Pulmonary Thromboendarterectomy

Defining Pulmonary Hypertension:

For over 30 years UCSD Medical Center pulmonologists specializing in chronic thromoboembolic pulmonary hypertension (CTEPH) and thromboembolic disease in conjunction with cardiothoracic surgeons have pioneered the diagnosis and treatment, natural history and surgical correction of pulmonary hypertension due to chronic large vessel thromboembolic obstruction of the pulmonary arteries. During this period of time, physicians, physician-scientists, and researchers have developed:

• Diagnostic methods which enhance definition of thrombus location
• Refined surgical selection criteria
• Developed new surgical approaches which optimize thromboendarterectomy
• Devised post-surgical management techniques to deal with the major, more predictable post-operative complications

As of December 2004, more than 2200 candidates from throughout the world have been evaluated and some 1900 patients have undergone a pulmonary thromboendarterectomy (PTE) at UCSD Medical Center. 89% of these patients have been operated since 1989. This increased rate of referrals reflects wider recognition of CTEPH as a surgically remediable disease, and the improved results of the operation. As this recognition increases worldwide, our referral base continues to expand and our recognition as a world renown Pulmonary Vascular Center fuels our research.

Our research has demonstrated that in order to optimize selection and outcome, the following pre-operative tests are key:

• CXR and EKG
• Hemogram, platelet count, bleeding time, PT, PTT, chemistry panel
• Antithrombin III, Protein C, Protein S levels, anticardiolipin antibody, APC R, Factor V, and lupus anticoagulant
• Echocardiogram with Doppler estimate of PA pressures
• Lung ventilation-perfusion scan
• Impedence plethysmography or duplex ultrasonography of the lower extremities
• Pulmonary function studies/DLCO measurements
• Rest and exercise arterial blood gas; expired gas studies if indicated
• Right heart catheterization and pulmonary angiography
• Coronary angiography (age >35, symptoms, prior CABG, etc), if indicated
• Pulmonary angioscopy (question of thrombus accessibility), if indicated
• Carotid duplex, if indicated
• Percutaneous placement of a Greenfield filter

Patients with significant symptoms and more moderate pulmonary hypertension due to previous large blood clots traveling to the lungs or the legs or pelvis may be candidates for a pulmonary thromboendarterectomy (PTE). In properly selected patients, the procedure can dramatically reduce symptoms and prevent death from heart and lung failure. A right heart catheterization and a very high quality pulmonary angiogram are necessary for the surgical team to decide operability. Our patients are meticulously evaluated to determine why blood clots have formed, and for other conditions such as coronary artery disease that may complicate surgery.

Patients referred to the Vascular Center have been referred by either a pulmonologist or cardiologist. Medical records and all diagnostic studies (X-rays and or CD) are forwarded to UCSD Medical Center. The evaluation process is two-to-three day process which is done at the Perlman Clinic in La Jolla. All patients referred to the Center must first have their medical records/diagnostic studies reviewed Center's pulmonologists and scheduled for evaluation by our program manager, Scott Cartwright.

Pulmonary thromboendarterectomy is a major open heart operation performed by very few centers throughout the world and even fewer in the country. Patients undergoing a PTE are placed on a heart and lung by-pass pump, the chest is opened through the breast bone, and the surgeon opens the main pulmonary artery and first branches. The old clots and thickened lining of the pulmonary artery are removed. Following the operation the pulmonary artery pressures fall rapidly to almost normal or acceptable levels. The operation carries a high risk with mortality in the 5-10% and possibly higher in those patients with significant risk factors.

Post operative care necessitates a multi-disciplinary approach and requires one to two days in the intensive care unit. If complications arise, these may require prolonged ventilator support due to lung injury, post-operative delirium, stoke and in some cases, death. All patients require an inferior vena caval filter and life-long anti-coagulation with Coumadin to prevent further clots from traveling to the lungs.

The diagnostic approach and management of patients with chronic thromboembolic pulmonary hypertension was pioneered by UCSD faculty and to date, our team has performed over 1900 PTE operations - more than all other centers worldwide combined.

If you wish to refer a patient to the Vascular Center, please contact:

Scott R. Cartwright
Program Manager
Division of Pulmonary and Critical Care Medicine
UCSD Medical Center - Thornton Hospital, La Jolla
Pulmonary Vascular Center
9300 Campus Point Drive, M/C 7372
La Jolla, CA 92037-7372
Phone: 888-777-4170
Fax: 858-657-7107

e-mail: Srcartwright@ucsd.edu