Venous thromboembolism surveillance after lung transplantation: missed events and clinical impact

This letter is in response to the letter to the editor by Dr. Wang on “Symptom-triggered diagnosis in lung transplant recipients: does it underestimate the true venous thromboembolism burden and its consequences?” (1) in response to our original article on “Risk factors and perioperative complications associated with deep venous thrombosis and pulmonary embolism after lung transplantation” (2).

We thank the authors for their thoughtful commentary on our recent report evaluating risk factors and perioperative complications associated with deep venous thrombosis (DVT) and pulmonary embolism (PE) after lung transplantation. We agree that any symptom-triggered diagnostic strategy may underestimate the “true” burden of venous thromboembolism (VTE), particularly if clinically silent or distal thrombi are not systematically captured (3). This limitation is inherent to many retrospective studies that reflect real-world practice patterns rather than protocolized surveillance.

Importantly, however, whether routine screening should be adopted for all lung transplant recipients remains uncertain (4,5). Implementing universal duplex ultrasonography would require substantial personnel time, equipment availability, and downstream clinical resources, and the net clinical benefit is not established. In the immediate post-transplant period, recipients frequently face competing risk, including bleeding, surgical-site complications, and fluctuating renal function, which complicate the decision to escalate anticoagulation solely on the basis of asymptomatic thrombi detected by screening (6). In our cohort, hemorrhagic complications were common among patients diagnosed with DVT/PE and were strongly associated with adverse outcomes, underscoring that a “detect-and-treat” approach could unintentionally increase iatrogenic harm if applied indiscriminately (2).

We also concur that clarifying the prognostic impact of asymptomatic DVT specifically in lung transplantation is a key evidence gap. It remains unclear what proportion of screening-detected thromboses would progress to clinically meaningful PE, contribute to morbidity, or affect survival, and whether early detection and treatment would improve patient-centered outcomes sufficiently to justify the additional costs and risks. Addressing these questions will require prospective studies with standardized surveillance protocols, careful adjudication of bleeding and thrombotic endpoints, and ideally an assessment of cost-effectiveness.

Going forward, we believe the most informative next step would be a multicenter prospective study that (I) applies predefined screening intervals early after transplantation; (II) captures both symptomatic and asymptomatic events; (III) standardizes management pathways (including when to anticoagulate vs. observe); and (IV) evaluates outcomes that matter clinically (PE, major bleeding, graft function, length of stay, and mortality). Until such data are available, a pragmatic alternative may be a targeted strategy focusing surveillance on patients at highest risk, rather than implementing universal screening for all recipients.

We appreciate the opportunity to respond and hope that our exchange will stimulate the prospective, practice-informing research needed to optimize VTE detection and management in this uniquely high-risk population.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2751/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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References

1. Wang J, Guo H. Symptom-triggered diagnosis in lung transplant recipients: does it underestimate the true venous thromboembolism burden and its consequences? J Thorac Dis 2026; [Crossref]
2. Kim NT, Miyashita Y, Kaihou T, et al. Risk factors and perioperative complications associated with deep venous thrombosis and pulmonary embolism after lung transplantation. J Thorac Dis 2025;17:9342-56. [Crossref] [PubMed]
3. Zheng M, Yousef I, Mamary AJ, et al. Venous thromboembolism in lung transplant recipients real world experience from a high volume center. J Heart Lung Transplant 2021;40:1145-52. [Crossref] [PubMed]
4. Kodadek LM, Haut ER. Screening and Diagnosis of VTE: The More You Look, The More You Find? Curr Trauma Rep 2016;2:29-34.
5. Tini G, Moriconi A, Ministrini S, et al. Ultrasound screening for asymptomatic deep vein thrombosis in critically ill patients: a pilot trial. Intern Emerg Med 2022;17:2269-77. [Crossref] [PubMed]
6. Liederman Z, Chan N, Bhagirath V. Current Challenges in Diagnosis of Venous Thromboembolism. J Clin Med 2020;9:3509. [Crossref] [PubMed]