INTRODUCTION
Thromboembolic phenomena can result from thrombosis and/or superficial venous
thrombophlebitis (SVT) of the upper limbs1. Most superficial thromboses also compete with phlebitis, in contrast
to deep vein thrombosis (DVT), where phlebitis may be absent2. Pulmonary thromboembolism (PTE) can
rarely be related to lower limb SVT (lower limbs)1. There are few
upper limb SVT reports (upper limbs) leading to PTE3-7, and
there are no reported cases related to cosmetic surgery.
In this article, we report 3 cases of patients who underwent cosmetic breast
plastic surgery who had confirmed upper limb SVT and evolved with PTE.
CASE REPORT
Check Chart 1.
Chart 1 - Details of the cases.
| Type |
Case 1 |
Case 2 |
Case 3 |
| Surgery performed |
Retromuscular augmentation mastopexy
(dual plane) and abdominoplasty
|
Retro augmentation mammoplasty
Muscular
(dual plane)
|
Retro Muscular Augmentation Mammoplasty (dual
plane)
|
| Date surgery |
19/12/2013 |
16/02/2016 |
Day 09/8/2017 |
| Site of surgery |
Hospital Metropolitano de Sarndi (PR)
- Private
|
Hospital do Câncer - Maringá (PR) - Private |
Hospital do Câncer - Maringá (PR) - Private |
| Duration of surgery |
Five hours and 30 minutes. |
1h20 min |
1 hour |
| Type and Duration of anesthesia |
Epidural and General 6h30min h |
General 1 h 50 min. |
General 1 h 30 min. |
| Use of BCP |
Suspended for 1 month pre-Operative
and after surgery
|
Suspended only after Surgery |
Didn't use |
| Chemo prophylaxis |
Made heparin intraoperatively and
maintained for 4 days postoperatively
|
not performed |
not performed |
| Venous puncture site |
RIGHT upper member |
RIGHT upper member |
LEFT upper limb |
| Ultrasound of upper limbs |
thrombophlebitis of basilica and
brachial veins BILATERALLY
|
left basilica thrombophlebitis at elbow
level
|
presence of imaging suggestive of occlusive
thrombotic residues in the median vein of the right elbow
|
| Ultrasound of lower limbs |
absence of thrombi in deep and
superficial vessels
|
absence of lesions in superficial and deep
veins
|
absence of lesions in superficial and deep
veins
|
D-dmin
*ref. positive = or > 500
ng/ml)
*FEU equivalent fibrinogenic units)
|
2110.00 ng/ml |
810.0 ng/ml |
4110 ng/ml |
| Pulmonary tomography |
Signs of pulmonary thromboembolism in
the distal third of the left pulmonary artery. Possible small
clots embolizing the posterior segment of the lower lobe to the
right
|
Discrete bilateral basal opacities, which may
correspond to the opacity of decubitus
|
SIGNS of PTE in the right lower lobe posterior
segment
|
| Pulmonary scintigraphy |
Not performed |
Presence of focal areas, with decreased
blood perfusion, of a subsegmental pattern dispersed in the
posterior segment of the right upper lobe, superior of the right
lower lobe, lateral of the middle lobe and lateral of the left
lower lobe, of a subsegmentary pattern, disagreeing with the
inhalation pattern. High probability of pulmonary
thromboembolism.
|
Not performed |
| 2. Presence of focal areas of
radiotracer hypocaptation located in the most basal portions of
the right lung, suggesting a parenchymal process
(atelectasis?)
|
| Investigation for thrombophilia |
Negative |
POSITIVE, diagnosed with
antiphospholipid antibody syndrome (point mutation C677T:
Heterozygous mutated), IgM Cardiolipin antibodies 64.0 MPL-U and
after 6 months 57.0 MPL-U (Positive higher than 40)
|
Negative |
| Other exams |
|
Normal echocardiogram |
|
Chart 1 - Details of the cases.
