Operability assessment and surgical treatment
PTE is the treatment of choice for CTEPH
Surgical resection of occlusive chronic thromboembolic material via pulmonary thromboendarterectomy (PTE), also referred to as pulmonary endarterectormy (PEA), is the guideline-recommended treatment of choice for patients with accessible PA lesions.1,2
PTE should be offered to all operable patients with a favorable risk:benefit ratio.2 PTE can normalize PAP in ~70 to 75% of patients and carries an operative mortality of ~2% at expert centers. Survival for PTE has been reported at >90% at 3 years, 87% at 5 years, and 78% at 10 years, but only 70% at 3 years in those who did not have surgery.1
However, not every patient is a candidate for PTE. In a 2011 international registry of 679 patients with CTEPH, 37% (247) were deemed to have inoperable disease.3
The most common reason patients were considered to have inoperable disease was because the lesions were considered too distal or inaccessible3
- Inaccessibility of occlusions (n=118/247)
- Comorbidities (n=33/247)
- Imbalance between increased pulmonary vascular resistance (PVR) and amount of accessible occlusions (n=25/247)
- PVR >1500 dyn∙sec∙cm-5 (n=6/247)
- Age (n=5/24)
- Other (n=56/247)
- Patients missing data (n=4/247)
An expert multidisciplinary team (MDT) is critical to evaluating operability and determining the final treatment approach.2 The MDT should consist of the PTE surgeon, a BPA specialist, a PH expert, and a pulmonary vascular radiologist.1
PTE operability assessment requires an expert team
PTE operability assessment is an inherently subjective exercise, and it depends on the experience and the skills of the CTEPH team and the PTE surgeon. Whenever feasible, seek an assessment from a second experienced CTEPH team if a patient is initially deemed to have inoperable disease.4
However, surgery or operability assessments are not the only referrals that should be made for patients with CTEPH. Ventilation/perfusion (V/Q) scan referrals are recommended for the early signs of CTEPH to ensure patients are properly diagnosed from the start.4
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References:
1. Kim NH, D'Armini AM, Delcroix M, et al. Chronic thromboembolic pulmonary disease. Eur Respir J. 2024;64(4):2401294. 2. Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2022;43(38):3618-3731. 3. Pepke-Zaba J, Delcroix M, Lang I, et al. Chronic thromboembolic pulmonary hypertension (CTEPH): results from an internationaI prospective registry. Circulation. 2011;124(18):1973-1981. 4. Kim NH, Delcroix M, Jais X, et al. Chronic thromboembolic pulmonary hypertension. Eur Respir J. 2019;53(1):1801915.
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