Acute Postoperative Pulmonary Thromboembolism as a Result of Intravascular Migration of a Pigtail Ureteral Stent Argyris S. Michalopoulos, MD, FCCM, Maria J. Tzoufi, MD, DEAA, George Theodorakis, MD, and Spyros D. Mentzelopoulos, MD, DEAA Department of Intensive Care Medicine, Henry Dunant General Hospital, Athens, Greece W e report an unusual case of acute, early post- operative pulmonary thromboembolism as a result of extreme intravascular migration of a pigtail ureteral stent with probable wedging of its tip into a pulmonary arterial branch. Case Report A 29-yr-old, 57-kg, 171-cm woman was subjected to pyelo- lithotomy under general endotracheal anesthesia. Her med- ical history included left kidney agenesis, two episodes of pyelonephritis within the past 3 mo, and mild (Grade 1) hydronephrosis. Before surgery, the clinical examination, electrocardiogram (ECG), and chest radiograph (CXR) were unremarkable; serum creatinine and 2-h creatinine clearance were 1.4 mg/dL and 65 mL/min, respectively. The opera- tion included right flank incision, removal of a large coral calculus from the renal pelvis and ureteropelvic junction via an intrahilar incision, antegrade placement of a self- retaining, 6F, 26-cm long, pigtail ureteral stent (Fig. 1), and closure of the pelvic wall and surgical wound. Before inser- tion, the surgeons confirmed that the stent’s tip was intact and that its distal curl exceeded 180° (1). On emergence from anesthesia, coughing occurred. After tracheal extubation, the patient was referred to the postan- esthesia care unit. Vigorous coughing (4 to 5 episodes of 1–2 min duration) occurred within the first 2 postextubation hours. Postoperative analgesia was patient controlled with IV fentanyl. Patient status was deemed as satisfactory dur- ing the first 12 postoperative hours (Table 1); she lay supine on her own preference. However, within the following hour, she complained of shortness of breath and “mild to moder- ate” pleuritic pain of sudden onset over the left lower hemi- thorax. Monitored variables indicated clinical deterioration (Table 1). Chest auscultation revealed diminished breath sounds and expiratory wheeze over the left lower hemithorax. Supplemental oxygen (inspired fraction, 0.31) was started. Diagnostic speculations included pulmonary embolism (small to moderate probability) (2,3), pneumonia (small probability because of the absence of high fever), and left ventricular ischemia (minimal probability) (4). A 12-lead ECG, transthoracic echocardiography, and an anteroposte- rior CXR were ordered (3). The ECG revealed only sinus tachycardia (115–120 bpm), a finding compatible with our first two speculations (3,5). Transthoracic echocardiography (performed by a cardiologist) revealed a foreign body within the right heart and pulmonary artery trunk. Mild tricuspid Accepted for publication July 9, 2002. Address correspondence and reprint requests to Spyros D. Men- tzelopoulos, MD, DEAA, 24-28 Ioustinianou St., GR-11473, Athens, Greece. Address e-mail to sdm@hol.gr. DOI: 10.1213/01.ANE.0000031247.30376.79 Figure 1. Intraoperative abdominal radiograph after placement of the self-retaining pigtail ureteral stent. The proximal curl of the stent (thick white arrow) is located at the level of the right kidney, whereas its distal curl and tip (thin white arrow) are situated within the ring of the pelvis and, thus, probably within the urinary bladder as well. ©2002 by the International Anesthesia Research Society 0003-2999/02 Anesth Analg 2002;95:1185–8 1185