Pulmonary thromboembolism due to superficial venous thrombophlebitis in upper limbs after cosmetic breast plastic surgery: report of 3 cases

Tromboses e tromboflebites superficiais de membros superiores são doenças frequentes e muitas vezes pouco valorizadas. Relatamos três pacientes no pós-operatório de cirurgias plásticas mamárias estéticas que apresentaram tromboflebite em membros superiores e que evoluíram com tromboembolismo pulmonar. Todas as pacientes apresentaram quadro clínico típico, com comprovação pelo Doppler ultrassonografia de trombose/flebite superficial de membros superiores e ausência de lesões em membros inferiores, bem como aumento de dímero-D e comprovação da embolia pulmonar por tomografia computadorizada ou cintilografia pulmonar. Os três casos evoluíram com melhora após anticoagulação e sem sequelas. ■ RESUMO

Pulmonary thromboembolism due to superficial venous thrombophlebitis in upper limbs after cosmetic breast plastic surgery: report of

Case Report
Superficial thrombosis and thrombophlebitis of the upper limbs are frequent and often underestimated diseases. We report three patients in the postoperative cosmetic breast plastic surgery period who presented thrombophlebitis in the upper limbs and who evolved with pulmonary thromboembolism. All patients had a typical clinical picture, with Doppler ultrasound evidence of thrombosis/superficial phlebitis of the upper limbs and absence of lesions in the lower limbs and an increase in D-dimer and evidence of pulmonary embolism by computed tomography or pulmonary scintigraphy. The three cases evolved with improvement after anticoagulation and without sequelae.

INTRODUCTION
Thromboembolic phenomena can result from thrombosis and/or superficial venous thrombophlebitis (SVT) of the upper limbs 1 . Most superficial thromboses also compete with phlebitis, in contrast to deep vein thrombosis (DVT), where phlebitis may be absent 2 . Pulmonary thromboembolism (PTE) can rarely be related to lower limb SVT (lower limbs) 1   Hoyos MBL www.rbcp.org.br 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.

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.

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).
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  PTE secondary to SVT of the upper limbs is rare in the absence of DVT 4 . 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 confirmed 8 . 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 surgery 10,11 . 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  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 phenomena 9,12 .
Hereditary thrombophilia (Chart 2) and oral contraceptives have a higher risk of thromboembolism, about 2 to 20 times 12 . Case 2 presented acquired thrombophilia (without a previous diagnosis) and use of oral contraception.
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. There is a case description of PTE in the literature due to SVT in a patient using hormone therapy only 4 . 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 risk 10 .
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 agents 10 .
Mechanical prophylaxis (elastic stockings, intermittent pneumatic devices) reduces venous stasis and distension. The pneumatic device has little fibrinolytic activity 10 . It is recommended to start it 30 minutes before anesthetic induction until the patient's discharge, in surgeries longer than one hour 10 .