{"paper_id":"1cc067e6-1ab4-4b7e-99df-62e5d453c0d2","body_text":"Postoperative Anastomotic Embolism and Persistent Chronic Nausea Following Pulmonary Artery Tear During Single-Port Thoracoscopic Lobectomy: A Case Report and Examination of Potential Mechanisms | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Postoperative Anastomotic Embolism and Persistent Chronic Nausea Following Pulmonary Artery Tear During Single-Port Thoracoscopic Lobectomy: A Case Report and Examination of Potential Mechanisms Deng Chengkun, Li Mingxue, Huang Ruoshan, Ji Hongbo, Cai Linsheng, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8127511/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 8 You are reading this latest preprint version Abstract This paper details the diagnosis and treatment of a 66-year-old male patient with invasive adenocarcinoma in the left upper lobe of the lung, who experienced a pulmonary artery injury during a single-port thoracoscopic lobectomy. During surgery, the basal trunk artery's root was torn due to enlarged lymph nodes encircling the pulmonary artery, necessitating an urgent conversion to thoracotomy for end-to-end anastomosis and reconstruction of the artery. Eighteen hours post-operation, the patient unexpectedly developed atrial fibrillation. A CTA scan confirmed an embolism in the left pulmonary basal trunk artery, leading to the administration of low-molecular-weight heparin and rivaroxaban for anticoagulation. Nausea recurred during this treatment, persisting for 12 months before resolving spontaneously upon cessation of the medication. Follow-up imaging indicated the embolism remained, though collateral circulation was compensating effectively. This case underscores the importance of devising an individualized vascular reconstruction strategy for managing complex pulmonary artery injuries, emphasizing the necessity of selecting the optimal repair method during surgery. New-onset atrial fibrillation post-surgery should be considered a potential indicator of pulmonary embolism, warranting prompt imaging evaluation. Furthermore, managing anticoagulant-related nausea is notably complex, potentially influenced by factors such as adverse drug reactions and abnormal neuroimmune responses triggered by embolic events. This study offers significant clinical insights into managing rare long-term complications following VATS. Pulmonary artery embolism Chronic nausea Pulmonary artery injury Single-port thoracoscopic surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Background With the advancement of minimally invasive techniques, Video-Assisted Thoracoscopic Surgery (VATS) has become a standard procedure for treating lung cancer. However, the limited field of view and restricted instrument movement in VATS present significant challenges, particularly the risk of pulmonary artery (PA) injury, a rare but severe complication for thoracic surgeons[ 1 ],[ 2 ]. These injuries often result from calcified lymph node adhesions and instrument manipulation, frequently leading to substantial intraoperative bleeding. Consequently, about half of such cases necessitate conversion to thoracotomy, significantly jeopardising perioperative safety. This paper presents a rare sequence of complex complications in a 66-year-old male who experienced a severe tear of the pulmonary artery. This occurred due to dense adhesions of calcified lymph nodes during a single-port VATS left upper lobectomy. Following an emergency conversion to thoracotomy and subsequent end-to-end anastomosis repair, the patient developed postoperative anastomotic embolism and new-onset atrial fibrillation. During anticoagulant therapy, he suffered from intractable chronic nausea, which persisted for nearly a year. This case aims to provide a comprehensive account of the clinical course, from the initial injury and repair to the rare long-term symptoms. It also seeks to explore underlying management strategies and pathogenesis, considering multiple hypotheses such as the effects of anticoagulant drugs and neuroimmune regulation. Case Presentation A 66-year-old male patient was admitted to the hospital following the detection of a solid nodule in the apical and posterior segment of the left upper lobe during a routine physical examination. The nodule measured approximately 1.7 cm by 2.2 cm, featuring spiculated margins, a lobulated appearance, and vacuole-like shadows, and was classified as Lung-RADS category 4B (Figure 1). A preoperative systematic evaluation of major organs revealed no significant abnormalities, and the TNM stage was determined to be cT1bN0M0. The patient, who had a 20-year history of smoking, had ceased smoking two years prior. He denied any history of gastrointestinal diseases. The surgical procedure involved a single-port thoracoscopic wedge resection of the left upper lobe. Intraoperative frozen pathology confirmed the presence of invasive adenocarcinoma, necessitating a left upper lobectomy with mediastinal lymph node dissection. During the dissection of the lingular segment artery, an enlarged lymph node, measuring 1.2 cm in diameter, was found tightly encasing the posterior wall of the blood vessel (Figure 2). This complication led to the inadvertent tearing of the lingular segment artery and the root of the basal trunk artery during blunt dissection, resulting in a rupture of 2.5 cm and significant bleeding. Consequently, an emergency conversion to thoracotomy was required, and the main left pulmonary artery was clamped to control the haemorrhage. An initial attempt to suture the side wall with 4-0 Prolene was unsuccessful due to a vascular stenosis rate exceeding 80%, accompanied by suture cutting. Ultimately, a longitudinal end-to-end anastomosis was performed to reconstruct the main pulmonary artery. During the operation, it was noted that the dorsal segment artery was pulsating, but the lumen of the basal trunk artery at the anastomosis site was narrowed, with an estimated stenosis rate approaching 70%. The left lower lung parenchyma turned red, indicating adequate perfusion. The surgery lasted 230 minutes, with a blood loss of 600 ml, yet no blood transfusion was necessary. Throughout the procedure, the mean arterial pressure was maintained above 65 mmHg, and SpO₂ levels remained stable above 90%. Postoperatively, the patient was successfully extubated and transferred to the general ward. In the early postoperative period, a bedside chest X-ray conducted 14 hours post-surgery revealed that the left lung had not fully re-expanded, with approximately 30% compression. Four hours later, the patient experienced a sudden onset of atrial fibrillation accompanied by hemodynamic instability, with a heart rate ranging from 100 to 140 bpm and blood pressure between 95-84/55-60 mmHg. To address these issues, amiodarone was administered for rhythm conversion and dopamine to elevate blood pressure. Bedside vascular ultrasonography of the neck and lower extremities showed no signs of venous thrombosis. Echocardiography indicated an enlarged right atrium, reduced motion amplitude of the right ventricular free wall, and tachycardia. Laboratory tests revealed elevated markers of infection and inflammation, with a WBC count of 10.4×10⁹/L, PCT at 0.153 μg/L, and CRP at 115.5 mg/L, while the high-sensitivity D-dimer was 3.066 mg/L. Pulmonary artery CTA (Figure 3) revealed exudation, consolidation, and a pleural effusion in the left lower lobe(Figure 3-A, B, C). Notably, while the artery to the dorsal segment remained patent (Figure 3-D, E), the basal segmental artery was completely occluded distal to the anastomosis.This led to a diagnosis of left pulmonary basal trunk artery embolism, prompting the initiation of anticoagulant therapy with low-molecular-weight heparin sodium injection at 4100 iu ih q12h. This dosage, calculated based on the patient's weight of 54 kg, was within the recommended treatment range. Following treatment, the atrial fibrillation converted to sinus rhythm after 35 hours, and hemodynamic stability was restored after 38 hours. At 24 hours post-operation, 310 ml of light bloody fluid was drained from the left thoracic cavity, and mild air leakage was noted during coughing. A chest X-ray at 40 hours post-operation showed that the left pneumothorax had largely resolved, although there was a slight increase in exudation in the left lower lung field compared to the previous examination. The chest tube was removed on the 6th day post-operation, and the patient was discharged on the 9th day after their condition stabilised. Anticoagulation and Nausea Symptoms Post-Discharge: Following discharge, the patient was prescribed rivaroxaban tablets at a dosage of 15 mg twice daily for 21 days, transitioning to 20 mg once daily thereafter. On the eighth day of rivaroxaban administration, the patient experienced intermittent nausea without vomiting. Over the subsequent three days, nausea intensified, accompanied by abdominal distension. Administration of 20 mg omeprazole enteric-coated tablets alleviated the nausea. However, on the seventeenth day, the patient experienced nausea again, this time with vomiting. Omeprazole provided no relief, prompting the patient to discontinue rivaroxaban independently. Nausea symptoms markedly improved by the second day after cessation, allowing normal eating, and rivaroxaban therapy was not resumed. By the twenty-fourth day, the patient experienced tolerable intermittent nausea. Despite continuing oral omeprazole, the condition persisted. One month post-discharge, the patient returned for a follow-up. A pulmonary artery CTA revealed embolism formation in the basal segment artery of the left lower lobe, with no significant change from previous assessments. Tests for blood cells, infection proteins, coagulation function, electrolytes, and thyroid function returned normal results. The high-sensitivity D-dimer level was 1.607 mg/L. A diagnosis of left pulmonary artery embolism was made, and