Because pulmonary thromboendarterectomy (PTE) (also called pulmonary endarterectomy [PEA]) is potentially curative, it is the primary treatment for patients with CTEPH.1
PTE should be offered to all eligible patients with CTEPH.1 The primary goals of PTE are improved outcomes and improved survival in CTEPH patients, and the majority of patients experience significant improvements in symptoms and hemodynamics.1-3 The international registry of incident cases of CTEPH reported a 3-year survival of 90% in those receiving PTE versus 70% in those who did not have surgery.1
However, not every patient is a candidate for PTE. In an international registry of 679 patients with CTEPH, 37% (247) were deemed to have inoperable disease.4
The most common reason patients were considered to have inoperable disease was because the lesions were considered too distal or inaccessible4
Inaccessibility of occlusions (n=118/247)
Imbalance between increased pulmonary vascular resistance (PVR) and amount of accessible occlusions (n=25/247)
PVR >1500 dyn∙sec∙cm-5 (n=6/247)
Patients missing data (n=4/247)
Every patient diagnosed with CTEPH should be evaluated by an expert CTEPH team, including a PTE surgeon, PH specialist, balloon pulmonary angioplasty (BPA) interventionist, and a CTEPH-trained radiologist, to assess their candidacy for PTE surgery.1
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.1
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.1
Watch as Dr Michael Madani of the PTE Program at UCSD discusses key steps in performing PTE surgery.
1. Kim NH, Delcroix M, Jais X, et al. Chronic thromboembolic pulmonary hypertension. Eur Respir J. 2019;53:1801915. 2. Keogh AM, Mayer E, Benza RL, et al. Interventional and surgical modalities of treatment in pulmonary hypertension. J Am Coll Cardiol. 2009;54(suppl 1):S67-S77. 3. Galiè N, Humbert M, Vachiery JL, et al; ESC Scientific Document Group. 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2016;37(1):67-119. 4. Pepke-Zaba J, Delcroix M, Lang I, et al. Chronic thromboembolic pulmonary hypertension (CTEPH): results from an international prospective registry. Circulation. 2011;124(18):1973-1981.