] Delos D, Rodeo SA. Venous thrombosis after arthroscopic shoulder surgery: pacemaker leads as a possible cause: pacemaker leads as a possible cause. HSS J 2011 Oct;7(3):282e5. [19] Kim SJ, Yoo KY, Lee HG, Kim WM, Jeong CW, Lee HJ. Fatal pulmonary embolism caused by thrombosis of contralateral axillary vein after arthroscopic right rotator cuff repair -A case report. Korean J Anesthesiol 2010 Dec;59(Suppl.):S172e5. [20] Brislin KJ, Field LD, Savoie 3rd FH. Complications after arthroscopic rotator cuff repair. Arthroscopy 2007 Feb;23(2):124e8. [21] Cortes ZE, Hammerman SM, Gartsman GM. Pulmonary embolism after shoulder arthroscopy: could patient positioning and traction make a difference? J Shoulder Elb Surg 2007 Mar-Apr;16(2):e16e7. [22] Mansfield AO. Alteration in fibrinolysis associated with surgery and venous thrombosis. Br J Surg 1972 Oct;59(10):754e7. [23] Constans J, Salmi LR, Sevestre-Pietri MA, Perusat S, Nguon M, Degeilh M, Labarere J, Gattolliat O, Boulon C, Laroche JP, Le Roux P, Pichot O, Quere I, Conri C, Bosson JL. A clinical prediction score for upper extremity deep venous thrombosis. Thromb Haemost 2008 Jan;99(1):202e7. [24] Kommareddy A, Zaroukian MH, Hassouna HI. Upper extremity deep venous thrombosis. Semin Thromb Hemost 2002 Feb;28(1):89e99. [25] Merminod T, Pellicciotta S, Bounameaux H. Limited usefulness of D-dimer in suspected deep vein thrombosis of the upper extremities. Blood Coagul Fibrinolysis 2006 Apr;17(3):225e6. [26] Kleinjan A, Di Nisio M, Beyer-Westendorf J, Camporese G, Cosmi B, Ghirarduzzi A, Kamphuisen PW, Otten HM, Porreca E, Aggarwal A, Brodmann M, Guglielmi MD, Iotti M, Kaasjager K, Kamvissi V, Lerede T, Marschang P, Meijer K, Palareti G, Rickles FR, Righini M, Rutjes AW, Tonello C, Verhamme P, Werth S, van Wissen S, Buller HR. Safety and feasibility of a diagnostic algorithm combining clinical probability, d-dimer testing, and ultrasonography for suspected upper extremity deep venous thrombosis: a prospective management study. Ann Med 2014 Apr 1;160(7):451e7. [27] Yamamoto T, Tamai K, Akutsu M, Tomizawa K, Sukegawa T, Nohara Y. Pulmonary embolism after arthroscopic rotator cuff repair: a case report. Case Rep Orthop 2013;2013:801752. [28] Goldhaber NH, Lee CS. Isolated pulmonary embolism following shoulder arthroscopy. Case Rep Orthop 2014;2014:279082. [29] National Clinical Guideline Centre A, Chronic C, National Institute for Health and Clinical Excellence: Guidance. Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. 2010. London: Royal College of Physicians (UK) National Clinical Guideline Centre - Acute and Chronic Conditions.
Please cite this article in press as: Watanabe H, et al., Pulmonary embolism associated with upper extremity deep venous thrombosis after shoulder arthroscopy: A case report, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.008
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Case Report
Pulmonary embolism associated with upper extremity deep venous thrombosis after shoulder arthroscopy: A case report Hisato Watanabe a, *, Yuichi Nagase b, Kazuya Tamai c, Sakae Tanaka d a
Department of Orthopaedic Surgery, Tokyo Metropolitan Bokutoh Hospital, Japan Department of Rheumatic Surgery, Tokyo Metropolitan Bokutoh Hospital, Japan c Center of Rheumatic Diseases, Dokkyo Medical University Hospital, Japan d Department of Orthopaedic Surgery, The University of Tokyo, Japan b
a r t i c l e i n f o Article history: Received 17 May 2016 Received in revised form 7 January 2017 Accepted 13 January 2017 Available online xxx
We report a case of upper extremity deep venous thrombosis (UEDVT) and subsequent symptomatic PE after the arthroscopic labrum repair in a 24-year-old man, and discuss the incidence, risk factors, and prophylaxis of UEDVT associated with arthroscopic shoulder surgery.
