Surgical Intervention in the Treatment of Pulmonary Embolism and Chronic Thromboembolic Pulmonary Hypertension

Pulmonary embolism is a common and often fatal condition affecting many patients across the world. Although, most acute pulmonary embolisms will resolve with adequate medical management, there is a subset of patients with massive pulmonary embolisms and severe hemodynamic instability who may benefit from emergency pulmonary embolectomy. However, pulmonary embolectomies are high risk operations that are only infrequently performed in such dire situations. In contrast, pulmonary thromboendarterectomy is the definitive treatment for chronic pulmonary hypertension as the result of thromboembolic disease and is now widely recognized as the treatment of choice for patients suffering from chronic thromboembolic pulmonary hypertension (CTEPH). Although the procedure is curative and in experienced hands carries a low morbidity and mortality, it is only rarely performed. The main problem is the fact that CTEPH remains significantly under-recognized. It is not uncommon for the patients suffering from this disease to be misdiagnosed and mistreated for a variety of other conditions. Furthermore, of those who are truly diagnosed, majority will be at late stages of the disease. However once correctly diagnosed and referred, pulmonary thromboendarterectomy will be highly effective and will provide a lifetime cure for such patients. Once chronic pulmonary hypertension develops, the prognosis is poor, and this prognosis is even worse in patients without an intracardiac shunt. In fact, survival of patients with chronic thromboembolic pulmonary hypertension is inversely related to the magnitude of pulmonary artery systolic pressure and pulmonary vascular resistance. Regardless of the exact incidence or the circumstances, it is clear that acute embolism and its chronic relation, fixed chronic thromboembolic occlusive disease, are both much more common than generally appreciated Therefore, despite an improved understanding of pathogenesis, diagnosis, and management, pulmonary emboli and the long-term sequelae of thromboembolic pulmonary hypertension remain frequent and often fatal disorders.