Pulmonary thromboendarterectomy

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Pulmonary thromboendarterectomy

Pulmonary thromboendarterectomy is the standard surgical treatment for chronic thromboembolic pulmonary hypertension (CTEPH) if the surgical risk is reasonable to tolerate a prolonged surgery. The centre and surgeon should also have adequate annual volume of cases to maintain competence. CTEPH may occur in about 4% of patients after an episode of acute pulmonary thromboembolism over a one year period. There are persons with CTEPH who do not have a distinct previous history of acute pulmonary embolism as well.

Pulmonary thromboendarterectomy is a technically challenging procedure and hence the importance of operator’s annual volume of procedures in maintaining competence. The surgery involves dissection of the entire pulmonary vascular tree with patient under circulatory arrest with profound hypothermia [1].

CTEPH has a poor long term prognosis with three year mortality of 90% in severe cases with mean pulmonary artery pressure of 50 mm Hg or more [2]. To have a good outcome with surgery, careful patient selection, meticulous surgical technique and excellent post operative care are needed.
True endarterectomy and not just embolectomy has to be performed in all affected pulmonary segments. Successful surgery improves ventilation perfusion mismatch, right ventricular function and reduces pulmonary hypertension and tricuspid regurgitation.

References

  1. Madani MM. Surgical Treatment of Chronic Thromboembolic Pulmonary Hypertension: Pulmonary Thromboendarterectomy. Methodist Debakey Cardiovasc J. 2016 Oct-Dec;12(4):213-218.
  2. Riedel M, Stanek V, Widimsky J, Prerovsky I. Longterm follow-up of patients with pulmonary thromboembolism. Late prognosis and evolution of hemodynamic and respiratory data. Chest. 1982 Feb; 81(2):151-8.