continued rivaroxaban anticoagulation therapy was advised. However, the patient declined further treatment due to persistent nausea, opting instead for rest at home. To objectively assess the nausea, the Nausea Visual Analog Scale (N-VAS, 0–10 points) was employed. The patient reported intermittent nausea, with severe episodes scoring between 6 and 8 on the VAS. Seventy-two days post-surgery, the patient was re-admitted due to worsening nausea, with a Nausea Visual Analogue Scale (N-VAS) score of 7. Upon admission, vital signs and physical examination were normal, and the D-dimer level was 0.323 mg/L. Electrocardiogram, echocardiogram, and vascular ultrasound of the lower extremities showed no significant abnormalities. Pulmonary artery CTA and pulmonary perfusion imaging CTP revealed an embolism in the basal segment artery of the left lower lobe, consistent with previous findings. The infarct in the left lung had been absorbed (Figure 4-A), and exudation and effusion in the left lower lobe were largely resolved (Figure 4-B), although multiple patchy areas of reduced perfusion persisted (Figure 4-C). Abdominal aortic CTA showed no abnormalities. Gastroscopy indicated chronic non-atrophic gastritis with erosion in the gastric body. Brain MRI, including DWI and enhancement, showed white matter hyperintensity, graded as modified Fazekas grade 1. During the hospital stay, a multidisciplinary team recommended triple antiemetic therapy: ondansetron (8 mg, IV, twice daily), metoclopramide (10 mg, IM, twice daily), and dexamethasone sodium phosphate (5 mg, IV, once daily), along with esomeprazole (40 mg, orally, once daily) for acid suppression and gastric protection. Despite two weeks of this regimen, nausea improved only slightly, with the N-VAS score remaining at 4 to 6. Given the persistent but manageable symptoms, and after thorough discussion with the patient and family, discharge was advised with home rest. Telephone follow-up indicated a decrease in the patient's N-VAS score from an average of 4 at three months post-surgery to 2 at six months, and further to 0-1 (essentially resolved) at twelve months, with a notable reduction in episode frequency. Over an 18-month follow-up period, multiple examinations showed no tumour recurrence or metastasis, and serum tumour markers remained normal. Pulmonary function tests indicated partial compensation and improvement post-surgery, with enhanced exercise tolerance. At the last follow-up, the patient was in good health, with no evidence of tumour recurrence. Table 1: Overview of Postoperative Clinical Progress, Diagnostic Evaluation, and Key Management Points for Patients Time Point Key Events & Clinical Manifestations Diagnostic Results Interventions Preoperative A 66-year-old male presented with a 1.7×2.2 cm nodule in the left upper lung, classified as Lung-RADS 4B. Chest CT revealed a spiculated, lobulated nodule with air bubbles, indicating clinical stage cT1bN0M0. None Intraoperative During a single-port VATS left upper lobectomy, a 2.5 cm tear occurred in the pulmonary artery (PA) due to adhesion to a 1.2 cm calcified lymph node, causing massive haemorrhage. None Emergency conversion to open surgery was performed, with clamping of the left main PA. A 4-0 Prolene lateral suture failed, resulting in >80% stenosis; a longitudinal end-to-end anastomosis was achieved with ~60% stenosis. The operation lasted 230 minutes with a blood loss of 600 mL; no blood transfusion was administered. 18 h postoperatively The patient experienced sudden atrial fibrillation (100–140 bpm) and hypotension (95–84/55–60 mmHg). Echocardiography showed an enlarged right atrium and reduced right ventricular motion; D-dimer was 3.066 mg/L; CTPA indicated occlusion of the left lower lung basal trunk, with dorsal segment patency. Amiodarone was administered for cardioversion, dopamine for pressor support, and low-molecular-weight heparin (4100 IU, subcutaneous injection, q12h) was given. 6–9 days postoperatively Thoracic drainage decreased, with no air leakage and the patient's condition stabilised. Chest X-ray initially showed a 30% left lung collapse (14 h postop), which resolved by 40 h postop. The thoracic drain was removed, and the patient was discharged. An anticoagulation regimen of Rivaroxaban (15 mg bid for 21 days, followed by 20 mg qd) was initiated. 8 days after rivaroxaban initiation The patient reported intermittent nausea and abdominal distension, with a Nausea Visual Analogue Scale (N-VAS) score of 3–4 points. None Omeprazole (20 mg orally) was prescribed, leading to partial symptom relief. 17 days after rivaroxaban initiation The patient experienced severe nausea (N-VAS: 6–8 points) and vomiting. None The patient self-discontinued rivaroxaban, resulting in significant symptom relief two days later. 1-month follow-up Intermittent nausea persisted, with an N-VAS score of 4–6 points. CTPA showed persistent basal trunk artery embolism; D-dimer was 1.607 mg/L. The patient refused further anticoagulation and was advised to rest at home. 72 days postoperatively Nausea worsened (N-VAS: 7 points), leading to hospital readmission. CTPA revealed left lower lung perfusion defects; gastroscopy indicated chronic non-atrophic gastritis with erosion; brain MRI showed cerebral white matter hyperintensity (modified Fazekas grade 1); D-dimer was 0.323 mg/L. A multidisciplinary team (MDT) consultation recommended Ondansetron (8 mg IV bid), metoclopramide (10 mg IM bid), dexamethasone (5 mg IV qd), and esomeprazole (40 mg orally qd) for 2 weeks, resulting in minimal relief (N-VAS: 4–6 points). 3–12 months postoperatively The patient experienced intermittent nausea, with gradually decreasing severity and frequency. None No anticoagulation was administered, and symptoms resolved spontaneously. 18 months postoperatively There was no tumour recurrence, and the patient showed improved pulmonary function and exercise tolerance. Chest CT and serum tumour markers were normal. None Discussion The advantages of single-port thoracoscopic surgery in lung cancer resection lie in its minimally invasive nature and the potential for rapid recovery. However, the limited surgical field and restricted movement of instruments complicate the management of complex vascular injuries, particularly when dissecting lymph nodes around the pulmonary artery[ 3 ]. Inadequate operating space can increase the risk of vascular damage. In this case, severe intraoperative injury to the pulmonary artery was directly caused by the dense adhesion between calcified lymph nodes and the vascular adventitia. The restricted view and limited manoeuvrability of single-port thoracoscopy hindered the assessment of such complex adhesions, and attempts at blunt dissection led to uncontrollable tearing. This situation underscores the importance of thoroughly evaluating the vascular-lymph node relationship preoperatively. Although CT imaging indicated lymph node calcification, the extent of adhesion to the pulmonary artery wall posed significant intraoperative challenges. At this juncture, promptly halting anatomical dissection and prioritising the isolation of the pulmonary artery trunk with a pre-placed occlusion band is crucial for risk management, aligning with existing literature recommendations[ 4 ],[ 5 ]. A large-scale analysis by Tomoyasu[ 1 ] et al. revealed that the incidence of pulmonary artery injury during VATS is 1.5%, with 50% of cases requiring conversion to open surgery for haemostasis. Notably, left upper lobectomy is a significant high-risk procedure for pulmonary artery injury (43.8% vs 18.8%, p = 0.012), with the left anterior segmental artery being the most frequently injured vessel. In the event of acute massive bleeding, immediate conversion to open surgery is the preferred approach, adhering to the principles of \"damage control\" surgery, which prioritises rapid haemorrhage control to save lives. Compared to continued attempts at haemostasis via thoracoscopy, open surgery offers optimal exposure and operational freedom, significantly reducing ischaemia time and minimising the risk of secondary injury from blind manoeuvres[ 6 ]. The pivotal technical insight from this treatment concerns the choice of repair method. For partial lacerations, direct suture repair is favoured. When the laceration involves less than one-third of the vessel's circumference, continuous suturing with 5 − 0 polypropylene sutures achieves a success rate of 92% to 95%. In contrast, for complex injuries such as circular defects or vessel transection, autologous pericardial patch angioplasty has demonstrated favourable outcomes. A retrospective study of 118 cases of pulmonary artery reconstruction, including 51 cases using autologous pericardial patches, with an average follow-up of 70 months, reported no thromboembolic events linked to this technique[ 7 ]. In the present case, the large laceration, approximately 2.5 cm, rendered the initial attempt at continuous suturing unsuccessful due to the vessel wall's fragility and excessive tension, which exacerbated the defect. Theoretically, autologous pericardial patch angioplasty is the optimal choice for managing extensive circular or longitudinal defects, as it effectively restores lumen diameter and reduces turbulence, thus minimising the risk of postoperative stenosis and thrombus formation. However, we must acknowledge the technical constraints faced by our team during this emergency. The surgeon's limited experience in complex vascular reconstruction, particularly with the pericardial patch technique, coupled with the urgency of the bleeding, resulted in inadequate preparation and confidence to execute this method immediately. Consequently, to swiftly restore blood flow and conclude the surgery, we resorted to longitudinal end-to-end anastomosis as a compromise. Although this approach successfully restored the main blood flow and preserved the lung lobe, it is important to highlight that this reluctantly adopted method likely contributed to subsequent anastomotic stenosis, hemodynamic alterations, and ultimately postoperative embolism. The inherent geometric changes and unavoidable tension of the anastomosis foster conditions conducive to turbulence and endothelial damage, which can lead to thrombus formation. Postoperative secondary pulmonary embolism (PE) and atrial fibrillation (AF) are serious complications following thoracic surgery. When they occur together, they often complicate diagnosis and treatment decisions. This case distinctly illustrates the causal link between them and their clinical progression. Eighteen hours post-surgery, the patient abruptly developed AF, accompanied by hemodynamic instability. A bedside cardiac ultrasound provided vital diagnostic insights, revealing an enlarged right atrial diameter and reduced motion of the right ventricular free wall. These findings directly indicate an acute increase in right ventricular afterload, strongly suggesting the presence of PE. Subsequent laboratory tests (D-dimer 3.066 mg/L) and computed tomography pulmonary angiography (CTPA) confirmed this diagnosis, identifying an embolism in the left lower lobe basal trunk artery with pulmonary infarction. The sequence of postoperative PE and AF in this case, supported by objective examinations, elucidates the pathophysiological process: anastomotic stenosis and endothelial injury lead to acute in-situ thrombosis and embolism; the embolism causes a sudden rise in right ventricular afterload, resulting in right-heart dilation and dysfunction; increased right atrial pressure and stretch ultimately trigger AF[ 8 ]. Moreover, the acute inflammatory response in the embolised area may worsen atrial electrical remodelling through cytokine release[ 9 ]. Hence, AF in this instance should be viewed as a hemodynamic complication secondary to acute PE. This assessment directly impacts clinical decision-making: the focus of treatment should be on anticoagulation rather than mere rhythm control. Following anticoagulation with low-molecular-weight heparin, AF was successfully converted to sinus rhythm without recurrence, and hemodynamics stabilised, retrospectively confirming PE as the cause. Studies indicate that 14% of patients with acute PE also experience AF, and newly-diagnosed PE is linked to the severity of AF (hazard ratio 1.78, 95% CI 1.13–2.80)[ 10 ]. This case suggests that in instances of newly-diagnosed AF post-thoracoscopic lung resection, especially when vascular reconstruction is involved and accompanied by hemodynamic instability, PE should be highly suspected. Bedside cardiac ultrasound serves as a crucial initial assessment tool; if it indicates increased right-heart load, CTPA should be promptly performed to confirm the diagnosis and commence anticoagulation, thus preventing misdiagnosis as common postoperative AF and avoiding delays in treating PE. Postoperative CT scans of the pulmonary artery revealed an embolism in the basal trunk artery of the patient's left lower lobe. This condition was closely linked to local stenosis following intraoperative pulmonary artery angioplasty. Literature indicates that turbulence and endothelial damage post-angioplasty can increase the risk of thrombosis threefold[ 11 ]. Despite the administration of anticoagulant therapy post-surgery, the anatomical narrowing of the basal trunk artery impeded the effective penetration of anticoagulant drugs into the thrombus. The local turbulence created by vascular anastomosis resulted in a \"dead-space effect,\" facilitating thrombus organisation and explaining the persistent embolism observed in follow-up pulmonary artery CTAs. Importantly, the patency of the dorsal segment artery may have allowed for limited collateral circulation via bronchial artery-pulmonary artery anastomosis, preventing the patient from experiencing a large-area pulmonary infarction. Animal studies suggest that when the lobar artery is completely or nearly obstructed, collateral blood flow is directly proportional to systemic arterial pressure. After three months, collateral circulation can compensate for up to two-thirds of normal pulmonary circulation, with more pronounced bronchial collateral development in cases of severe pulmonary artery stenosis[ 12 ]. This mechanism aptly explains why, in this instance, despite the persistent embolism, the damage to pulmonary parenchyma remained minimal. The origins of the chronic nausea experienced by the patient post-surgery are multifaceted and necessitate thorough investigation. Primarily, the gastrointestinal side effects of rivaroxaban are the most immediate cause. Adverse reactions, including nausea and abdominal distension, occur in approximately 5% to 10% of cases. This may be due to the drug's direct stimulation of the gastric mucosa, inhibition of prostaglandin synthesis, and effects on local barrier function. In this instance, nausea emerged on the eighth day of medication and notably subsided within two days of discontinuation, indicating a strong temporal link to the drug's adverse effects. Nonetheless, the persistence and recurrence of symptoms for nearly a year post-withdrawal suggest additional underlying factors. Gastroscopy revealed only chronic non-atrophic gastritis with erosion, without any organic lesions to account for the persistent and severe nausea. Postoperative gastroparesis was considered; however, the absence of typical symptoms such as early satiety and vomiting of food residues, along with the preservation of the vagus nerve's main trunk during surgery, significantly reduces the likelihood of direct surgical damage to the nerve branches innervating the gastrointestinal tract. Furthermore, the spontaneous remission after a year does not align with typical postoperative gastroparesis characteristics. Additionally, significant surgical trauma, stress, and prolonged discomfort might have triggered or worsened psychogenic nausea[ 13 ]. Unfortunately, early objective examinations, such as electrogastrography and gastric emptying tests, were not conducted to definitively exclude motility disorders, nor were effective psychological assessment tools employed. This represents a limitation of the study. To elucidate why symptoms persist long after drug withdrawal, we hypothesise a complex neuroimmune regulatory mechanism may be at play. Drawing from the specifics of this case, we suggest a potential pathway: Pulmonary artery embolism results in local pulmonary tissue ischemia, inflammation, and acidosis. These conditions might activate spinal afferent nerves in the lungs, such as acid-sensitive channels, subsequently influencing regulatory centres like the nucleus of the solitary tract in the brainstem. Persistent abnormal afferent signals could lead to central sensitisation and disruption of neuroimmune interactions[ 14 ],[ 15 ], impacting gastrointestinal motility and sensory function via the vagus nerve and sympathetic nervous system, thus causing prolonged nausea[ 16 ]. It is important to emphasise that this hypothesis is speculative, grounded in existing literature and the clinical progression of this case, necessitating further research for validation. Regrettably, this study did not measure serum cytokine levels (e.g., IL-6, TNF-α) to confirm a systemic inflammatory state, nor did it assess autonomic nervous function through heart rate variability analysis. Consequently, direct evidence supporting this mechanism remains lacking. In summary, the chronic nausea in this case likely arises from a combination of factors: Rivaroxaban appears to have directly initiated the symptoms, while the ongoing condition may be linked to abnormal neuroimmune regulation and central sensitization caused by the embolism event. This may be further complicated by the psychophysiological effects of surgical stress. For similar patients in the future, a multi-dimensional assessment is advised, encompassing inflammatory markers, gastrointestinal motility, and psychological evaluations, to enable a more comprehensive diagnosis and management approach. Declarations Funding Yunnan Provincial Department of Science and Technology-Kunming Medical University Joint Special Top Project on Applied Basic Research (Project No. 202401AY070001-370). Consent for publication A written informed consent was obtained from the patient for publication of this case report and any accompanying images. Authors , contributions DCK provided the clinical data included in the text. LMX,HRS,JHB and FYD participated in the treatment decisions. CLS wrote the manuscript draft. WJF and KQB revised it critically and approved the modified text. WJF and approved the final version of the manuscript. All the authors read and approved the final manuscript. References Tomoyasu M, Deguchi H, Kudo S, et al. Evaluation of pulmonary artery bleeding during thoracoscopic pulmonary resection for lung cancer. Thorac Cancer. 2022;13(21):3001-3006. doi:10.1111/1759-7714.14649 Bertolaccini L, Davoli F, Pardolesi A, et al. Conversion due to vascular injury during video-assisted thoracic surgery lobectomy: A multicentre retrospective analysis from the Italian video-assisted thoracic surgery group registry. Eur J Surg Oncol. 2019;45(5):857-862. doi:10.1016/j.ejso.2018.12.023 Kim K, Kim HK, Park JS, et al. Video-assisted thoracic surgery lobectomy: single institutional experience with 704 cases. Ann Thorac Surg. 2010;89(6):S2118-S2122. doi:10.1016/j.athoracsur.2010.03.017 Bertolaccini L, Calabrese F, Brandolini J, Solli P. Vascular injuries during VATS lobectomies: keep calm, compress and have a plan. Ann Transl Med. 2019;7(1):19. doi:10.21037/atm.2018.11.33 Choi YS. Management of Complications During Video-Assisted Thoracic Surgery Lung Resection and Lymph Node Dissection. J Chest Surg. 2021;54(4):263-265. Thoracoscopic Surgery Group of the Thoracic and Cardiovascular Surgery Branch, Chinese Medical Association; Minimally Invasive Thoracic Surgery Expert Committee of the Thoracic Surgery Branch, Chinese Medical Doctor Association. Clinical Practice Guidelines for Thoracoscopic Lobectomy in China [J]. Chinese Medical Journal, 2018, 98(47): 3832-3841. Ma Q, Liu D, Guo Y, et al. Surgical techniques and results of the pulmonary artery reconstruction for patients with central non-small cell lung cancer. J Cardiothorac Surg. 2013;8:219. Bryce YC, Perez-Johnston R, Bryce EB, Homayoon B, Santos-Martin EG. Pathophysiology of right ventricular failure in acute pulmonary embolism and chronic thromboembolic pulmonary hypertension: a pictorial essay for the interventional radiologist. Insights Imaging. 2019;10(1):18. Hashem A, Khalouf A, Mohamed MS, et al. COVID-19 Infection Is Associated With Increased In-Hospital Mortality and Complications in Patients With Acute Heart Failure: Insight From National Inpatient Sample (2020). J Intensive Care Med. 2023;38(11):1068-1077. Bikdeli B, Abou Ziki MD, Lip GYH. Pulmonary Embolism and Atrial Fibrillation: Two Sides of the Same Coin? A Systematic Review [published correction appears in Semin Thromb Hemost. 2017 Dec;43(8):e1. Goldberg JB, Giri J, Kobayashi T, et al. Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association. Circulation. 2023;147(9):e628-e647. HEIMBURG P. BRONCHIAL COLLATERAL CIRCULATION IN EXPERIMENTAL STENOSIS OF THE PULMONARY ARTERY. Thorax. 1964;19(4):306-310. Singh P, Yoon SS, Kuo B. Nausea: a review of pathophysiology and therapeutics. Therap Adv Gastroenterol. 2016;9(1):98-112. doi:10.1177/1756283X15618131 Gu Yun, Zhuang Zhong. New progress in study of inflammatory reflex[J]. Chinese Journal of Pathophysiology,2016,32(12):2300-2304. Kelly MJ, Breathnach C, Tracey KJ, Donnelly SC. Manipulation of the inflammatory reflex as a therapeutic strategy. Cell Rep Med. 2022;3(7):100696. doi:10.1016/j.xcrm.2022.100696 Chang FY, Lu CL. Hiccup: mystery, nature and treatment. J Neurogastroenterol Motil. 2012;18(2):123-130. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Reviewers agreed at journal 28 Jan, 2026 Reviews received at journal 26 Jan, 2026 Reviewers agreed at journal 24 Jan, 2026 Reviewers agreed at journal 24 Jan, 2026 Reviewers invited by journal 23 Jan, 2026 Editor assigned by journal 22 Nov, 2025 Submission checks completed at journal 22 Nov, 2025 First submitted to journal 16 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8127511\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Case Report\",\"associatedPublications\":[],\"authors\":[{\"id\":580705649,\"identity\":\"1fba8dbc-dda0-4d81-b908-56b51659bbbb\",\"order_by\":0,\"name\":\"Deng Chengkun\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First People's Hospital of Qujing City\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Deng\",\"middleName\":\"\",\"lastName\":\"Chengkun\",\"suffix\":\"\"},{\"id\":580705650,\"identity\":\"0c100605-442d-45fe-86d0-f2e9bf377a39\",\"order_by\":1,\"name\":\"Li Mingxue\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First People's Hospital of Qujing City\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Li\",\"middleName\":\"\",\"lastName\":\"Mingxue\",\"suffix\":\"\"},{\"id\":580705651,\"identity\":\"5f7d28b0-9be6-4527-8827-858c6cb38ac5\",\"order_by\":2,\"name\":\"Huang Ruoshan\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First People's Hospital of Qujing City\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Huang\",\"middleName\":\"\",\"lastName\":\"Ruoshan\",\"suffix\":\"\"},{\"id\":580705652,\"identity\":\"69c30318-5d29-4879-8eca-3584aa3047ba\",\"order_by\":3,\"name\":\"Ji Hongbo\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First People's Hospital of Qujing City\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ji\",\"middleName\":\"\",\"lastName\":\"Hongbo\",\"suffix\":\"\"},{\"id\":580705653,\"identity\":\"70c1c918-8de6-4f2d-a214-c93e923d56b1\",\"order_by\":4,\"name\":\"Cai Linsheng\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First People's Hospital of Qujing City\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Cai\",\"middleName\":\"\",\"lastName\":\"Linsheng\",\"suffix\":\"\"},{\"id\":580705654,\"identity\":\"c3ee5d82-8470-4aeb-9bcc-cd3d5853fc3c\",\"order_by\":5,\"name\":\"Fu Yudong\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First People's Hospital of Qujing City\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Fu\",\"middleName\":\"\",\"lastName\":\"Yudong\",\"suffix\":\"\"},{\"id\":580705655,\"identity\":\"8d388bb4-101c-45c0-b213-9cad5d76d74c\",\"order_by\":6,\"name\":\"Kan Qiangbo\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First People's Hospital of Qujing City\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Kan\",\"middleName\":\"\",\"lastName\":\"Qiangbo\",\"suffix\":\"\"},{\"id\":580705656,\"identity\":\"18ae1d98-79dd-40fc-8460-f35770028a0a\",\"order_by\":7,\"name\":\"Wang Junfeng\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIie3RMQrCMBSA4VeEdgnU8ZVCbyBECqFTPUtwcO3YSVqEeoUew8k5JYOjq+LSTK45QAdTnZySUTD//D6SlwD4fD/Z8NRIkYRR2yrtRiSDoiqymMhDjm5kwaDWdZ70u25JXAAdZDjeKPLTXXWAUGarxkaEjNb9TB68GyvY5kxYCBNXkeKHHCmC4Gc7kZBO74sNHRJHEqI5xawfOJKNkAtqiHlkbh6ZOuyS9DIYcdqbr7wopesysxLArwlqG5+LG5cpn8/n++temXBGm8n3dVcAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"The First People's Hospital of Qujing City\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Wang\",\"middleName\":\"\",\"lastName\":\"Junfeng\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-11-16 13:38:24\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8127511/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8127511/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s13019-026-04155-0\",\"type\":\"published\",\"date\":\"2026-04-20T15:58:13+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":101785086,\"identity\":\"7e6938d6-cd47-4d91-b4d2-19562296396d\",\"added_by\":\"auto\",\"created_at\":\"2026-02-03 15:33:37\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":107885,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eRepresentative chest CT image demonstrating a nodule in the left upper lobe (arrow).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8127511/v1/43105d924e1378345fd7a5e1.png\"},{\"id\":101785084,\"identity\":\"1aea0ae8-6a14-4465-9e3f-8bed808e13b1\",\"added_by\":\"auto\",\"created_at\":\"2026-02-03 15:33:37\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":5713,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eChest CT scan demonstrating an enlarged lymph node (arrow) adjacent to the left upper lobe lingular artery.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8127511/v1/7f7b37bf8218d23c394b8ffa.png\"},{\"id\":101785087,\"identity\":\"b173e515-be5b-421a-b965-c474b8f6a242\",\"added_by\":\"auto\",\"created_at\":\"2026-02-03 15:33:37\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":388828,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003ePostoperative follow-up pulmonary artery CTA.\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e(A）Axial image shows a consolidation (approximately 2.8 cm in diameter, green arrow) in the basal segment of the left lower lobe.（B）Axial image reveals patchy and linear opacities in the left lower lobe, suggestive of postoperative changes.（C）Axial image demonstrates a left-sided pleural effusion (blue arrow).（D）Axial image indicates significant stenosis of the left main pulmonary artery (yellow arrow). The segmental artery to the superior segment is patent, while the basal trunk is completely occluded distal to the anastomosis.（E）Three-dimensional reconstruction of the pulmonary artery confirms the patent segmental artery to the superior segment (red arrow), which serves as a critical collateral pathway.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8127511/v1/7412b09058c128e357b43511.png\"},{\"id\":101785085,\"identity\":\"2e223173-b3bb-4f83-8a19-5d4aaa972540\",\"added_by\":\"auto\",\"created_at\":\"2026-02-03 15:33:37\",\"extension\":\"png\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":277992,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003e(A) \\u003c/strong\\u003eChest CT image shows complete resolution of the consolidation in the left lower lobe.（B） Chest CT image demonstrates resolution of the left pleural effusion and pulmonary exudation.（C） Computed tomography perfusion (CTP) image reveals multiple patchy areas of decreased perfusion (red arrows) in the left lower lobe, indicating incomplete recovery of blood flow.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"4.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8127511/v1/2e66070a2745a640583d11f4.png\"},{\"id\":107929312,\"identity\":\"60c0a0da-fab8-41f5-9408-8a8023f8b1cf\",\"added_by\":\"auto\",\"created_at\":\"2026-04-27 16:14:49\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":908847,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8127511/v1/b025b8e8-9ef2-43d3-8c1f-7ed43ad4dcdc.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Postoperative Anastomotic Embolism and Persistent Chronic Nausea Following Pulmonary Artery Tear During Single-Port Thoracoscopic Lobectomy: A Case Report and Examination of Potential Mechanisms\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eWith the advancement of minimally invasive techniques, Video-Assisted Thoracoscopic Surgery (VATS) has become a standard procedure for treating lung cancer. However, the limited field of view and restricted instrument movement in VATS present significant challenges, particularly the risk of pulmonary artery (PA) injury, a rare but severe complication for thoracic surgeons[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e],[\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. These injuries often result from calcified lymph node adhesions and instrument manipulation, frequently leading to substantial intraoperative bleeding. Consequently, about half of such cases necessitate conversion to thoracotomy, significantly jeopardising perioperative safety.\\u003c/p\\u003e \\u003cp\\u003eThis paper presents a rare sequence of complex complications in a 66-year-old male who experienced a severe tear of the pulmonary artery. This occurred due to dense adhesions of calcified lymph nodes during a single-port VATS left upper lobectomy. Following an emergency conversion to thoracotomy and subsequent end-to-end anastomosis repair, the patient developed postoperative anastomotic embolism and new-onset atrial fibrillation. During anticoagulant therapy, he suffered from intractable chronic nausea, which persisted for nearly a year. This case aims to provide a comprehensive account of the clinical course, from the initial injury and repair to the rare long-term symptoms. It also seeks to explore underlying management strategies and pathogenesis, considering multiple hypotheses such as the effects of anticoagulant drugs and neuroimmune regulation.\\u003c/p\\u003e\"},{\"header\":\"Case Presentation\",\"content\":\"\\u003cp\\u003eA 66-year-old male patient was admitted to the hospital following the detection of a solid nodule in the apical and posterior segment of the left upper lobe during a routine physical examination. The nodule measured approximately 1.7 cm by 2.2 cm, featuring spiculated margins, a lobulated appearance, and vacuole-like shadows, and was classified as Lung-RADS category 4B (Figure 1). A preoperative systematic evaluation of major organs revealed no significant abnormalities, and the TNM stage was determined to be cT1bN0M0. The patient, who had a 20-year history of smoking, had ceased smoking two years prior. He denied any history of gastrointestinal diseases. \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe surgical procedure involved a single-port thoracoscopic wedge resection of the left upper lobe. Intraoperative frozen pathology confirmed the presence of invasive adenocarcinoma, necessitating a left upper lobectomy with mediastinal lymph node dissection. During the dissection of the lingular segment artery, an enlarged lymph node, measuring 1.2 cm in diameter, was found tightly encasing the posterior wall of the blood vessel (Figure 2). This complication led to the inadvertent tearing of the lingular segment artery and the root of the basal trunk artery during blunt dissection, resulting in a rupture of 2.5 cm and significant bleeding. Consequently, an emergency conversion to thoracotomy was required, and the main left pulmonary artery was clamped to control the haemorrhage. An initial attempt to suture the side wall with 4-0 Prolene was unsuccessful due to a vascular stenosis rate exceeding 80%, accompanied by suture cutting. Ultimately, a longitudinal end-to-end anastomosis was performed to reconstruct the main pulmonary artery. During the operation, it was noted that the dorsal segment artery was pulsating, but the lumen of the basal trunk artery at the anastomosis site was narrowed, with an estimated stenosis rate approaching 70%. The left lower lung parenchyma turned red, indicating adequate perfusion. The surgery lasted 230 minutes, with a blood loss of 600 ml, yet no blood transfusion was necessary. Throughout the procedure, the mean arterial pressure was maintained above 65 mmHg, and SpO₂ levels remained stable above 90%. Postoperatively, the patient was successfully extubated and transferred to the general ward.\\u003c/p\\u003e\\n\\u003cp\\u003eIn the early postoperative period, a bedside chest X-ray conducted 14 hours post-surgery revealed that the left lung had not fully re-expanded, with approximately 30% compression. Four hours later, the patient experienced a sudden onset of atrial fibrillation accompanied by hemodynamic instability, with a heart rate ranging from 100 to 140 bpm and blood pressure between 95-84/55-60 mmHg. To address these issues, amiodarone was administered for rhythm conversion and dopamine to elevate blood pressure. Bedside vascular ultrasonography of the neck and lower extremities showed no signs of venous thrombosis. Echocardiography indicated an enlarged right atrium, reduced motion amplitude of the right ventricular free wall, and tachycardia. Laboratory tests revealed elevated markers of infection and inflammation, with a WBC count of 10.4\\u0026times;10⁹/L, PCT at 0.153 \\u0026mu;g/L, and CRP at 115.5 mg/L, while the high-sensitivity D-dimer was 3.066 mg/L. Pulmonary artery CTA (Figure 3) revealed exudation, consolidation, and a pleural effusion in the left lower lobe(Figure 3-A, B, C). Notably, while the artery to the dorsal segment remained patent (Figure 3-D, E), the basal segmental artery was completely occluded distal to the anastomosis.This led to a diagnosis of left pulmonary basal trunk artery embolism, prompting the initiation of anticoagulant therapy with low-molecular-weight heparin sodium injection at 4100 iu ih q12h. This dosage, calculated based on the patient\\u0026apos;s weight of 54 kg, was within the recommended treatment range. Following treatment, the atrial fibrillation converted to sinus rhythm after 35 hours, and hemodynamic stability was restored after 38 hours. At 24 hours post-operation, 310 ml of light bloody fluid was drained from the left thoracic cavity, and mild air leakage was noted during coughing. A chest X-ray at 40 hours post-operation showed that the left pneumothorax had largely resolved, although there was a slight increase in exudation in the left lower lung field compared to the previous examination. The chest tube was removed on the 6th day post-operation, and the patient was discharged on the 9th day after their condition stabilised.\\u003c/p\\u003e\\n\\u003cp\\u003eAnticoagulation and Nausea Symptoms Post-Discharge: Following discharge, the patient was prescribed rivaroxaban tablets at a dosage of 15 mg twice daily for 21 days, transitioning to 20 mg once daily thereafter. On the eighth day of rivaroxaban administration, the patient experienced intermittent nausea without vomiting. Over the subsequent three days, nausea intensified, accompanied by abdominal distension. Administration of 20 mg omeprazole enteric-coated tablets alleviated the nausea. However, on the seventeenth day, the patient experienced nausea again, this time with vomiting. Omeprazole provided no relief, prompting the patient to discontinue rivaroxaban independently. Nausea symptoms markedly improved by the second day after cessation, allowing normal eating, and rivaroxaban therapy was not resumed. By the twenty-fourth day, the patient experienced tolerable intermittent nausea. Despite continuing oral omeprazole, the condition persisted. One month post-discharge, the patient returned for a follow-up. A pulmonary artery CTA revealed embolism formation in the basal segment artery of the left lower lobe, with no significant change from previous assessments. Tests for blood cells, infection proteins, coagulation function, electrolytes, and thyroid function returned normal results. The high-sensitivity D-dimer level was 1.607 mg/L. A diagnosis of left pulmonary artery embolism was made, and continued rivaroxaban anticoagulation therapy was advised. However, the patient declined further treatment due to persistent nausea, opting instead for rest at home. To objectively assess the nausea, the Nausea Visual Analog Scale (N-VAS, 0\\u0026ndash;10 points) was employed. The patient reported intermittent nausea, with severe episodes scoring between 6 and 8 on the VAS.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;Seventy-two days post-surgery, the patient was re-admitted due to worsening nausea, with a Nausea Visual Analogue Scale (N-VAS) score of 7. Upon admission, vital signs and physical examination were normal, and the D-dimer level was 0.323 mg/L. Electrocardiogram, echocardiogram, and vascular ultrasound of the lower extremities showed no significant abnormalities. Pulmonary artery CTA and pulmonary perfusion imaging CTP revealed an embolism in the basal segment artery of the left lower lobe, consistent with previous findings. The infarct in the left lung had been absorbed (Figure 4-A), and exudation and effusion in the left lower lobe were largely resolved (Figure 4-B), although multiple patchy areas of reduced perfusion persisted (Figure 4-C). Abdominal aortic CTA showed no abnormalities. Gastroscopy indicated chronic non-atrophic gastritis with erosion in the gastric body. Brain MRI, including DWI and enhancement, showed white matter hyperintensity, graded as modified Fazekas grade 1. During the hospital stay, a multidisciplinary team recommended triple antiemetic therapy: ondansetron (8 mg, IV, twice daily), metoclopramide (10 mg, IM, twice daily), and dexamethasone sodium phosphate (5 mg, IV, once daily), along with esomeprazole (40 mg, orally, once daily) for acid suppression and gastric protection. Despite two weeks of this regimen, nausea improved only slightly, with the N-VAS score remaining at 4 to 6. Given the persistent but manageable symptoms, and after thorough discussion with the patient and family, discharge was advised with home rest.\\u003c/p\\u003e\\n\\u003cp\\u003eTelephone follow-up indicated a decrease in the patient\\u0026apos;s N-VAS score from an average of 4 at three months post-surgery to 2 at six months, and further to 0-1 (essentially resolved) at twelve months, with a notable reduction in episode frequency. Over an 18-month follow-up period, multiple examinations showed no tumour recurrence or metastasis, and serum tumour markers remained normal. Pulmonary function tests indicated partial compensation and improvement post-surgery, with enhanced exercise tolerance. At the last follow-up, the patient was in good health, with no evidence of tumour recurrence.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 1: Overview of Postoperative Clinical Progress, Diagnostic Evaluation, and Key Management Points for Patients\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"719\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 107px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTime Point\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 182px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eKey Events \\u0026amp; Clinical Manifestations\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 178px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eDiagnostic Results\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 253px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eInterventions\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 107px;\\\"\\u003e\\n \\u003cp\\u003ePreoperative\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 182px;\\\"\\u003e\\n \\u003cp\\u003eA 66-year-old male presented with a 1.7\\u0026times;2.2 cm nodule in the left upper lung, classified as Lung-RADS 4B.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 178px;\\\"\\u003e\\n \\u003cp\\u003eChest CT revealed a spiculated, lobulated nodule with air bubbles, indicating clinical stage cT1bN0M0.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 253px;\\\"\\u003e\\n \\u003cp\\u003eNone\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 107px;\\\"\\u003e\\n \\u003cp\\u003eIntraoperative\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 182px;\\\"\\u003e\\n \\u003cp\\u003eDuring a single-port VATS left upper lobectomy, a 2.5 cm tear occurred in the pulmonary artery (PA) due to adhesion to a 1.2 cm calcified lymph node, causing massive haemorrhage.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 178px;\\\"\\u003e\\n \\u003cp\\u003eNone\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 253px;\\\"\\u003e\\n \\u003cp\\u003eEmergency conversion to open surgery was performed, with clamping of the left main PA. A 4-0 Prolene lateral suture failed, resulting in \\u0026gt;80% stenosis; a longitudinal end-to-end anastomosis was achieved with ~60% stenosis. The operation lasted 230 minutes with a blood loss of 600 mL; no blood transfusion was administered.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 107px;\\\"\\u003e\\n \\u003cp\\u003e18 h postoperatively\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 182px;\\\"\\u003e\\n \\u003cp\\u003eThe patient experienced sudden atrial fibrillation (100\\u0026ndash;140 bpm) and hypotension (95\\u0026ndash;84/55\\u0026ndash;60 mmHg).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 178px;\\\"\\u003e\\n \\u003cp\\u003eEchocardiography showed an enlarged right atrium and reduced right ventricular motion; D-dimer was 3.066 mg/L; CTPA indicated occlusion of the left lower lung basal trunk, with dorsal segment patency.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 253px;\\\"\\u003e\\n \\u003cp\\u003eAmiodarone was administered for cardioversion, dopamine for pressor support, and low-molecular-weight heparin (4100 IU, subcutaneous injection, q12h) was given.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 107px;\\\"\\u003e\\n \\u003cp\\u003e6\\u0026ndash;9 days postoperatively\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 182px;\\\"\\u003e\\n \\u003cp\\u003eThoracic drainage decreased, with no air leakage and the patient\\u0026apos;s condition stabilised.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 178px;\\\"\\u003e\\n \\u003cp\\u003eChest X-ray initially showed a 30% left lung collapse (14 h postop), which resolved by 40 h postop.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 253px;\\\"\\u003e\\n \\u003cp\\u003eThe thoracic drain was removed, and the patient was discharged. An anticoagulation regimen of Rivaroxaban (15 mg bid for 21 days, followed by 20 mg qd) was initiated.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 107px;\\\"\\u003e\\n \\u003cp\\u003e8 days after rivaroxaban initiation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 182px;\\\"\\u003e\\n \\u003cp\\u003eThe patient reported intermittent nausea and abdominal distension, with a Nausea Visual Analogue Scale (N-VAS) score of 3\\u0026ndash;4 points.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 178px;\\\"\\u003e\\n \\u003cp\\u003eNone\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 253px;\\\"\\u003e\\n \\u003cp\\u003eOmeprazole (20 mg orally) was prescribed, leading to partial symptom relief.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 107px;\\\"\\u003e\\n \\u003cp\\u003e17 days after rivaroxaban initiation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 182px;\\\"\\u003e\\n \\u003cp\\u003eThe patient experienced severe nausea (N-VAS: 6\\u0026ndash;8 points) and vomiting.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 178px;\\\"\\u003e\\n \\u003cp\\u003eNone\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 253px;\\\"\\u003e\\n \\u003cp\\u003eThe patient self-discontinued rivaroxaban, resulting in significant symptom relief two days later.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 107px;\\\"\\u003e\\n \\u003cp\\u003e1-month follow-up\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 182px;\\\"\\u003e\\n \\u003cp\\u003eIntermittent nausea persisted, with an N-VAS score of 4\\u0026ndash;6 points.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 178px;\\\"\\u003e\\n \\u003cp\\u003eCTPA showed persistent basal trunk artery embolism; D-dimer was 1.607 mg/L.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 253px;\\\"\\u003e\\n \\u003cp\\u003eThe patient refused further anticoagulation and was advised to rest at home.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 107px;\\\"\\u003e\\n \\u003cp\\u003e72 days postoperatively\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 182px;\\\"\\u003e\\n \\u003cp\\u003eNausea worsened (N-VAS: 7 points), leading to hospital readmission.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 178px;\\\"\\u003e\\n \\u003cp\\u003eCTPA revealed left lower lung perfusion defects; gastroscopy indicated chronic non-atrophic gastritis with erosion; brain MRI showed cerebral white matter hyperintensity (modified Fazekas grade 1); D-dimer was 0.323 mg/L.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 253px;\\\"\\u003e\\n \\u003cp\\u003eA multidisciplinary team (MDT) consultation recommended Ondansetron (8 mg IV bid), metoclopramide (10 mg IM bid), dexamethasone (5 mg IV qd), and esomeprazole (40 mg orally qd) for 2 weeks, resulting in minimal relief (N-VAS: 4\\u0026ndash;6 points).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 107px;\\\"\\u003e\\n \\u003cp\\u003e3\\u0026ndash;12 months postoperatively\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 182px;\\\"\\u003e\\n \\u003cp\\u003eThe patient experienced intermittent nausea, with gradually decreasing severity and frequency.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 178px;\\\"\\u003e\\n \\u003cp\\u003eNone\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 253px;\\\"\\u003e\\n \\u003cp\\u003eNo anticoagulation was administered, and symptoms resolved spontaneously.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 107px;\\\"\\u003e\\n \\u003cp\\u003e18 months postoperatively\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 182px;\\\"\\u003e\\n \\u003cp\\u003eThere was no tumour recurrence, and the patient showed improved pulmonary function and exercise tolerance.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 178px;\\\"\\u003e\\n \\u003cp\\u003eChest CT and serum tumour markers were normal.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 253px;\\\"\\u003e\\n \\u003cp\\u003eNone\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThe advantages of single-port thoracoscopic surgery in lung cancer resection lie in its minimally invasive nature and the potential for rapid recovery. However, the limited surgical field and restricted movement of instruments complicate the management of complex vascular injuries, particularly when dissecting lymph nodes around the pulmonary artery[\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. Inadequate operating space can increase the risk of vascular damage. In this case, severe intraoperative injury to the pulmonary artery was directly caused by the dense adhesion between calcified lymph nodes and the vascular adventitia. The restricted view and limited manoeuvrability of single-port thoracoscopy hindered the assessment of such complex adhesions, and attempts at blunt dissection led to uncontrollable tearing. This situation underscores the importance of thoroughly evaluating the vascular-lymph node relationship preoperatively. Although CT imaging indicated lymph node calcification, the extent of adhesion to the pulmonary artery wall posed significant intraoperative challenges. At this juncture, promptly halting anatomical dissection and prioritising the isolation of the pulmonary artery trunk with a pre-placed occlusion band is crucial for risk management, aligning with existing literature recommendations[\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e],[\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. A large-scale analysis by Tomoyasu[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e] et al. revealed that the incidence of pulmonary artery injury during VATS is 1.5%, with 50% of cases requiring conversion to open surgery for haemostasis. Notably, left upper lobectomy is a significant high-risk procedure for pulmonary artery injury (43.8% vs 18.8%, p\\u0026thinsp;=\\u0026thinsp;0.012), with the left anterior segmental artery being the most frequently injured vessel. In the event of acute massive bleeding, immediate conversion to open surgery is the preferred approach, adhering to the principles of \\\"damage control\\\" surgery, which prioritises rapid haemorrhage control to save lives. Compared to continued attempts at haemostasis via thoracoscopy, open surgery offers optimal exposure and operational freedom, significantly reducing ischaemia time and minimising the risk of secondary injury from blind manoeuvres[\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe pivotal technical insight from this treatment concerns the choice of repair method. For