2. Case report
1. Introduction Deep venous thrombosis (DVT) and pulmonary embolism (PE) are a common, sometimes vital complication of musculoskeletal surgery. It is well known that the incidence of DVT or PE is lower in arthroscopic surgeries than in open surgeries, and lower in upper extremity than lower extremity surgeries. It is likely, however, that many cases may go undiagnosed as they are asymptomatic or present with indistinct symptoms [1]. When examined with ultrasound or venography, the incidence of DVT in patients undergoing arthroscopic knee surgery has been reported to be 6e18%, approximately 10e25% of which is symptomatic [2e4]. These studies indicate that the risk of venous thromboembolism (VTE) after knee arthroscopy is higher than previously believed. On the other hand, a systematic review showed the incidence of symptomatic VTE following arthroscopic shoulder surgery as 0.038% among 92,440 procedures [5]. Although some authors reported a higher incidence such as 0.3% [6] or 0.42% [7], the VTE after arthroscopic shoulder surgery seems to be uncommon compared to the arthroscopic knee surgery. However, shoulder arthroscopy is being used increasingly to perform a variety of diagnostic and therapeutic procedures, so that the number of patients who develop VTE is expected to rise.
* Corresponding author. Department Orthopaedic Surgery, Tokyo Metropolitan Bokutoh Hospital, 4-23-15 Koutohbashi, Sumida-ku, Tokyo, 1300022, Japan. E-mail address: [email protected] (H. Watanabe).
A 24-year-old Japanese male visited us complaining of three episodes of shoulder dislocation. His body weight was 110 kg and the body height was 175 cm, with the body mass index (BMI) of 35.9 kg/m2. Physical examination showed a positive anterior apprehension sign with abduction and external rotation of right shoulder, while the range-of-motions were normal. He had an anteroinferior labrum injury of right shoulder on MRI, so that an arthroscopic Bankart repair was planned. The patient had no history of smoking or medication, and reported negative personal and family history for thrombophilia. The preoperative laboratory data including complete blood count and D-dimer, electrocardiogram and chest X-ray did not reveal any abnormalities. At surgery under general anesthesia, the patient was placed in a beach-chair position without traction on the arm. Four anchors were used to reattach the avulsed labrum. Perfusion pressure was ranged from 40 to 50 mm Hg. The operation was uneventful, with minimal blood loss, except for a prolonged time of operation of 180 min and anesthesia of 210 min. During surgery, sequential compression devices were applied on the lower extremities as a routine procedure, but no other prophylaxis for DVT such as anticoagulant administration was applied. sault position with a The operated shoulder was placed in a De sling and a bandage for three weeks. Surgical incisions were clean and dry throughout the postoperative period. Edema around the surgical site was noted, but was consistent with the normal postoperative course. Six days postoperatively, the patient developed tachycardia with a heart rate of 120 beats/min, associated with decreased oxygen saturation at room air to 89%. Although a complete blood count, serum chemistries, and cardiac enzyme levels were normal, serum D-dimer level was high (82.3 mg/mL
http://dx.doi.org/10.1016/j.jos.2017.01.008 0949-2658/© 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Watanabe H, et al., Pulmonary embolism associated with upper extremity deep venous thrombosis after shoulder arthroscopy: A case report, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.008
2
H. Watanabe et al. / Journal of Orthopaedic Science xxx (2017) 1e4
Enhanced CT demonstrated thrombi obstructing bilateral pulmonary arteries as well as the subclavian through basilar vein of the affected arm (Figs. 1e3). Thus, a diagnosis of PE caused by UEDVT was reached. The treatment started with oxygen therapy and intravenous heparin administration, which later was replaced by oral anticoagulant. Seven days after the start of anticoagulation therapy, the patient's symptoms improved. The anticoagulant was continued for an additional 3 months to obtain further improvement. The enhanced CT taken 6 months postoperatively still showed a small nonocclusive residual thrombus in the left pulmonary artery, but it finally diminished on a repeat enhanced CT 9 months postoperatively. The anticoagulant therapy was stopped afterwards. Additional measurements of lupus anticoagulant, anticardiolipin antibodies, and antiphospholipid antibodies proved negative. He had normal levels for antithrombin 3, protein C, protein S, and fibrinogen. The chest X-ray did not show a cervical rib, and physical examination maneuver did not indicate thoracic outlet syndrome either. Following the removal of bandage, the patient resumed physical therapy and progressed appropriately without restriction. Six months postoperatively, the active range-of-motions were 180 in flexion, 45 in external rotation, and Th12 in internal rotation posteriorly. The muscle strength with regard to supraspinatus, infraspinatus, subscapularis, and biceps was normal. He is currently doing well without post-thrombotic syndrome.
