Pulmonary thromboendarterectomy

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Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and Keywords: PTE

Overview

In thoracic surgery, a pulmonary thromboendarterectomy, is an operation that removes organized clotted blood (thrombus) from the pulmonary arteries. PTE is a treatment for chronic thromboembolic pulmonary hypertension (pulmonary hypertension induced by recurrent/chronic pulmonary emboli).[1][2]

Pulmonary Thromboendarterectomy

Indication

PTE is a treatment for chronic thromboembolic pulmonary hypertension (pulmonary hypertension induced by recurrent/chronic pulmonary emboli).[1][2]

Surgery

A PTE has significant risk; mortality for the operation is typically 5%. PTEs are risky because of the intensity of the procedure and the intricacies involved. PTEs involve a full cardiopulmonary bypass (CPB), deep hypothermia and full cardiac arrest, with the critical procedure carried out in a standstill operation.[3] The reason for the complexity of procedure is due to the anatomical features. The obvious part is that a pulmonary bypass is required. The first part is that the blood going to the lungs has to be diverted from the pulmonary vasculature. Lung function needs to be taken care of by a machine. Less obvious is that hypothermia is required. This goes back to the pathophysiology of emboli; they are organized, somewhat delicate, essentially part of the vessel wall, and hard to remove completely, unlike in an acute pulmonary embolectomy (for acute pulmonary embolism, which is done without hypothermia).[4][5] Making this task more difficult is the anatomy of the lung and the pathophysiology of chronic thromboembolic pulmonary hypertension (CTEPH). The lungs also get blood from the bronchial arteries, which are often enlarged. The practical implication is that a conventional cardiopulmonary bypass (CPB) is not sufficient to do the surgery because too much blood would be in the surgical field, and the delicate thrombi would be difficult to remove completely.

The solution is a full cardiac arrest, which can be done with hypothermia. Once the surgeons begin the cardiopulmonary bypass, they induce a deep hypothermia (18-20 degrees Celsius) to preserve the patient's brain. Once the patient is cooled off sufficiently, the CPB machine is turned off and the surgeon has time to do the delicate work, which takes about 40 minutes, and consists of carefully removing the organized thrombus. The most challenging part of the surgery is finding the optimal plane to dissect the pulmonary artery. If the surgeon dissects too deeply into the vessel wall, the pulmonary vessels may rupture. If the surgeon does not dissect deep enough, the clot breaks proximally during extraction and the distal part of the pulmonary vasculture will not have its pulmonary blood flow restored. The right lung is typically done first because it is easier. Video cameras (angioscopes) are used to see deeper into the pulmonary vasculture. Bypass time is approximately 6 hours.[6]

Recovery/ICU

The ICU recovery involves several challenges. Most patients get significant reperfusion pulmonary edema at places where thrombi were removed. These patients have less than ideal oxygen saturation values. This results because with the thrombus removal the surgeon strips out the pulmonary endothelium. The challenge for the ICU physician is getting the extra water out of the lungs, (for which they make use of the strong diuretic furosemide) to get decent oxygen saturation values, yet maintain the blood pressure. Maintaining these two parameters can be a challenge. Maintaining a good oxygen saturation can be accomplished by running the patient dry (with a diuretic) and setting a high BiPAP (bidirectional positive airway pressure). The problem is that a high BiPAP leads to a poor venous return, which means the blood pressure suffers. Adding volume would help with the blood pressure, but it would make the edema worse so it is generally avoided. Adding albumin does not help; the pulmonary arteries are too porous post-operation. So, a balancing act is required between blood pressure and oxygen saturation that is controlled with the BiPAP and the diuretic.

Post-Surgery

The benefits of PTEs are significant. After surgery, most patients no longer suffer from shortness of breath, and therefore they have a much improved quality of life. Further, pulmonary vascular resistance usually drops back close to normal levels. Since the pulmonary resistance is proportional to the pressure driving the pulmonary flow (P=Q*R), it follows that the pulmonary pressure decreases. This in turn means that the work per time (power) decreases because it is equal to the pressure gradient times the volumetric flow, which in this case is the cardiac output. As a result of the operation, patients are spared from pulmonary hypertension and further right ventricular hypertrophy. Most patients who previously had right heart dysfunction often recover adequate function.[7]

History and Development

The UCSD Medical Center's cardiothoracic surgery department is widely recognized as a pioneer in the relatively new surgery, having performed more PTEs than the rest of the world combined. They have performed over 2100 since 1970. They also have the lowest mortality rate, which is less than 5%.

Pulmonary Embolectomy vs Pulmonary Thromboendarterectomy

Pulmonary embolectomy and pulmonary thromboendarterectomy (PTEs) aim to remove the thrombus in the pulmonary artery; however, they differ in many ways.

  • PTE is performed non-emergently whilst pulmonary embolectomy is typically performed as an emergency procedure.
  • PTE is typically performed using hypothermia and full cardiac arrest.
  • PTE is done for chronic pulmonary embolism, while embolectomy is performed for severe acute pulmonary embolism.

References

  1. 1.0 1.1 Rahnavardi M, Yan TD, Cao C, Vallely MP, Bannon PG, Wilson MK (2011). "Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension : a systematic review". Ann Thorac Cardiovasc Surg. 17 (5): 435–45. PMID 21881372.
  2. 2.0 2.1 Luckraz H, Dunning J (2001). "Pulmonary thromboendarterectomy". Ann R Coll Surg Engl. 83 (6): 427–30. PMC 2503682. PMID 11777141.
  3. Dahm M, Mayer E, Eberle B, Kramm T, Guth S, Moersig W, Oelert H., [Surgical aspects of pulmonary thrombendarterectomy], Zentralbl Chir. 1997;122(8):649-54. PMID 9412095.
  4. Guilmet D, Arnaud-Crozat E, Bachet J, Goudot B, Dubois C, Brodaty D, de Lentdecker P, Diaz F, Teodori G, Caubarrere I, et al., [Surgical treatment of chronic pulmonary embolism using thromboembolectomy under extracorporeal circulation and deep hypothermia--a new approach route. 3 cases] Arch Mal Coeur Vaiss. 1989 Oct;82(10):1719-25.
  5. Moser KM, Auger WR, Fedullo PF, Jamieson SW. Chronic thromboembolic pulmonary hypertension: clinical picture and surgical treatment. Eur Respir J. 1992 Mar;5(3):334-42. PMID 1572447
  6. Dahm M, Mayer E, Eberle B, Kramm T, Guth S, Moersig W, Oelert H., [Surgical aspects of pulmonary thrombendarterectomy], Zentralbl Chir. 1997;122(8):649-54. PMID 9412095.
  7. Kramm T, Mayer E, Dahm M, Guth S, Menzel T, Pitton M, Oelert H., Long-term results after thromboendarterectomy for chronic pulmonary embolism. Eur J Cardiothorac Surg. 1999 May;15(5):579-83; discussion 583-4. PMID 10386400.



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