partial lacerations, direct suture repair is favoured. When the laceration involves less than one-third of the vessel's circumference, continuous suturing with 5\\u0026thinsp;\\u0026minus;\\u0026thinsp;0 polypropylene sutures achieves a success rate of 92% to 95%. In contrast, for complex injuries such as circular defects or vessel transection, autologous pericardial patch angioplasty has demonstrated favourable outcomes. A retrospective study of 118 cases of pulmonary artery reconstruction, including 51 cases using autologous pericardial patches, with an average follow-up of 70 months, reported no thromboembolic events linked to this technique[\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. In the present case, the large laceration, approximately 2.5 cm, rendered the initial attempt at continuous suturing unsuccessful due to the vessel wall's fragility and excessive tension, which exacerbated the defect. Theoretically, autologous pericardial patch angioplasty is the optimal choice for managing extensive circular or longitudinal defects, as it effectively restores lumen diameter and reduces turbulence, thus minimising the risk of postoperative stenosis and thrombus formation. However, we must acknowledge the technical constraints faced by our team during this emergency. The surgeon's limited experience in complex vascular reconstruction, particularly with the pericardial patch technique, coupled with the urgency of the bleeding, resulted in inadequate preparation and confidence to execute this method immediately. Consequently, to swiftly restore blood flow and conclude the surgery, we resorted to longitudinal end-to-end anastomosis as a compromise. Although this approach successfully restored the main blood flow and preserved the lung lobe, it is important to highlight that this reluctantly adopted method likely contributed to subsequent anastomotic stenosis, hemodynamic alterations, and ultimately postoperative embolism. The inherent geometric changes and unavoidable tension of the anastomosis foster conditions conducive to turbulence and endothelial damage, which can lead to thrombus formation.\\u003c/p\\u003e \\u003cp\\u003ePostoperative secondary pulmonary embolism (PE) and atrial fibrillation (AF) are serious complications following thoracic surgery. When they occur together, they often complicate diagnosis and treatment decisions. This case distinctly illustrates the causal link between them and their clinical progression. Eighteen hours post-surgery, the patient abruptly developed AF, accompanied by hemodynamic instability. A bedside cardiac ultrasound provided vital diagnostic insights, revealing an enlarged right atrial diameter and reduced motion of the right ventricular free wall. These findings directly indicate an acute increase in right ventricular afterload, strongly suggesting the presence of PE. Subsequent laboratory tests (D-dimer 3.066 mg/L) and computed tomography pulmonary angiography (CTPA) confirmed this diagnosis, identifying an embolism in the left lower lobe basal trunk artery with pulmonary infarction. The sequence of postoperative PE and AF in this case, supported by objective examinations, elucidates the pathophysiological process: anastomotic stenosis and endothelial injury lead to acute in-situ thrombosis and embolism; the embolism causes a sudden rise in right ventricular afterload, resulting in right-heart dilation and dysfunction; increased right atrial pressure and stretch ultimately trigger AF[\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. Moreover, the acute inflammatory response in the embolised area may worsen atrial electrical remodelling through cytokine release[\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. Hence, AF in this instance should be viewed as a hemodynamic complication secondary to acute PE. This assessment directly impacts clinical decision-making: the focus of treatment should be on anticoagulation rather than mere rhythm control. Following anticoagulation with low-molecular-weight heparin, AF was successfully converted to sinus rhythm without recurrence, and hemodynamics stabilised, retrospectively confirming PE as the cause. Studies indicate that 14% of patients with acute PE also experience AF, and newly-diagnosed PE is linked to the severity of AF (hazard ratio 1.78, 95% CI 1.13\\u0026ndash;2.80)[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]. This case suggests that in instances of newly-diagnosed AF post-thoracoscopic lung resection, especially when vascular reconstruction is involved and accompanied by hemodynamic instability, PE should be highly suspected. Bedside cardiac ultrasound serves as a crucial initial assessment tool; if it indicates increased right-heart load, CTPA should be promptly performed to confirm the diagnosis and commence anticoagulation, thus preventing misdiagnosis as common postoperative AF and avoiding delays in treating PE.\\u003c/p\\u003e \\u003cp\\u003ePostoperative CT scans of the pulmonary artery revealed an embolism in the basal trunk artery of the patient's left lower lobe. This condition was closely linked to local stenosis following intraoperative pulmonary artery angioplasty. Literature indicates that turbulence and endothelial damage post-angioplasty can increase the risk of thrombosis threefold[\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. Despite the administration of anticoagulant therapy post-surgery, the anatomical narrowing of the basal trunk artery impeded the effective penetration of anticoagulant drugs into the thrombus. The local turbulence created by vascular anastomosis resulted in a \\\"dead-space effect,\\\" facilitating thrombus organisation and explaining the persistent embolism observed in follow-up pulmonary artery CTAs. Importantly, the patency of the dorsal segment artery may have allowed for limited collateral circulation via bronchial artery-pulmonary artery anastomosis, preventing the patient from experiencing a large-area pulmonary infarction. Animal studies suggest that when the lobar artery is completely or nearly obstructed, collateral blood flow is directly proportional to systemic arterial pressure. After three months, collateral circulation can compensate for up to two-thirds of normal pulmonary circulation, with more pronounced bronchial collateral development in cases of severe pulmonary artery stenosis[\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. This mechanism aptly explains why, in this instance, despite the persistent embolism, the damage to pulmonary parenchyma remained minimal.\\u003c/p\\u003e \\u003cp\\u003eThe origins of the chronic nausea experienced by the patient post-surgery are multifaceted and necessitate thorough investigation. Primarily, the gastrointestinal side effects of rivaroxaban are the most immediate cause. Adverse reactions, including nausea and abdominal distension, occur in approximately 5% to 10% of cases. This may be due to the drug's direct stimulation of the gastric mucosa, inhibition of prostaglandin synthesis, and effects on local barrier function. In this instance, nausea emerged on the eighth day of medication and notably subsided within two days of discontinuation, indicating a strong temporal link to the drug's adverse effects. Nonetheless, the persistence and recurrence of symptoms for nearly a year post-withdrawal suggest additional underlying factors. Gastroscopy revealed only chronic non-atrophic gastritis with erosion, without any organic lesions to account for the persistent and severe nausea. Postoperative gastroparesis was considered; however, the absence of typical symptoms such as early satiety and vomiting of food residues, along with the preservation of the vagus nerve's main trunk during surgery, significantly reduces the likelihood of direct surgical damage to the nerve branches innervating the gastrointestinal tract. Furthermore, the spontaneous remission after a year does not align with typical postoperative gastroparesis characteristics. Additionally, significant surgical trauma, stress, and prolonged discomfort might have triggered or worsened psychogenic nausea[\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. Unfortunately, early objective examinations, such as electrogastrography and gastric emptying tests, were not conducted to definitively exclude motility disorders, nor were effective psychological assessment tools employed. This represents a limitation of the study.\\u003c/p\\u003e \\u003cp\\u003eTo elucidate why symptoms persist long after drug withdrawal, we hypothesise a complex neuroimmune regulatory mechanism may be at play. Drawing from the specifics of this case, we suggest a potential pathway: Pulmonary artery embolism results in local pulmonary tissue ischemia, inflammation, and acidosis. These conditions might activate spinal afferent nerves in the lungs, such as acid-sensitive channels, subsequently influencing regulatory centres like the nucleus of the solitary tract in the brainstem. Persistent abnormal afferent signals could lead to central sensitisation and disruption of neuroimmune interactions[\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e],[\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e], impacting gastrointestinal motility and sensory function via the vagus nerve and sympathetic nervous system, thus causing prolonged nausea[\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e]. It is important to emphasise that this hypothesis is speculative, grounded in existing literature and the clinical progression of this case, necessitating further research for validation. Regrettably, this study did not measure serum cytokine levels (e.g., IL-6, TNF-α) to confirm a systemic inflammatory state, nor did it assess autonomic nervous function through heart rate variability analysis. Consequently, direct evidence supporting this mechanism remains lacking.