Fig. 2. Thrombus in the bilateral pulmonary artery. (arrow).
3. Discussion Takahashi reported the overall incidence of DVT after arthroscopic shoulder surgery was 10 of 175 patients (5.7%) and UEDVT was one patient (0.58%) [8]. This low incidence of UEDVT compared with lower extremity DVT may be related to several facts: 1) fewer and smaller valves are present in the veins of the upper extremity; 2) bedridden patients generally have less cessation of arm movements as compared to leg movements; 3) less hydrostatic pressure in the arms; 4) increased fibrinolytic activity in the endothelium of the upper extremity as compared to the lower extremity [9]. The thrombus in the UEDVT is located most often in the subclavian vein (18e67%), followed by axillary (5e25%) and brachial (4e11%) veins [10,11]. In the current case, the thrombosis involved the subclavian to basilar veins, which was consistent with a common occurrence. In reviewing the literature, we found 20 cases of UEDVT and/or PE as a complication of arthroscopic shoulder surgery (Table 1) [6,7,12e20]. Possible risk factors in these 20 cases included obesity
Fig. 1. (a), (b): Enhanced CT showed thrombus blocked from brachiocephalic.
Fig. 3. (a), (b): Enhanced CT showed contrast filling distal to medial cubital vein but occlusion from basilic vein by thrombus.
(9 cases), diabetes mellitus (4 cases), smoking habit (2 cases), mutation of genes resulting in increased coagulation (2 cases), anticardiolipin antibodies (1 case), protein C deficiency (1 case), and venous compression by a tumor (1 case). Surgery related risk factors included prolonged operation time [7,16], lateral decubitus position of the patient [7,16]), arm traction [21,16], and immobilization in the plaster cast or sling [17]. One report pointed out that fluid-induced soft-tissue swelling can be a cause of venous compression [13]. In our patient, the operation time was prolonged to 3 h. Although few studies clearly showed that the longer operation time increases the risk of perioperative VTE, prolonged operation time may affect the clotting cascade or result in the release of thrombogenic factors [22]. Additionally prolonged operation time may lead to increase use of perfusate resulted in fluid-induced soft tissue swelling. Furthermore, it is very probable in our patient with the BMI of 35.9 that postoperative immobilization of the swollen sault position could have increased the tissue presarm in the De sure of the arm and impeded venous flow accordingly. In the clinical setting, it is important to notice signs of DVT as early as possible. Constans proposed a simple scoring system to assess the clinical probability of UEDVT using four items, i.e., venous material (presence of central venous catheter or
Please cite this article in press as: Watanabe H, et al., Pulmonary embolism associated with upper extremity deep venous thrombosis after shoulder arthroscopy: A case report, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.008
Authors
Patients
Location of UEDVT
Interval to onset
Symptoms
PE
Operation
Position
Traction
Anesthesia
Ope time
Postoperative sling
Risk factor
Burkhart
32M
Basilic and innominate veins
PO3 days
As debridement
Lateral decubitus
N
NR
65 min
NR
Large mediastinal mass for Hodgkin's disease
