Yonsei Med J.  2006 Apr;47(2):271-275. 10.3349/ymj.2006.47.2.271.

Reperfusion Pulmonary Edema after the Removal of Hepatocellular Carcinoma Embolus

Affiliations
  • 1Department of Anesthesiology, School of Medicine, The Catholic University of Korea, Seoul, Korea. euns1503@catholic.ac.kr

Abstract

To report a non-fatal case of reperfusion pulmonary edema (RPE) after the removal of a hepatocellular carcinoma embolus, which had caused an acute obstruction of the tricuspid valve and pulmonary vasculature during a hepatic lobectomy. Pulmonary embolism caused by hepatocellular carcinoma embolus is extremely rare, and, in the present case, it was associated with unusual clinical features. A 69-year-old ASA II woman with hepatocellular carcinoma was presented for an elective left hepatic lobectomy. During the surgery, the tumor embolus was dislodged from the interior of the lumen of the inferior vena cava (IVC), which then drifted into the tricuspid valve area and pulmonary vasculature. The patient showed the specific signs of acute pulmonary embolism, such as a reduction in end-tidal carbon dioxide, an increase in central venous pressure, and a decrease in arterial pressure. The patient exhibited the symptoms for about 10 minutes. After this period, however, cardiovascular variables became relatively stable, even during a mechanical obstruction due to cross-clamping the pulmonary artery for embolectomy. After several hours of pulmonary embolectomy, the patient experienced an episode of RPE. The ventilatory supports for the treatment of RPE were successful, and the patient recovered without any complications. The patient's case in the present study demonstrates that pulmonary embolism may occur as a result of a hepatocellular carcinoma extending into the IVC during operative management. The anesthesiologist should be careful of the possibilities of RPE after removal of the tumor embolus.

Keyword

Complications; pulmonary embolism; liver; hepatocellular carcinoma; lung; reperfusion edema

MeSH Terms

Vena Cava, Inferior
Tomography, X-Ray Computed
Time Factors
Reperfusion
Radiography, Thoracic
Pulmonary Embolism/diagnosis/radiography
Pulmonary Edema
Liver Neoplasms/*pathology
Liver/pathology
Humans
Female
Edema
Cardiovascular System
Carcinoma, Hepatocellular/*pathology
Aged

Figure

  • Fig. 1 Contrast-enhanced computed tomography of the abdomen showing a huge tumor in the left hepatic lobe (arrow) and thrombosis in the lumen of inferior vena cava (arrowhead).

  • Fig. 2 Contrast-enhanced computed tomography of the chest showing a large filling defect in the left pulmonary interlobar artery. Arrowhead indicates the pulmonary embolus.

  • Fig. 3 Pulmonary angiography showing a large filling defect in the left interlobar artery (arrowheads), which demonstrates the presence of pulmonary embolism.

  • Fig. 4 Macroscopic appearance of the tumor embolus extracted from the left pulmonary artery, which was identified pathologically as hepatocellular carcinoma with intravascular thrombi formation and marked necrosis.

  • Fig. 5 Chest radiograph taken 10 hours after the end of the surgery showing confluent patchy consolidations and increased ground-glass opacities in the left lung, suggesting pulmonary edema.


Cited by  1 articles

Open Pulmonary Thromboembolectomy in Patients with Major Pulmonary Thromboembolism
Sak Lee, Suk-Won Song, Gijong Yi, Young-Nam Youn, Kyung-Jong Yoo, Byung-Chul Chang
Yonsei Med J. 2008;49(6):973-977.    doi: 10.3349/ymj.2008.49.6.973.


Reference

1. Horgan MJ, Lum H, Malik AB. Pulmonary edema after pulmonary artery occlusion and reperfusion. Am Rev Respir Dis. 1989. 140:1421–1428.
2. Milne B, Cervenko FW, Morales A, Salerno TA. Massive intraoperative pulmonary tumor embolus from renal cell carcinoma. Anesthesiology. 1981. 54:253–255.
3. Wilkinson CJ, Kimovec MA, Uejima T. Cardiopulmonary bypass in patients with malignant renal neoplasms. Br J Anaesth. 1986. 58:461–465.
4. Utley JR, Mobin-Uddin K, Segnitz RH, Belin RP, Utley JF. Acute obstruction of tricuspid valve by Wilm's tumor. J Thorac Cardiovasc Surg. 1973. 66:626–628.
5. Carson JL, Kelley MA, Duff A, Weg JG, Fulkerson WJ, Palevsky HI, et al. The clinical course of pulmonary embolism. N Engl J Med. 1992. 326:1240–1245.
6. Sasaoka N, Kawaguchi M, Sha K, Sakamoto T, Shimokawa M, Kitaguchi K, et al. Intraoperative immediate diagnosis of acute obstruction of tricuspid valve and pulmonary embolism due to renal cell carcinoma with transesophageal echocardiography. Anesthesiology. 1997. 87:998–1001.
7. Yamashita C, Azami T, Okada M, Toyoda Y, Wakiyama H, Yoshida M, et al. Usefulness of cardiopulmonary bypass in reconstruction of inferior vena cava occupied by renal cell carcinoma tumor thrombus. Angiology. 1999. 50:47–53.
8. Capan LM, Miller SM. Monitoring for suspected pulmonary embolism. Anesthesiol Clin North America. 2001. 19:673–703.
9. Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest. 2002. 121:877–905.
10. Sharma GV, McIntyre KM, Sharma S, Sasahara AA. Clinical and hemodynamic correlates in pulmonary embolism. Clin Chest Med. 1984. 5:421–437.
11. Miller RL, Das S, Anandarangam T, Leibowitz DW, Alderson PO, Thomashow B, et al. Association between right ventricular function and perfusion abnormalities in hemodynamically stable patients with acute pulmonary embolism. Chest. 1998. 113:665–670.
12. Stratmann G, Gregory GA. Neurogenic and humoral vasoconstriction in acute pulmonary thromboembolism. Anesth Analg. 2003. 97:341–354.
13. Levinson RM, Shure D, Moser KM. Reperfusion pulmonary edema after pulmonary artery thromboendarterectomy. Am Rev Respir Dis. 1986. 134:1241–1245.
Full Text Links
  • YMJ
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr