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Review
. 2022 Mar;11(2):180-188.
doi: 10.21037/acs-2021-pte-185.

Pulmonary endarterectomy: technique and pitfalls

Stefan Guth  1 , Eckhard Mayer  1 , Diethard Prüfer  1 , Christoph B Wiedenroth  1
Affiliations
Review

Pulmonary endarterectomy: technique and pitfalls

Stefan Guth et al. Ann Cardiothorac Surg. 2022 Mar.

Abstract

Chronic thromboembolic pulmonary hypertension (CTEPH) remains a rare and underdiagnosed disease. After one or several episodes of acute pulmonary embolism, around 3% of patients develop CTEPH and two-thirds of these patients are potential surgical candidates. Besides surgery, additional treatment modalities are pulmonary arterial hypertension medication and balloon pulmonary angioplasty. Patients should be evaluated in CTEPH expert centers to ensure the most appropriate therapy. Pulmonary endarterectomy (PEA) is a complex, but standardized surgical procedure aiming to clear the obstructed pulmonary arteries completely. For optimal visualization, deep hypothermic circulatory arrest is a prerequisite. This article will give an overview of the evaluation, indication and surgical management of patients with CTEPH.

Keywords: Chronic thromboembolic pulmonary hypertension (CTEPH); balloon pulmonary angioplasty (BPA); pulmonary endarterectomy (PEA).

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Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Schematic view of the right pulmonary artery in 30° left anterior oblique view showing high grade stenoses and complete obstructions of the pulmonary artery tree.
Figure 2
Figure 2
Dual-action forceps and suction and dissection devices (angled and straight) are important instruments for pulmonary endarterectomy.
Figure 3
Figure 3
A sternotomy is performed from the superior border of the manubrium sterni to the xiphoid.
Figure 4
Figure 4
In preparation for the pulmonary endarterectomy, cannulas are inserted into the ascending aorta, both venae cavae (superior and inferior) from the right atrium to give adequate access to the right pulmonary artery. Additionally, vent-catheters are placed into the pulmonary trunk and into the left atrium via the right superior pulmonary vein.
Figure 5
Figure 5
Access to the right pulmonary artery with a spreader between superior vena cava and ascending aorta. The superior vena cava is kept open by the inserted venous cannula.
Figure 6
Figure 6
The principle of the endarterectomy. The incision lays in the central part of the pulmonary artery and from here the dissection plane must be prepared forward to the distal obstructing material. For distal visibility, deep hypothermic circulatory arrest is mandatory.
Figure 7
Figure 7
Removal of a centrally located bulk of obstructive material. This is only the first step and after this, the endarterectomy to the distal segmental and subsegmental artery must be performed.
Figure 8
Figure 8
Raising the correct dissection plane in the proximal artery. Often it is the fragile transparent intimal layer.
Figure 9
Figure 9
Regularly, the endarterectomy must be started in segmental or subsegmental arteries and makes the surgery difficult. This is illustrated here by an occlusive sieve plate in a distal artery.
Figure 10
Figure 10
View inside the right artery after successful endarterectomy with clearly open ostia to the segmental arteries.
Figure 11
Figure 11
Endarterectomy specimen of the right and left pulmonary arteries with a ruler (1 to 10 cm).
Figure 12
Figure 12
Schematic depiction of the therapeutic modalities for CTEPH-patients: proximal arteries are the domain for pulmonary endarterectomy, far distally medical pulmonary artery hypertension medication is the treatment of choice and in between BPA has its place. CTEPH, chronic thromboembolic pulmonary hypertension; BPA, balloon pulmonary angioplasty; PEA, pulmonary endarterectomy; PA, pulmonary artery.
See this image and copyright information in PMC

References

    1. Guth S, D'Armini AM, Delcroix M, et al. Current strategies for managing chronic thromboembolic pulmonary hypertension: results of the worldwide prospective CTEPH Registry. ERJ Open Res 2021;7:e00850-2020. 10.1183/23120541.00850-2020 - DOI - PMC - PubMed
    1. Galiè N, Humbert M, Vachiery JL, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J 2016;37:67-119. 10.1093/eurheartj/ehv317 - DOI - PubMed
    1. Delcroix M, Lang I, Pepke-Zaba J, et al. Long-Term Outcome of Patients With Chronic Thromboembolic Pulmonary Hypertension: Results From an International Prospective Registry. Circulation 2016;133:859-71. 10.1161/CIRCULATIONAHA.115.016522 - DOI - PubMed
    1. Madani MM. Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: state-of-the-art 2020. Pulm Circ 2021;11:20458940211007372. 10.1177/20458940211007372 - DOI - PMC - PubMed
    1. Wiedenroth CB, Liebetrau C, Gall H, et al. The effective systematic heparin pre-treatment on thrombus formation on pulmonary artery catheter tips during pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: a randomized, double-blind study. J Thromb Thrombolysis 2017;44:335-40. 10.1007/s11239-017-1547-4 - DOI - PubMed