Case 1. A 31-year-old female patient without comorbidities who
underwent a mastopexy of retromuscular augmentation and abdominoplasty without
liposuction. She wore elastic stockings during the procedure and for one more
week, an anti-thrombosis device for 24 hours, subcutaneous heparinization in
the
intra and postoperative periods for four days (heparin from 10 to 15 thousand
U/day), and contraception suspended for 30 days before surgery. After 15 days,
she had pain in her upper limbs, and on the 18th day, she had sudden dyspnea
diagnosed with PTE (Figures 1 and 2). She was hospitalized for 7 days, 5 of
them in an intensive care unit, oxygen supplementation (without orotracheal
intubation), observation, and anticoagulation. It evolved without sequelae.
Figure 1 - Case 1: Pulmonary Computed Tomography: Arrow indicating failure
of filling in the left pulmonary artery.
Figure 1 - Case 1: Pulmonary Computed Tomography: Arrow indicating failure
of filling in the left pulmonary artery.
Figure 2 - Case 1: Pulmonary Computed Tomography: Arrow indicating pleural
effusion in left lower lobe
Figure 2 - Case 1: Pulmonary Computed Tomography: Arrow indicating pleural
effusion in left lower lobe
Case 2. A 35-year-old female patient with no comorbidities who
underwent breast augmentation. She developed a sudden dyspneic condition with
no
complaints until the 10th postoperative day, confirming PTE (Figure 3). She was admitted for three days
for observation, oxygen supplementation (without orotracheal intubation), and
anticoagulation. It evolved without sequelae. Contraceptive suspension (BCP)
only after surgery.
Figure 3 - Case 2: pulmonary scintigraphy - presence of focal areas, with
decreased blood perfusion, of a subsegmental pattern dispersed in
the posterior segment of the right upper lobe, superior of the right
lower lobe, lateral of the middle lobe and lateral of the left lower
lobe, of subsegmental pattern, discordant with the pattern
Figure 3 - Case 2: pulmonary scintigraphy - presence of focal areas, with
decreased blood perfusion, of a subsegmental pattern dispersed in
the posterior segment of the right upper lobe, superior of the right
lower lobe, lateral of the middle lobe and lateral of the left lower
lobe, of subsegmental pattern, discordant with the pattern
Case 3. A 17-year-old female patient without comorbidities who
underwent a breast augmentation. There were no complaints until the 6th
postoperative day, when she developed sudden dyspnea, confirming PTE (Figure 4). She was hospitalized for five
days, two in an intensive care unit, for observation, oxygen supplementation
(without orotracheal intubation), and anticoagulation. It evolved without
sequelae. Family history of postoperative embolism in grandfather and uncle.
Figure 4 - Case 3: pulmonary computed tomography - arrows indicating filling
failure in segmental arteries of the right lower lobe.
Figure 4 - Case 3: pulmonary computed tomography - arrows indicating filling
failure in segmental arteries of the right lower lobe.
DISCUSSION
PTE is especially feared after cosmetic surgery. In the cases described, it is
surprising that the embolic source is from upper limbs (Figure 5).
Figure 5 - Schematic representation of the superficial and deep veins of the
upper limb
Figure 5 - Schematic representation of the superficial and deep veins of the
upper limb
SVT is a common disease, usually identifying a palpable cord (best sign with
positive predictive value), hyperemic, painful, and hot in the course of the
superficial vein1. In more severe cases of
the upper limb, it can extend to axillary veins. In case 1, thrombosis reached
brachial veins.
PTE secondary to SVT of the upper limbs is rare in the absence of DVT4. SVT is probably little detected and is at
least 2 to 3 times more frequent than deep. It usually resolves spontaneously.
In lower limbs, SVT evolves in 20 to 33% for asymptomatic PTE and 2 to 13% for
symptomatic. There is no data for upper limbs.
In cases 1 and 3, computed tomography (CT) was compatible, and in case 2,
pulmonary scintigraphy confirmed the diagnosis of PTE (inconclusive CT). Doppler
ultrasonography of the upper limb was associated with the absence of thrombi
in
the lower limbs. Therefore, PTEs resulting from SVT of the upper limb
(compatible clinic, positive D-dimer, and CT or pulmonary scintigraphy proving
PTE) were confirmed8. Besides, patients
improved after anticoagulation.
As a cause of upper limbs thromboembolic phenomena, the use of central venous
catheters (chemotherapy, prolonged antibiotic therapy, or parenteral nutrition)
is found, as well as peripheral venous catheters (often “trivialized” in
conventional medicine)9. In cases 2 and 3,
it is noteworthy that the SVT was contralateral to the punctured limb, and in
case 1, bilateral.