Polzhofer
48M
Cephalic vein
PO7 days
þ
ASD
Lateral decubitus
3 kg
G
NR
NR
Obesity (BMI 36.8 kg/m2), DM
Creighton
43M
Brachial, medial antecubital and distal cephalic veins
PO7 days
þ
As labrum repair
Beach chair
N
B
60 min
NR
NR
Kuremsky
71M
Basilic vein
PO3 weeks
ARCR
Lateral decubitus
N
B
NR
NR
Obesity (BMI 32 kg/m2)
46F
Subclavian and axillary veins
PO6 weeks
N
B
NR
NR
Protein C deficiency
Subclavian vein Basilic and humeral veins
PO4 weeks PO4 days
Lateral decubitus Beach chair
N N
B B
NR 80 min
NR NR
66M
Humeral, cephalic, and basilic veins
PO6 days
Pain and swelling at the medial arm
ARCR pancapsular plication AS capsular repair AS labrum repair ARCR ARCR
Lateral decubitus
18M 30M
Pain, swelling and tenderness from the elbow to the axilla Anxiety, severe dyspnea, hypertension and tachycardia Pain and swelling POD14 shortness of breath Redness, swelling, induration and pain Pain from the neck to the hand NR Pain and swelling
Beach chair
N
B
80 min
NR
21M
Humeral and basilic veins
PO3 weeks
Pain and swelling
þ
AS capsuloplasty
Lateral decubitus
4 kg
G
45 min
þ
54M
Innominate, subclavian and distal axillary veins
PO3 weeks
ARCR
Lateral decubitus
4 kg
B
50 min
þ
Hariri
25M
Junction of the brachial and axillary veins
PO10 days
þ
AS capsuloplasty
Lateral decubitus
3 kg
G
150 min
þ
Smoking
Manaqibwala
58M
PO11 days
2e3 kg
GþB
NR
þ
Obesity (BMI 26.5 kg/m2)
PO11 days
ASD distal clavicle exc. ASD distal clavicle exc.
Lateral decubitus
46M
Middle upper arm to antecubital fossa Brachial and basilic veins
Lateral decubitus
2e3 kg
GþB
NR
þ
Obesity (BMI 35.9 kg/m2)
43M
Basilic and brachial veins
PO12 days
57M
Basilic and brachial veins
PO11 days
66F
Brachial vein
PO5 days
Delos
68M
Axillary, brachial and basilic veins
PO6 days
Kim
45F
NR
PO1 day
Pain, swelling and redness of the axillary region Basilar-thoracic pain associated with bloody sputum Pain and swelling at the medial elbow Swelling and tenderness extending down the volar forearm Tenderness at the medial elbow Swelling and tenderness at the medial elbow Tenderness around the elbow Swelling and tenderness at the medial elbow Cardiac arrest
Obesity (BMI 25 kg/m2) Antiphospholipid antibody syndrome Mutation of the 1691 A gene C677T gene for the methylenetetrahydrofolate reductase enzyme Heterozygous mutation for the gene cording for methylenetetrahydrofolate reductase (MTHFR-C677T) NR
Brislin Takahashi
NR 69F
NR Subclavian vein
PO1 month PO4 weeks
NR Asymptomatic
Bongiovanni
Garofalo
þ
ARCR
Lateral decubitus
2e3 kg
GþB
NR
þ
Obesity (BMI 27.1 kg/m2)
ARCR
Lateral decubitus
2e3 kg
GþB
NR
þ
Obesity (BMI 28 kg/m2), DM, smoking
ARCR
Lateral decubitus
2e3 kg
GþB
NR
þ
Obesity (BMI 26.8 kg/m2)
ARCR
Beach chair
N
B
NR
þ
Pacemaker, DM
þ
ARCR
Beach chair
N
G
360 min
NR
þ
ARCR Patch graft
NR Beach chair
NR NR
NR G
NR NR
NR NR
Prolonged ope time, DM, Obesity (BMI 27.9 kg/m2) NR Hypertension
H. Watanabe et al. / Journal of Orthopaedic Science xxx (2017) 1e4
Please cite this article in press as: Watanabe H, et al., Pulmonary embolism associated with upper extremity deep venous thrombosis after shoulder arthroscopy: A case report, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.008
Table 1 20 cases of UEDVT and/or PE as a complication of arthroscopic shoulder surgery.
