Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic
thromboembolic pulmonary hypertension (PH), provided lesions are proximal enough in
the pulmonary vasculature to be surgically accessible and the patient is well enough
to benefit from the operation in the longer term. It is a major cardiothoracic operation,
requiring specialized techniques and instruments developed over several decades to
access and dissect out the intra-arterial fibrotic material. While in-hospital operative
mortality is low (<5%), particularly in high-volume centers, careful perioperative
management in the operating theater and intensive care is mandatory to balance ventricular
performance, fluid balance, ventilation, and coagulation to avoid or treat complications.
Reperfusion pulmonary edema, airway hemorrhage, and right ventricular failure are
the most problematic complications, often requiring the use of extracorporeal membrane
oxygenation to bridge to recovery. Successful PEA has been shown to improve both morbidity
and mortality in large registries, with survival >70% at 10 years. For patients not
suitable for PEA or with residual PH after PEA, balloon pulmonary angioplasty and/or
PH medical therapy may prove beneficial. Here, we describe the indications for PEA,
specific surgical and perioperative strategies, postoperative monitoring and management,
and approaches for managing residual PH in the long term.
Keywords
chronic thromboembolic pulmonary hypertension - pulmonary hypertension - pulmonary
embolism - pulmonary endarterectomy - pulmonary thromboendarterectomy
