Technical Advances of Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension

doi:10.1053/j.semtcvs.2006.09.003

Seminars in Thoracic and Cardiovascular Surgery

Volume 18, Issue 3, Autumn 2006, Pages 243-249

https://doi.org/10.1053/j.semtcvs.2006.09.003 Get rights and content

Pulmonary endarterectomy is the definitive treatment for chronic pulmonary hypertension as the result of thromboembolic disease. Although significant progress has been made over the last decade in recognition, diagnostic modalities, and treatment of this disease, chronic thromboembolic pulmonary hypertension (CTEPH) continues to be severely underdiagnosed and as a consequence pulmonary endarterectomy remains an uncommon procedure. Patients with CTEPH may present with a variety of debilitating cardiopulmonary symptoms. However, once diagnosed, there is no curative role for medical management, and surgery remains the only option. Medical management in these patients is only palliative, and surgery by means of transplantation for this type of pulmonary hypertension is an inappropriate use of resources with less than satisfactory results. In this article we describe the technical advances of pulmonary endarterectomy and the current procedure as it is performed at University of California–San Diego Medical Center.

Section snippets

Technical Principles of the Procedure

There are several guiding principles for this operation. First and foremost the approach must be bilateral, because, for pulmonary hypertension to be a major factor, both pulmonary arteries must be substantially involved. Furthermore, it is extremely unlikely to have unilateral disease as the result of thromboembolism. In fact we believe that a small subgroup of our patients, who truly do have unilateral disease, perhaps suffer from an underlying pulmonary vascular pathologic problem with

Preoperative and Anesthetic Considerations

Much of the preoperative preparation is common to any open-heart procedure. Routine monitoring for anesthetic induction includes a surface electrocardiogram, cutaneous oximetry, and radial artery pressures. After anesthetic induction a pulmonary artery catheter is placed for monitoring of pulmonary pressures as well as pulmonary vascular calculations. A femoral artery catheter, in addition to a radial arterial line, is also placed at this time. This provides more accurate measurements during

Surgical Technique

The surgical approach for this procedure is through a median sternotomy to gain access to both sides. The median sternotomy should be performed with extra attention given to all the engorged and collateral venous circulation that could develop as a result of persistent high right atrial pressures. After a median sternotomy incision is made, the pericardium is incised longitudinally and attached to the wound edges. Typically the right heart is severely enlarged, with a tense right atrium and a

Conclusions

It is increasingly apparent that pulmonary hypertension caused by chronic pulmonary embolism is a condition which is under-recognized and carries a poor prognosis. Because of the obstructive nature of this disease, medical therapy remains ineffective in prolonging life and at best only transiently improves the symptoms. The only therapeutic alternative to pulmonary endarterectomy is lung transplantation. The advantages of thromboendarterectomy include a lower operative mortality and excellent