M: Male F: Female NR: No record PO: Postoperative AS: Arthroscopic ASD: Arthroscopic subacromial decompression. ARCR: Arthroscopic rotator cuff repair N: None G: General anesthesia. B: Brachial plexus block DM: Diabetes Mellitus.
3
4
H. Watanabe et al. / Journal of Orthopaedic Science xxx (2017) 1e4
pacemaker), localized pain, unilateral pitting edema, and other diagnosis at least as plausible as UEDVT [23]. This scoring system would be useful in defining patients with high clinical probability of UEDVT particularly when ultrasound is negative, in which case patients should be further investigated by enhanced CT. However, these four items may possibly be indistinct from postoperative local changes. In addition, since one-third of patients with UEDVT are asymptomatic [24], a low clinical probability in this scoring system does not exclude the diagnosis of UEDVT. Actually, in reviewing the UEDVT cases reported to date, the range of symptoms varied from asymptomatic to pain and/or swelling of the arm, a prominence of superficial veins in the upper arm and chest, cyanosis of the hand, numbness and tingling of the fingers, and functional impairment. Given the wide variety of presentations, we think that UEDVT cannot be reliably diagnosed on the basis of history and physical examination alone. As was the case in our patient, D-dimer testing has been shown to have a high sensitivity and negative predictive value for both DVT and PE. Merminod showed diagnostic value of D-dimer in UEDVT, the sensitivity of 100% and the negative predictive value of 100%, in a sample of 52 consecutive patients [25]. Kleinjan et al. proposed a diagnostic algorithm for UEDVT that the combination of clinical decision score, D-dimer testing, and ultrasonography can safely and effectively exclude UEDVT [26]. Taking into account that PE could possibly develop postoperatively without preceding upper or lower extremity DVT [27,28], we should probably check D-dimer measurements before and after arthroscopic shoulder surgery, particularly when the patient has at least one risk factor for VTE such as obesity in the current case. There is no established treatment protocol for UEDVT because of the lack of cases and large-scale randomized trials. The National Institute of Clinical Excellence (NICE) does not recommend routine thromboprophylaxis for patients undergoing upper extremity surgery [29]. Similarly, no other current guidelines recommend the administration of VTE prophylaxis in shoulder arthroscopy, because of its minimal tissue invasiveness. To determine whether DVT prophylaxis after arthroscopic shoulder surgery would be beneficial, a well-designed, randomized controlled study is needed. 4. Conclusion Because of the limited number of cases, as well as the low prevalence rate, it is difficult to draw any firm conclusion on the cause, risk factors, or proper prophylaxis of UEDVT and PE. Even if the clinical symptoms are lacking, measurement of D-dimer can be of help in excluding UEDVT following arthroscopic shoulder surgery. Conflict of interest The authors declare that they have no conflict of interest. Disclaimer None. References [1] Bernardi E, Piccioli A, Marchiori A, Girolami B, Prandoni P. Upper extremity deep vein thrombosis: risk factors, diagnosis, and management. Semin Vasc Med 2001;1(1):105e10. [2] Ramos J, Perrotta C, Badariotti G, Berenstein G. Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy. Cochrane Database Syst Rev 2008 Oct 8;(4):CD005259.
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Please cite this article in press as: Watanabe H, et al., Pulmonary embolism associated with upper extremity deep venous thrombosis after shoulder arthroscopy: A case report, Journal of Orthopaedic Science (2017), http://dx.doi.org/10.1016/j.jos.2017.01.008