Thromboembolism is a potentially serious complication following any surgical procedure. Its incidence is particularly high after elective orthopedic procedures, such as a total knee arthroplasty. We present a patient who developed a massive thromboembolism captured by real-time echocardiography, who was undergoing ultrasound as part of an unrelated clinical study.
Massive Thromboembolism Captured By Real-Time Echocardiography
Rebecca Schroeder, MD
Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.
Contact: Rebecca Schroeder, MD. E-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
|
Citation: Schroeder R. Massive thromboembolism captured by real-time echocardiography. J Surg Radiol. 2010 Jul 1;1(1).
Received: May 3, 2010; Accepted: May 13, 2010; Published: May 13, 2010 Copyright: © 2010 Surgisphere Corporation. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. |
Contents - Discussion - References |
Case Presentation
A 55 year- old male was admitted for elective total knee arthroplasty (TKA) for severe osteoarthritis. His past medical history was significant for hypertension, obesity, type II diabetes, and chronic knee pain. His relevant medications included citalopram, hydrochlorothiazide and metformin. He received no anticoagulants preoperatively. Prior to the induction of general anesthesia, he underwent a femoral nerve block for postoperative analgesia. Intraoperatively, a thigh tourniquet was placed and the patient underwent a computer-guided left TKA using a navigation system designed and manufactured by Zimmer (Warsaw, Indiana).
Continuous intraoperative transesophageal echocardiography was performed as part of an unrelated clinical research protocol and was recorded on videotape. The thigh tourniquet was released after 90 minutes of inflation. Upon release, the oxygen saturation decreased to 88% and blood pressure decreased from 120/70 to 100/50. A very large thrombus was noted in the right atrium of the heart, taking approximately 30 seconds to travel to the right ventricle and then the pulmonary system. On later review, the thrombus was tubular and measured approximately 4.5 cm in length. The blood pressure and oxygen saturation returned to baseline, and no clinical sequelae were noted. The patient was discharged to home on postoperative day 7
Figure 1. Real-time echocardiography demonstrating a large thromboembolism in the right atrium following release of a tourniquet during a total knee arthroplasty. A. Still image seconds before migration of clot into right atrium. B. Large clot within the right atrium. C. Migration of the clot into the right ventricle.
Discussion
The incidence of thromboembolism during total joint replacement has been documented to be as high as 100% in multiple clinical studies, although the clinical significance of this phenomenon has been debated.1-5 The pattern of relatively mild decreases in oxygen saturation and blood pressure combined with an increase in end tidal CO2 is routinely observed upon release of a thigh tourniquet, particularly one that has been inflated for a significant period of time. Though the exact pathophysiology of these changes remains unclear, they are generally attributed to the return of hypothermic, acidotic blood to the heart and lungs. With the advent of transesophageal echocardiography as both a clinical and a research tool, it has been possible to view what is returning to the heart in a real-time manner at the time of tourniquet release. Kato et al. have shown that essentially all patients suffer embolic events during TKA at the time of tourniquet release.6 Nearly 27% of these patients have an embolism over 0.5 cm in diameter, leading to a shift in the atrial septum toward the left to signify an increase in right-sided cardiac pressures.6 While the clinical significance of these emboli are not completely clear, it has been shown in large series that over 20% patients become delirious following joint replacement, and almost 50% have some residual cognitive deficit at 3 months following discharge.7 Further, one study has also documented echogenic material on the left side of the heart and in the cerebral circulation even in the absence of a patent foramen ovale.8
In our patient, it is likely that the material was thrombus given its shape, overall appearance, and its timing. However, some authors have shown that fragments of fat, bone, marrow and even methylmethacrylate in the venous circulation during joint procedures.9,10 Regardless of its origin, the potential for large thromboembolism should be appreciated by all physicians caring for patients undergoing total joint replacement during the entire perioperative period.
References
- Jameson SS, Bottle A, Malviya A, Muller SD, Reed MR. The impact of national guidelines for the prophylaxis of venous thromboembolism on the complications of arthroplasty of the lower limb. J Bone Joint Surg Br. 2010 Jan;92(1):123-9. | CrossRef | PubMed |
- Deirmengian CA, Lonner JH. What’s new in adult reconstructive knee surgery. J Bone Joint Surg Am. 2009 Dec;91(12):3008-18. | CrossRef | PubMed |
- Lieberman JR, Barnes CL, Lachiewicz PF, Hanssen AD, Clarke HD, Pellegrini VD Jr. Venous thromboembolism debate in joint arthroplasty. J Bone Joint Surg Am. 2009 Aug;91 Suppl 5:29-32. | CrossRef | PubMed |
- Cusick LA, Beverland DE. The incidence of fatal pulmonary embolism after primary hip and knee replacement in a consecutive series of 4253 patients. J Bone Joint Surg Br. 2009 May;91(5):645-8. | CrossRef | PubMed |
- Haas SB, Barrack RL, Westrich G. Venous thromboembolic disease after total hip and knee arthroplasty. Instr Course Lect. 2009;58:781-93. | PubMed |
- Kato N, Nakanishi K, Yoshino S, Ogawa R. Abnormal echogenic findings detected by transesophageal echocardiography and cardiorespiratory impairment during total knee arthroplasty with tourniquet. Anesthesiology 2002; 97:1123-8. | CrossRef | PubMed |
- Lavernia CJ, Kock S, Forteza A, et al. Cognitive dysfunction in arthroplasty surgery: cerebral fat embolism? 52nd Annual Meeting of the Orthopaedic Research Society, March 19-22, 2006: Chicago, IL, USA.
- Sulek CA, Davies LK, Enneking FK, Gearen PA, Lobato EB. Cerebral microembolism diagnosed by transcranial Doppler during total knee arthroplasty. Anesthesiology 1999; 91:672-6. | CrossRef | PubMed |
- Weissman BN, Sosman JL, Braunstein EM, Dadkhahipoor H, et al. Intravenous methylmethacrylate after total hip replacement. J Bone Joint Surg Am 1984; 66-A:443-50.
- David K, Daniel RR. Intraoperative cardiac arrest and mortality in hop survey. Orthop Rev 1980; 9:51-6.
| Next > |
|---|