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Evaluation and Management of Chronic Thromboembolic Pulmonary Hypertension
2023, Chest
Chronic thromboembolic pulmonary hypertension (CTEPH) is a treatable form of pulmonary hypertension and right heart failure. CTEPH (group 4 pulmonary hypertension) is caused by persistent organized thromboembolic obstruction of the pulmonary arteries from incompletely resolved acute pulmonary embolism. CTEPH also may present without prior VTE history, which can contribute to its underrecognition. The true incidence of CTEPH is unclear, but is estimated to be approximately 3% after acute pulmonary embolism. $\dot{V} / \dot{Q}$ scintigraphy is the best screening test for CTEPH, with CT scan imaging and other advanced imaging methods now playing a larger role in disease detection and confirmation. Perfusion defects on $\dot{V} / \dot{Q}$ scintigraphy in the setting of pulmonary hypertension are suggestive of CTEPH, but pulmonary angiography and right heart catheterization are required for confirmation and treatment planning. CTEPH potentially is curative with pulmonary thromboendarterectomy surgery, with mortality rates of approximately 2% at expert centers. Advances in operative techniques are allowing more distal endarterectomies to be performed successfully with favorable outcomes. However, more than one-third of patients may be considered inoperable. Although these patients previously had minimal therapeutic options, effective treatments now are available with pharmacotherapy and balloon pulmonary angioplasty. Diagnosis of CTEPH should be considered in all patients with suspicion of pulmonary hypertension. Treatments for CTEPH have advanced with improvements in outcomes for both operable and inoperable patients. Therapy should be tailored based on multidisciplinary team evaluation to ensure optimal treatment response.
ISHLT consensus statement: Perioperative management of patients with pulmonary hypertension and right heart failure undergoing surgery
2022, Journal of Heart and Lung Transplantation
Pulmonary hypertension (PH) is a risk factor for morbidity and mortality in patients undergoing surgery and anesthesia. This document represents the first international consensus statement for the perioperative management of patients with pulmonary hypertension and right heart failure. It includes recommendations for managing patients with PH being considered for surgery, including preoperative risk assessment, planning, intra- and postoperative monitoring and management strategies that can improve outcomes in this vulnerable population. This is a comprehensive document that includes common perioperative patient populations and surgical procedures with unique considerations.
Advances in treatment of chronic thromboembolic pulmonary hypertension
2022, Thrombosis Research
Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is a progressive pulmonary vascular disease which can lead to right heart failure and death, if left untreated. CTEPH is caused by persistent obstruction of large, middle-sized, or distal pulmonary arteries due to limited thromboembolic resolution in the pulmonary vascular arterial tree. Every patient with CTEPH should undergo evaluation for Pulmonary Endarterectomy (PEA) after referral to institutions with an experienced multidisciplinary CTEPH team. Although management of distal thromboembolic lesions with PEA remains a challenge due to their difficult accessibility, limited distal CTEPH is not considered an absolute contraindication for PEA, as more expertise surgical teams operate on them successfully. Furthermore, in up to 30–50% of patients who undergo PEA, curative treatment is not achieved due to incomplete thrombi removal or extensive pulmonary microvascular disease. Medical therapies that target the underlying pulmonary microvascular disease can offer symptomatic and hemodynamic benefits, although they do not deal with the core mechanism of the disease which is the removal of thromboembolic material from pulmonary vasculature. Recent research has provided evidence suggesting balloon pulmonary angioplasty (BPA) is a reasonable treatment option for inoperable CTEPH and recurrent/persistent pulmonary hypertension after PEA. Advancements in diagnostic modalities and refinements of BPA technique have decreased the complication rate and increased its beneficial effects in hemodynamics, symptoms, right ventricular function and long-term survival. Ongoing trials and future prospective cohorts will provide evidence regarding the optimal selection of patients and lesions prone to BPA treatment along with hybrid therapeutic strategies combining pharmacological therapy, PEA and BPA, which can potentially change the standard of care in CTEPH.
Pulmonary thromboendarterectomy in symptomatic patients with chronic thromboembolic disease without pulmonary arterial hypertension
2022, Cirugia Cardiovascular
La hipertensión pulmonar tromboembólica crónica es una rara consecuencia del embolismo pulmonar agudo. La cirugía de tromboendarterectomía pulmonar es el tratamiento de elección. El tratamiento quirúrgico está empezando a considerarse en pacientes con oclusión vascular crónica significativa e intolerancia al ejercicio, pero sin hipertensión pulmonar en reposo (enfermedad tromboembólica crónica). Desde febrero de 1996, hemos realizado 307 tromboendarterectomías pulmonares consecutivas, 10 (3,2%) presentaban la enfermedad sin hipertensión pulmonar en reposo.
Analizamos los resultados de la tromboendarterectomía pulmonar en pacientes con enfermedad tromboembólica crónica, intervenidos en nuestro centro.
No hubo mortalidad hospitalaria, ni morbilidad asociada a la cirugía. Todos los enfermos se encontraban en clase funcional I-II tras la cirugía (p = 0,024), objetivándose una mejoría postquirúrgica en el 70% de los pacientes, ninguno presentó un empeoramiento de su situación clínica tras la intervención. Durante el seguimiento (media de 63 meses [rango 63-125]), ninguno de ellos desarrolló hipertensión pulmonar tromboembólica crónica, y la supervivencia fue del 100%.
La tromboendarterectomía pulmonar en este grupo de pacientes, cuando es realizada en un centro experto, puede obtener excelentes resultados a corto-medio plazo.
Chronic thromboembolic pulmonary hypertension is a rare consequence of acute pulmonary embolism. Pulmonary thromboendarterectomy surgery is the treatment of choice. Surgical treatment is beginning to be considered in patients with significant chronic vascular occlusion and exercise intolerance, but without pulmonary hypertension at rest (chronic thromboembolic disease). Since February 1996, we have performed 307 consecutive pulmonary thromboendarterectomies, 10 (3.2%) had disease without pulmonary hypertension at rest.
We analysed the results of pulmonary thromboendarterectomy in patients with chronic thromboembolic disease who underwent surgery in our centre.
There was no hospital mortality or morbidity associated with surgery. All patients were in functional class I-II after surgery (p = .024), and 70% of patients showed improvement after surgery; none of them presented a worsening of their clinical situation after surgery. During follow-up (mean 63 months [range 63-125]), none of the patients developed chronic thromboembolic pulmonary hypertension, and survival was 100%.
Pulmonary thromboendarterectomy in this group of patients, when performed in an expert centre, can obtain excellent short-medium term results.
Surgical Management of Chronic Thromboembolic Pulmonary Hypertension
2022, Cardiology Clinics
Advanced Surgical and Percutaneous Approaches to Pulmonary Vascular Disease
2021, Clinics in Chest Medicine

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Technical Advances of Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension

Section snippets

Technical Principles of the Procedure

Preoperative and Anesthetic Considerations

Surgical Technique

Conclusions

Clin Chest Med

Ann Thorac Surg

Chest

Ann Thorac Surg

Chest

Ann Thorac Surg

Chest