Pulmonary vein thrombosis
Pulmonary vein thrombosis is a sudden blockage of the pulmonary artery or its branches by thrombotic masses. Pathology requires urgent medical attention, as it poses a direct threat to life. Pulmonary vein thrombosis is indicated by chest pain, blue discoloration of the skin of the neck and face, choking, increased heart rate, collapse.
A thrombus can enter the pulmonary artery from the right atrium or right ventricle, or be brought along the venous bed of the systemic circulation. It creates an obstacle to the normal blood supply to the lung tissue, which is often fatal.
On Earth, about 0.1% of the world's population dies every year precisely because of the presence of a blood clot in the lungs. Moreover, in 90% of cases, patients are misdiagnosed, so they do not receive adequate therapy. Otherwise, the number of deaths could be reduced to 2-8%.
About 10% of patients die in the first day or even hours after massive pulmonary vein thrombosis. Within a year, another 25% of case histories will end in death. In general, pulmonary vein thrombosis ranks first among undiagnosed pathological conditions.
Content:
- Causes of pulmonary vein thrombosis
- Pulmonary vein thrombosis symptoms
- Complications of pulmonary vein thrombosis
- Diagnostics of the pulmonary vein thrombosis
- Pulmonary vein thrombosis treatment
- Prevention of pulmonary vein thrombosis
Causes of pulmonary vein thrombosis
A thrombus in the pulmonary vein is not formed. It gets there with the blood flow from other localizations, blocking the lumen of the vessel.
Therefore, the causes of pulmonary vein thrombosis can be considered:
- The presence in the patient of such a pathology as deep vein thrombosis of the leg. Combination of deep and superficial thrombosis of the lower leg.
- Thrombosis of the inferior vena cava and branches departing from it.
- Cardiopathology: ischemic heart disease, rheumatism accompanied by stenosis, atrial fibrillation, hypertension, infectious endocarditis, cardiomyopathy, non-rheumatic myocarditis.
- Generalized sepsis.
- Cancer tumors. Thrombosis of the pulmonary vein is most often caused by neoplasms of the lungs, stomach and pancreas themselves.
- Thrombophilia, as a pathology of the blood system, which leads to an increase in its coagulability.
- APS is a syndrome in which reactions occur in the body that provoke the formation of blood clots. They can be located in a variety of places.
In addition to the reasons leading to pulmonary vein thrombosis, risk factors can be distinguished, including:
- Long-term presence of a person in a forced immobilized state. The danger is represented by: immobility after surgery, adherence to bed rest for various diseases, long flights by airplane or by train, etc.
- Damage to the vessel wall: endovascular surgery performed, stenting and vein prosthetics, placement of a venous catheter, oxygen starvation of the body. Various viruses and bacteria, systemic reactions of the body, accompanied by an inflammatory process, can injure the vascular wall.
- Venous congestion against the background of a slow blood flow through the vessels, which is observed in chronic cardiovascular and pulmonary insufficiency.
- The presence of a malignant tumor in the body.
- Undergoing treatment with diuretic drugs when too much medication is required. The more fluid is removed from the body, the higher the viscosity of the blood, which means it will be easier for blood clots to form.
- Phlebeurysm. This disease is essential for the blood to stagnate and blood clots form.
- Pronounced disorders in metabolic processes, which is observed against the background of diabetes mellitus or obesity.
- Hemostasis disorders.
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Age over 50 and previous surgeries. So, in patients under 40 years of age after surgery against a background of minor trauma, pulmonary artery thrombosis is extremely rare, as an exception. In patients over 40-50 years old, thrombosis acts as a leading factor that worsens the prognosis of surgery. Such patients account for up to 75% of all fatal cases of pulmonary vein thrombosis. Especially dangerous in this regard are operations performed on the respiratory and peritoneal organs.
- Leading a sedentary lifestyle.
- Childbirth, which proceeded with various complications.
- Taking hormonal drugs for contraception.
- Erythremia.
