212. Routine Surveillance for Screening and Diagnosis of Asymptomatic Venous Thromboembolism After Pleurotomy for Malignant Mesothelioma
Luis Eduardo De Leon, Carlos Edmundo Bravo-Iniguez, Sam Williams Fox, Jeffrey Tarascio, Samuel Freyaldenhoven, Moshe Lapidot, *Michael T. Jaklitsch, *Raphael Bueno
Brigham & Women's Hospital/Harvard Medical School, Boston, MA
Invited Discussant:*Mark Onaitis
Objective: Venous thromboembolism (VTE) after pleurectomy in patients with mesothelioma ranges between 5%-28%. The value of routine screening for detection of VTE events in thoracic surgical patients remains unclear. The purpose of this study was to determine the incidence of VTE and utility of a routine surveillance program in patients undergoing surgery for malignant mesothelioma for whom routine prophylaxis was utilized at a single large volume center.
Methods: Patients undergoing pleurectomy for mesothelioma between May 2016 and August 2018 were included. An aggressive standardized surveillance program to look for VTE in this group included lower ± upper extremity noninvasive studies (LENIS/UENIS) preoperatively followed by LENIS ± UENIS every 7 days postoperatively, or earlier if symptomatic. All patients received external pneumatic compression sleeves in addition to standardized prophylactic heparin (5000U) before and after surgery. If either deep vein thrombosis (DVT) or pulmonary embolus (PE) were discovered, heparin drip was initiated until conversion to therapeutic Lovenox. VTE included objectively confirmed evidence of new DVT, or PE using ultrasound, ventilation/perfusion scanning, helical CT scanning, or pulmonary angiography.
Results: One hundred patients underwent pleurectomy for mesothelioma in a 27-month period. 81 (81%) patients were male. Median age at surgery was 71 years (30-85 years). 63(63%) patients had intraoperative heated chemotherapy (IOHC) at the time of pleurectomy. Median hospital length of stay was 15 days (4-85 days). During the study, 32 (32%) patients developed evidence of thrombosis: 23(23%) developed only DVT without embolism, 3 (3%) only PE and 6 (6%) both DVT and PE. There was no statistical difference in the rate of VTE based on IOHC. Table 1 shows the distribution of VTEs for the cohort. Patients underwent a median of 3 (1-5) LENIS during their hospital course. Median time to diagnosis was 7 days (1-14 days) postoperatively. Of the 29 patients who developed DVT, 10 (34%) were asymptomatic at the time of diagnosis, and none of these developed a PE or other complication related to anticoagulation. There were 2 (2%) events of postoperative bleeding within the cohort, one of which occurred in a patient with a symptomatic upper extremity DVT and right upper and lower lobe segmental PE. Operative mortality was 5%, none related to VTE.
Conclusions: The incidence of venous thromboembolism is high (32%) when screening asymptomatic patients undergoing pleurectomy for mesothelioma despite standardized prophylaxis. Up to 34% of patients with DVT are asymptomatic at the time of diagnosis, and the incidence of complications related to anticoagulation is low. Routine surveillance with LENIS/UENIS is safe and warranted in order to early diagnose and treat asymptomatic deep vein thrombosis before it progresses to symptomatic or fatal pulmonary embolism.