\\u003c/p\\u003e \\u003cp\\u003eIn summary, the chronic nausea in this case likely arises from a combination of factors: Rivaroxaban appears to have directly initiated the symptoms, while the ongoing condition may be linked to abnormal neuroimmune regulation and central sensitization caused by the embolism event. This may be further complicated by the psychophysiological effects of surgical stress. For similar patients in the future, a multi-dimensional assessment is advised, encompassing inflammatory markers, gastrointestinal motility, and psychological evaluations, to enable a more comprehensive diagnosis and management approach.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eYunnan Provincial Department of Science and Technology-Kunming Medical University Joint Special Top Project on Applied Basic Research (Project No. 202401AY070001-370).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA written informed consent was obtained from the patient for publication of this case report and any accompanying images.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u003csup\\u003e,\\u0026nbsp;\\u003c/sup\\u003econtributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eDCK provided the clinical data included in the text. LMX,HRS,JHB and FYD participated in the treatment decisions. CLS wrote the manuscript draft. WJF and KQB revised it critically and approved the modified text. WJF and approved the final version of the manuscript. All the authors read and approved the final manuscript.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003eTomoyasu M, Deguchi H, Kudo S, et al. Evaluation of pulmonary artery bleeding during thoracoscopic pulmonary resection for lung cancer. Thorac Cancer. 2022;13(21):3001-3006. doi:10.1111/1759-7714.14649\\u003c/li\\u003e\\n \\u003cli\\u003eBertolaccini L, Davoli F, Pardolesi A, et al. Conversion due to vascular injury during video-assisted thoracic surgery lobectomy: A multicentre retrospective analysis from the Italian video-assisted thoracic surgery group registry. Eur J Surg Oncol. 2019;45(5):857-862. doi:10.1016/j.ejso.2018.12.023\\u003c/li\\u003e\\n \\u003cli\\u003eKim K, Kim HK, Park JS, et al. Video-assisted thoracic surgery lobectomy: single institutional experience with 704 cases. Ann Thorac Surg. 2010;89(6):S2118-S2122. doi:10.1016/j.athoracsur.2010.03.017\\u003c/li\\u003e\\n \\u003cli\\u003eBertolaccini L, Calabrese F, Brandolini J, Solli P. Vascular injuries during VATS lobectomies: keep calm, compress and have a plan. Ann Transl Med. 2019;7(1):19. doi:10.21037/atm.2018.11.33\\u003c/li\\u003e\\n \\u003cli\\u003eChoi YS. Management of Complications During Video-Assisted Thoracic Surgery Lung Resection and Lymph Node Dissection. J Chest Surg. 2021;54(4):263-265.\\u003c/li\\u003e\\n \\u003cli\\u003eThoracoscopic Surgery Group of the Thoracic and Cardiovascular Surgery Branch, Chinese Medical Association; Minimally Invasive Thoracic Surgery Expert Committee of the Thoracic Surgery Branch, Chinese Medical Doctor Association. Clinical Practice Guidelines for Thoracoscopic Lobectomy in China [J]. Chinese Medical Journal, 2018, 98(47): 3832-3841.\\u003c/li\\u003e\\n \\u003cli\\u003eMa Q, Liu D, Guo Y, et al. Surgical techniques and results of the pulmonary artery reconstruction for patients with central non-small cell lung cancer. J Cardiothorac Surg. 2013;8:219.\\u003c/li\\u003e\\n \\u003cli\\u003eBryce YC, Perez-Johnston R, Bryce EB, Homayoon B, Santos-Martin EG. Pathophysiology of right ventricular failure in acute pulmonary embolism and chronic thromboembolic pulmonary hypertension: a pictorial essay for the interventional radiologist. Insights Imaging. 2019;10(1):18.\\u003c/li\\u003e\\n \\u003cli\\u003eHashem A, Khalouf A, Mohamed MS, et al. COVID-19 Infection Is Associated With Increased In-Hospital Mortality and Complications in Patients With Acute Heart Failure: Insight From National Inpatient Sample (2020). J Intensive Care Med. 2023;38(11):1068-1077.\\u003c/li\\u003e\\n \\u003cli\\u003eBikdeli B, Abou Ziki MD, Lip GYH. Pulmonary Embolism and Atrial Fibrillation: Two Sides of the Same Coin? A Systematic Review [published correction appears in Semin Thromb Hemost. 2017 Dec;43(8):e1.\\u003c/li\\u003e\\n \\u003cli\\u003eGoldberg JB, Giri J, Kobayashi T, et al. Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association. Circulation. 2023;147(9):e628-e647.\\u003c/li\\u003e\\n \\u003cli\\u003eHEIMBURG P. BRONCHIAL COLLATERAL CIRCULATION IN EXPERIMENTAL STENOSIS OF THE PULMONARY ARTERY. Thorax. 1964;19(4):306-310.\\u003c/li\\u003e\\n \\u003cli\\u003eSingh P, Yoon SS, Kuo B. Nausea: a review of pathophysiology and therapeutics. Therap Adv Gastroenterol. 2016;9(1):98-112. doi:10.1177/1756283X15618131\\u003c/li\\u003e\\n \\u003cli\\u003eGu Yun, Zhuang Zhong. New progress in study of inflammatory reflex[J]. Chinese Journal of Pathophysiology,2016,32(12):2300-2304.\\u003c/li\\u003e\\n \\u003cli\\u003eKelly MJ, Breathnach C, Tracey KJ, Donnelly SC. Manipulation of the inflammatory reflex as a therapeutic strategy. Cell Rep Med. 2022;3(7):100696. doi:10.1016/j.xcrm.2022.100696\\u003c/li\\u003e\\n \\u003cli\\u003eChang FY, Lu CL. Hiccup: mystery, nature and treatment. J Neurogastroenterol Motil. 2012;18(2):123-130.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"journal-of-cardiothoracic-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"jcts\",\"sideBox\":\"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)\",\"snPcode\":\"13019\",\"submissionUrl\":\"https://submission.nature.com/new-submission/13019/3\",\"title\":\"Journal of Cardiothoracic Surgery\",\"twitterHandle\":\"@BioMedCentral\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Pulmonary artery embolism, Chronic nausea, Pulmonary artery injury, Single-port thoracoscopic surgery\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8127511/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8127511/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eThis paper details the diagnosis and treatment of a 66-year-old male patient with invasive adenocarcinoma in the left upper lobe of the lung, who experienced a pulmonary artery injury during a single-port thoracoscopic lobectomy. During surgery, the basal trunk artery's root was torn due to enlarged lymph nodes encircling the pulmonary artery, necessitating an urgent conversion to thoracotomy for end-to-end anastomosis and reconstruction of the artery. Eighteen hours post-operation, the patient unexpectedly developed atrial fibrillation. A CTA scan confirmed an embolism in the left pulmonary basal trunk artery, leading to the administration of low-molecular-weight heparin and rivaroxaban for anticoagulation. Nausea recurred during this treatment, persisting for 12 months before resolving spontaneously upon cessation of the medication. Follow-up imaging indicated the embolism remained, though collateral circulation was compensating effectively. This case underscores the importance of devising an individualized vascular reconstruction strategy for managing complex pulmonary artery injuries, emphasizing the necessity of selecting the optimal repair method during surgery. New-onset atrial fibrillation post-surgery should be considered a potential indicator of pulmonary embolism, warranting prompt imaging evaluation. Furthermore, managing anticoagulant-related nausea is notably complex, potentially influenced by factors such as adverse drug reactions and abnormal neuroimmune responses triggered by embolic events. This study offers significant clinical insights into managing rare long-term complications following VATS.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Postoperative Anastomotic Embolism and Persistent Chronic Nausea Following Pulmonary Artery Tear During Single-Port Thoracoscopic Lobectomy: A Case Report and Examination of Potential Mechanisms\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-02-03 15:33:33\",\"doi\":\"10.21203/rs.3.rs-8127511/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewerAgreed\",\"content\":\"216874220952345281630130439122190179963\",\"date\":\"2026-01-28T10:31:15+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-01-26T11:55:35+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"26641495530738837498306386259539539084\",\"date\":\"2026-01-24T15:58:22+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"179690151365014892247132074392610785863\",\"date\":\"2026-01-24T07:44:27+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-01-23T09:30:53+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-11-22T05:50:56+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-11-22T05:49:57+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Journal of Cardiothoracic Surgery\",\"date\":\"2025-11-16T13:28:21+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"journal-of-cardiothoracic-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"jcts\",\"sideBox\":\"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)\",\"snPcode\":\"13019\",\"submissionUrl\":\"https://submission.nature.com/new-submission/13019/3\",\"title\":\"Journal of Cardiothoracic Surgery\",\"twitterHandle\":\"@BioMedCentral\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"253aab2c-9ab3-4a7c-8101-2952eff4e799\",\"owner\":[],\"postedDate\":\"February 3rd, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-27T16:13:41+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-8127511\",\"link\":\"https://doi.org/10.1186/s13019-026-04155-0\",\"journal\":{\"identity\":\"journal-of-cardiothoracic-surgery\",\"isVorOnly\":false,\"title\":\"Journal of Cardiothoracic Surgery\"},\"publishedOn\":\"2026-04-20 15:58:13\",\"publishedOnDateReadable\":\"April 20th, 2026\"},\"versionCreatedAt\":\"2026-02-03 15:33:33\",\"video\":\"\",\"vorDoi\":\"10.1186/s13019-026-04155-0\",\"vorDoiUrl\":\"https://doi.org/10.1186/s13019-026-04155-0\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8127511\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8127511\",\"identity\":\"rs-8127511\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}