What Is Pulmonary Thromboendarterectomy

Since the onset of the COVID-19 pandemic, healthcare has witnessed significant shifts, including an increased incidence of blood clots and their associated complications. Many studies indicate that individuals recovering from COVID have a higher risk of developing blood clots, adding to the already complex array of health challenges. 

There are certain conditions including chronic thromboembolic pulmonary hypertension (CTEPH), which is a serious condition known for chronic blood clots in the lungs, increasing pressure in the lungs and heart. As a result, the need for effective treatments for these conditions has become more pressing than ever. One such solution is a lifesaving procedure for pulmonary embolism called pulmonary thromboendarterectomy (PTE).

Introduction

Pulmonary thromboendarterectomy is a specialised procedure designed to remove blood clots from the pulmonary arteries of the lungs.¹ These arteries are essential for transporting blood from the heart to the lungs for oxygenation. When blood clots block these arteries, it can cause serious health problems, including high blood pressure in the lungs (pulmonary hypertension), failure of the right side of the heart, permanent damage to the lungs and even death. Pulmonary thromboendarterectomy (PTE) is particularly beneficial when oral medications fail to provide effective treatment for an individual's chronic thromboembolic pulmonary hypertension.

Symptoms not to ignore

Certain symptoms associated with CTEPH should not be ignored, including:

• Sudden shortness of breath
• Chest pain
• Abnormal lungs sound
• Rapid heartbeat
• Excessive sweating
• Leg swelling and pain
• Blue-tinged skin or cyanosis

While PTE is a critical procedure, it carries certain risks, including stroke, respiratory complications, and persistent hypertension. To minimise these risks, patients undergo a comprehensive preoperative evaluation to assess their overall health and determine if they are suitable candidates for the surgery. This consists of pulmonary function tests (PFTs), cardiac functioning and evaluation tests and a review of any underlying conditions.

History and development of PTE

Back in the mid-20th century, there were limited options for the treatment of CTEPH and the patients often faced poor prognosis. Over the years, significant advancements in surgical techniques and postoperative care have transformed PTE into a highly effective treatment. 

These innovations have further enhanced the effectiveness and safety of PTE.² Additionally, minimally invasive techniques and robotic-assisted surgeries are being developed to reduce the invasiveness of the procedure. These technological advancements have made PTE accessible to a wider range of patients, including those who previously may not have been considered suitable candidates.

PTE surgical technique

Pulmonary thromboendarterectomy is performed with great precision and is typically performed with the help of a median sternotomy (an incision along the breastbone). The patient is then placed on a machine known as cardiopulmonary bypass (CPB).⁸ This machine temporarily takes over the roles of the heart and the lungs to ensure continuous oxygenation and blood circulation. 

The next step involves lowering the temperature of the human body to about 18-20 degrees Celsius, known as the deep hypothermic circulatory arrest (DHCA) technique.^3,9 This is a critical part of PTE surgery as it slows down metabolism, and stops blood circulation and the function of the brain for about 30 minutes. This procedure reduces the risk of neurological injury as well. 

Next, the surgeon dissects the pulmonary arteries and begins the extraction of the thrombus (blood clot) using various devices such as forceps and suction.⁴ Throughout the procedure, vital signs and hemodynamic parameters are closely monitored to ensure the patient’s stability. After achieving the surgical objectives and ensuring haemostasis (the cessation of bleeding) in the pulmonary arteries, the chest is closed in layers.

Postoperative care

Long-term follow-up is essential after PTE to monitor signs of bleeding, infection, and hemodynamic stability. Immediately following the surgery, patients are monitored in the intensive care unit (ICU) for these vital signs. Mechanical ventilation is often necessary to improve the quality of life and prevent the recurrence of thromboembolic events.⁵ Lifelong anticoagulation therapy is usually necessary, requiring regular monitoring and adjustments. Early rehabilitation and thorough postoperative management are crucial for a successful recovery.

Risks and complications

PTE offers effective treatment for chronic thromboembolic pulmonary hypertension, but it is not without risks. Some complications may include:

• Bleeding
• Stroke
• Infection
• Arrhythmias

To mitigate these risks, careful patient selection is necessary. The use of antibiotics can help manage the risk of infection, and specialised training in PTE surgery ensures the procedure is performed with precision.^6.7

FAQs

What is pulmonary thromboendarterectomy?

Pulmonary thromboendarterectomy is a surgical procedure to remove blood clots from the pulmonary arteries which take blood from the heart to the lungs for oxygenation. It is an effective treatment for cases of chronic thromboembolic pulmonary hypertension (CTEPH).

What are the symptoms of CTEPH?

Certain serious symptoms of CTEPH include chest pain, sudden shortness of breath, rapid heart rate, leg pain and swelling, fainting, cyanosis and coughing out blood.

What are the risks associated with pulmonary thromboendarterectomy?

As with any surgical procedure, there are certain risks associated with pulmonary thromboendarterectomy and these include the risk of bleeding, infections, arrhythmias, respiratory complications, and sometimes even stroke. Careful patient selection and appropriate antibiotics can help to reduce the incidence of complications of this procedure.

What care should be taken after pulmonary thromboendarterectomy?

Post-operative care includes maintaining haemodynamic stability which may require ICU care, mechanical ventilation and even the use of lifelong anticoagulants. Proper monitoring and rehabilitation are essential for a smooth recovery.

Summary

In conclusion, pulmonary thromboendarterectomy (PTE) is a vital treatment option for chronic thromboembolic pulmonary hypertension, offering significant benefits for patients. While the procedure carries potential risks and complications such as bleeding, infection, stroke, and arrhythmias, careful patient selection, meticulous surgical technique, and comprehensive post-operative care can help mitigate these risks. 

With advancements in surgical techniques and perioperative management, PTE has become safer and more effective, leading to improved outcomes and enhanced quality of life for patients. Long-term follow-up is crucial to monitor for late complications and ensure ongoing management of the condition. Overall, PTE represents a cornerstone in the treatment of chronic thromboembolic pulmonary hypertension, offering hope and improved prognosis for affected individuals.