- Systemic lupus erythematosus.
- Hereditary diseases such as congenital antithrombin deficiency 3.
- Smoking. Under the influence of nicotine, vasospasm occurs, blood pressure increases, venous congestion develops, which increases the risk of blood clots.
A life-threatening condition occurs due to the fact that an obstacle arises in the path of blood flow, which increases the pressure in the pulmonary vein. When it becomes too strong, the load on the right ventricle of the heart increases. This leads to heart failure, which often leads to the death of the patient.
The right ventricle expands, and little blood enters the left ventricle. This causes a drop in blood pressure levels. The larger the vessel into which the thrombus has fallen, the stronger the disturbance.
Depending on where the blood clot is located, the percentage of death varies:
- If the blockage occurs in the main branch of the pulmonary artery or in its main trunk, then the probability of death of the patient rises to 75%.
- If the thrombus has stopped in the lobar and segmental branches, then the death of patients occurs in 6% of cases.
- With blockage of small pulmonary branches, lethal outcome is almost always avoided.
Pulmonary vein thrombosis symptoms
The symptoms of pulmonary vein thrombosis are manifold. They depend on how extensive the lesion is, what is the general state of health of the person, how quickly the thrombosis develops. The difficulty in making the correct diagnosis lies in the fact that pulmonary vein thrombosis has many symptoms that appear in a variety of combinations.
There are several basic signs that may accompany such a pathology:
- Cardiac syndrome. It develops in the first few hours after the onset of the disease. In this case, the person experiences chest pain. He has an increased heart rate, possibly the development of a collapse. Blood pressure drops sharply, and heart rate can be up to 100 beats per minute. The veins in the neck swell. About 20% of patients develop coronary insufficiency, accompanied by atrial fibrillation. With massive blockage of the vein, the patient develops cor pulmonale, which is manifested by the venous pulse and pulsation of the cervical veins. Edema of the face and neck is not observed.
- Pulmonary pleural syndrome. This syndrome accompanies cardiac disorders and is expressed in the appearance of shortness of breath. The number of breaths per minute reaches 30-40. Although the person does not have enough air, he does not show the desire to take a sitting position, preferring to lie down. Dyspnea always accompanies pulmonary vein thrombosis. Against the background of lung perfusion, human skin becomes cyanotic or ashy. Although cyanosis of the skin is not always a symptom, it is pathognomic for pulmonary vein thrombosis. It develops in only 16% of patients. A more permanent sign should be considered a pronounced pallor of the skin, which develops as a result of a spasm of small vessels.
- Abdominal syndrome, which is manifested by a painful attack. Severe pain behind the breastbone can be triggered by vasospasm, which occurs in response to violations in their patency, and can be caused by overstretching of the ventricle of the heart. Lung infarction, as a complication of thrombosis, also leads to severe pain, which gains intensity during breathing. This condition is characterized by a cough with bloody sputum. Sometimes pain can be localized in the right hypochondrium, which is caused by inflammation of the pleura or intestinal paresis. In this case, the liver increases in size, becomes painful when touched. The patient may develop hiccups, vomiting, belching.
- Renal syndrome. It is expressed in secretory anuria, when a person stops excreting urine.
- Cerebral syndrome. It is manifested by disorders of the brain. A person can lose consciousness, he often has seizures. Other manifestations of cerebral syndrome: tinnitus, vomiting, dizziness. In severe cases, the patient falls into a coma.
- Feverish syndrome. Body temperature rises to subfebrile levels or even higher. This is due to the development of inflammation in the lung tissue. The increased body temperature persists for 2-12 days. If the patient survived the acute stage, and he was saved, then after 14-21 days he may have an immunological reaction of the body. It is expressed in the appearance of a skin rash, repeated pleurisy, an increase in the level of eosinophils in the blood.
To increase the likelihood of a correct diagnosis and save the patient's life, you should remember about such indicators of thrombosis as:
- In almost 50% of cases, pulmonary vein thrombosis begins with a short loss of consciousness of the patient, or his being in a light-headed state.