Several studies suggest a predictive score for safety parameters in plastic
surgery10,11. However, only in case 1 did the surgery
last for more than 4 hours, and in the others, it was close to 1 hour. Despite
preventive measures for thromboembolism, patient 1 presented bilateral upper
limbs SVT that extended to deep, probably due to prolonged immobilization and
delay in diagnosis.
The research for preoperative thrombophilia is questionable (rarity of these
situations and high cost). It should only be performed in the case of
unexplained thromboembolic phenomena9,12.
Hereditary thrombophilia (Chart 2) and
oral contraceptives have a higher risk of thromboembolism, about 2 to 20
times12. Case 2 presented acquired
thrombophilia (without a previous diagnosis) and use of oral contraception.
Chart 2 - Classification of thrombophilias.
| Classification of thrombophilias13 |
| Hereditary |
Antithrombin deficiency protein deficiency
C
Protein Deficiency Protein S Protein Deficiency
Z
resistance APC (APCR)
Factor V Leiden mutation
(R506Q)
Prothrombin G20210A gene Mutation
MTHFR
mutation (variants 677C>T and 1298A>C)
PAI-1
675G>A mutation (4G/5G) and
844A>G
Dysfibrinogenemias High Factor IX
High
Factor XI
|
| Acquired |
| Antiphospholipid antibody syndrome (APLS) |
| Mixed/combined |
| Hyperhomocysteinemia high factor VIII activity
increased fibrinogen
|
| Other thrombophilias |
ACE Ins/del fibrinogen (455G>A)
factor
XIII (Val34Leu)
APOE (Cys112Arg and
Arg158Cys)
EPCR (4678G/C)
|
Chart 2 - Classification of thrombophilias.
There is a case description of PTE in the literature due to SVT in a patient
using hormone therapy only4. Hormone
therapy or oral contraception increases the chance of thromboembolism by up to
four times. Thus, the importance of hormonal suspension, even in cases of lower
risk10.
The most important chemoprophylaxis in venous thrombosis would be with
fibrinolytic agents (heparin or low molecular weight heparin), while in
arterial, it is based on the use of antiplatelet agents10.
Mechanical prophylaxis (elastic stockings, intermittent pneumatic devices)
reduces venous stasis and distension. The pneumatic device has little
fibrinolytic activity10. It is
recommended to start it 30 minutes before anesthetic induction until the
patient’s discharge, in surgeries longer than one hour10.
There are no reports of post-plastic surgery PTE from upper limb SVT. Several
factors could explain this fact, such as:
the inadequate position of the upper limbs during the intraoperative
period;
postoperative immobilization, especially in cases of retromuscular
breast implant (postoperative usually more painful);
exaggerated immobilization of the limbs and/or inappropriate flexing
of the limbs, for example, due to the excessive time of electronic
devices (cell phones or computers), leading to an inadequate posture
for drainage and consequent local stasis. In these cases, an elastic
band (for non-displacement) above the prostheses was used.
CONCLUSION
Cosmetic breast augmentation surgery with implants, although usually not long,
can also lead to non-local complications. Superficial thrombophlebitis,
triggered by excessive rest and/or venipuncture, is often overlooked and can
progress to thrombosis of larger vessels or even PTE.
Preoperatively, it is suggested to follow the prophylaxis protocols for
thromboembolism. In the intraoperative period, it is recommended that the arms’
position be constantly monitored and the use of elastic stockings, pneumatic
apparatus in the lower limbs, and chemoprophylaxis. Postoperative surveillance
of the upper limbs is also suggested to avoid excessive edema, and active
research for thrombophlebitis.
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1. Clínica Dra. Márcia Balbina L. Hoyos,
Plastic Surgery, Maringá, PR, Brazil.
Corresponding author: Márcia Balbina Lorenzo
Hoyos, Avenida Doutor Luiz Teixeira Mendes, 2418, Zona 05, Maringá,
PR, Brazil. Zip Code: 87015-001. E-mail:
mblhoyos@gmail.com
Article received: November 20, 2019.
Article accepted: July 15, 2020.
Conflicts of interest: none
