Pulmonary endarterectomy: the potentially curative treatment for patients with chronic thromboembolic pulmonary hypertension

Abstract

Pulmonary endarterectomy (PEA) is the treatment of choice to relieve pulmonary artery obstruction in patients with chronic thromboembolic pulmonary hypertension (CTEPH). It is a complex surgical procedure with a simple principle: removal of obstructive thromboembolic material from the pulmonary arteries in order to reduce pulmonary vascular resistance, relieve pulmonary hypertension (PH) and alleviate right ventricular dysfunction. In the majority of patients there is symptomatic and prognostic benefit. However, not all patients with CTEPH are suitable for treatment with PEA. Operability assessment is not always easy, being largely subjective and based on experience. It is therefore important that all patients are referred to an experienced CTEPH centre for careful evaluation of suitability for surgery. The most common reason for inoperability is distal vasculopathy accounting for a high proportion of the vascular resistance. Surgery requires cardiopulmonary bypass and periods of deep hypothermic circulatory arrest. Complications include reperfusion lung injury and persistent PH. However, with careful patient selection, surgical technique and post-operative management, PEA is a highly effective treatment with mortality rates <5% at experienced centres. Patients who are unsuitable for surgery may be candidates for medical therapy.

FIGURE 1

Example scans for a typical patient with operable chronic thromboembolic pulmonary hypertension. a) Perfusion (Q′) and b) ventilation (V′) lung scans. R: right; L: left; ANT: anterior; POST: posterior; LPO: left posterior oblique; RPO: right posterior oblique. c) Computed tomography pulmonary angiography scan. d) Pulmonary angiogram.

FIGURE 2

a) Longitudinal incision in the right pulmonary artery, exposed between the superior vena cava and aorta. b) Developing the endarterectomy dissection plane in the left pulmonary artery. c) Removing the occluded endarterectomy “tails” from the left upper lobe segmental vessels.