- In 45% of cases, the pathology is accompanied by chest pain and pain in the heart.
- In 54% of cases, people suffer from suffocation.
- In more than 50% of cases, patients develop a pulmonary infarction, which is expressed by chest pain, shortness of breath, bloody cough, wheezing in the lungs.
Depending on the course of the disease, there are three forms of it:
- A lightning-fast course of thrombosis, when the death of a person occurs suddenly, within the first 10 minutes from the onset of the first symptoms. The cause of death in a fulminant form of thrombosis is reduced to cardiac arrest or suffocation.
- The acute form of thrombosis, when the patient has severe pain behind the sternum, breathing becomes intermittent, blood pressure drops sharply. Most often, acute thrombosis becomes the cause of death of a person in the first day from the beginning of its development.
- Subacute form, when symptoms develop gradually, leading to a lung infarction. The prognosis is more favorable, but a lethal outcome is likely.
- Chronic form, when the patient develops symptoms of heart and lung failure, which gradually increase in intensity.
Complications of pulmonary vein thrombosis
Complications of pulmonary thrombosis are many and varied. They are the ones that influence the life span of a person. The main complications of a blood clot in the lungs include: pulmonary infarction, vascular embolism in the systemic circulation, increased pressure in the vascular stack of the lungs of a chronic course. The sooner a person receives assistance adequate to his disease, the less the risk that he will develop severe complications.
The main pathological conditions that are provoked by pulmonary thrombosis include:
- Lung infarction. A heart attack develops after 2-3 days from the onset of the disease. The complication is accompanied by acute chest pain, bloody sputum, shortness of breath, fever.
- Pleurisy. This condition is a consequence of a lung infarction, it is expressed in inflammation of the pleura. An inflammatory reaction develops as a result of sweating of fluid accumulated in the lungs into the pleural cavity.
- Pneumonia.
- Lung abscess. In the place where the lung infarction occurred, the tissues begin to decay. This can lead to the formation of an abscess (abscess).
- Acute renal failure.
The most formidable complication of pulmonary vein thrombosis is the sudden death of a person.
Diagnostics of the pulmonary vein thrombosis
The primary goal of diagnosing pulmonary vein thrombosis is to determine the location of the thrombus. It is important to qualitatively and in the shortest possible time assess the damage that the blood clot caused to the patient's health, as well as how much hemodynamics in the body is impaired. It is imperative to find the place from which the thrombus has come off, which will eliminate the recurrence of the pathological condition.
The patient should be placed in the vascular surgery department, where there is equipment that will allow the highest quality diagnostic measures and start treatment.
Patient examination scheme:
- Examination, collection of anamnesis, qualitative assessment of risk factors for the presence of pulmonary thrombosis in the patient.
- Blood sampling for biochemical analysis.
- Study of the gas composition of blood, conducting a cologram. This method makes it possible to clarify the diagnosis, but only on its basis it cannot be assumed that the patient has precisely pulmonary vein thrombosis.
- ECG of the heart in dynamics. The procedure is required to perform differential diagnosis with heart failure, myocardial infarction and pericarditis. The method makes it possible to determine the further tactics of the patient's management, but the direct diagnosis of pulmonary vein thrombosis does not allow establishing.
- X-rays of light. The method allows you to make a differential diagnosis with pneumonia, rib fracture, pleurisy and other lung pathologies.
- Lung scintigraphy. A method that allows you to make the correct diagnosis with high accuracy, but the clinic must have a gamma camera.
- Duplex scanning. This method has a high informative value, but when obtaining normal research results, pulmonary vein thrombosis cannot be ruled out.
- D-dimer test. It takes about 4 hours to interpret the data, which often becomes critical for patients.
- Pulmonary angiopulmonography, which allows you to clarify the location of the thrombus. This method can be called safe and most often used when pulmonary thrombosis is suspected. However, not all clinics have the equipment that is needed to conduct this study. In addition, pulmonary angiography is an invasive and costly procedure.
- Phlebography of veins using contrast. This is an expensive and painful type of research, which belongs to invasive techniques.
So, of all the listed methods, only angiopulmonography and scintigraphy can accurately diagnose. The rest of the studies are auxiliary.
The differential diagnosis is carried out with pneumothorax, entrapment of a diaphragmatic hernia, tumors that compress the pulmonary vein.
Pulmonary vein thrombosis treatment
The basic tasks of pulmonary vein thrombosis therapy include:
- Make every effort to eliminate the threat of death from pulmonary or heart failure.
- To normalize the blood supply to the lung tissue.
- Prevent recurrence of thrombosis.
The patient is urgently hospitalized and placed in the intensive care unit. All measures are taken there to normalize the blood supply to the lung tissue. With the help of drugs Droperidol, Pentamin or Euphyllin, doctors achieve unloading of the small circle of blood circulation. Additionally, bronchodilators, cardiac glycosides are administered, oxygen therapy is performed.
With a submassive thrombus, catheterization of the pulmonary vein is performed, the thrombus is divided into fragments using the endovascular technique, and drugs are directly fed to it aimed at dissolving it.
To prevent blood clotting, high doses of heparin are injected into the body without interruption through a vein. The venous supply of the drug can be continued for 7 days, until the patient's condition improves. Then they switch to subcutaneous injections. In parallel with heparin, the patient is administered Reopolyglucin or Reomacrodex. This is especially true in the first 2 days from the start of therapy.
Drugs used to destroy a blood clot: Fibrinolysin, Aspergamine. Preparations for activating the endogenous process of destruction of a thrombus by the body itself: Streptase, Urokinase.
The indication for emergency embolectomy is the presence of a blood clot in the pulmonary trunk, or its main branches. If a patient has a severe degree of impaired lung perfusion, then the survival rate of such patients, even after the operation, remains low (no more than 12%). Nevertheless, embolectomy without preliminary diagnosis is the only chance to save life. Therefore, the surgeon should not let him go.
Contraindications for surgical intervention are: the presence of a malignant tumor of stage 4, as well as severe circulatory failure against the background of pathologies of the heart and blood vessels.
To prevent recurrent pulmonary vein thrombosis, a special cava filter is placed on the patient. It is administered either through the atrium, or plication of the inferior vena cava is performed with a mechanical suture. The procedure is carried out only after the performed ebolectomy. Kava filters can have a different design, which the doctor chooses at his own discretion.
As a rule, pulmonary vein thrombosis does not cause any pronounced health problems, if the patient survived after this complication. Although 17% of patients still develop stenosis of the main pulmonary trunk. This complication is called chronic pulmonary hypertension. It is accompanied by shortness of breath, which disturbs the patient even while he is at rest. This condition significantly worsens the prognosis for life. Most of the case histories in this case are fatal within 3-4 years.
Prevention of pulmonary vein thrombosis
In the prevention of pulmonary vein thrombosis, people over 40 years old, patients who have suffered a heart attack or stroke, and patients with obesity need it. It is also indicated for people who have a history of deep vein thrombosis of the lower extremities, or pulmonary vein thrombosis.
To prevent a blood clot from entering the lungs, you must adhere to the following recommendations:
- Regularly undergo ultrasound of the veins of the lower extremities.
- Wear elastic stockings.
- Take heparin as directed by your doctor.
- Do not give up setting the kava filter.
- Timely treat thrombophlebitis.
Pulmonary thrombosis is a serious pathology that requires emergency medical attention. But even in this case, the absence of death or disability cannot be guaranteed. Therefore, it is necessary to take into account all the risk factors leading to this condition and strive to prevent them.
The author of the article: Volkov Dmitry Sergeevich | c. m. n. surgeon, phlebologist
Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma from the Educational and Scientific Medical Center of the Presidential Administration of the Russian Federation.
