Pulmonary Thromboendarterectomy - How I Do It

P. Gregorio¹, C. Bermudez², R. Fujimoto^1
1University of Pennsylvania, Philadelphia, Pennsylvania ²Hospital of the University of Pennsylvania, Dept. of Cardiovascular S, Philadelphia, Pennsylvania

Please explain the educational or technical point that this video addresses.: Pulmonary thromboendarterectomy (PTE) is a highly specialized surgical procedure that significantly improves the quality of life for patients with chronic thromboembolic pulmonary hypertension (CTEPH) and chronic thromboembolic disease (CTED). For surgeons in training, learning this complex and delicate procedure is crucial, however, considering the size and depth of the dissection plane, this can be an arduous task.

A comprehensive video on PTE can provide residents with a clear, step-by-step guide, highlighting each critical phase of the surgery, from patient preparation to postoperative care. Visual learning aids, such as videos, allow residents to observe the intricate techniques and precise movements required, which are difficult to grasp through textbooks or verbal instructions alone.

In the presented case, a 10 mm/30° rigid endoscope was used during the surgery to allow better visualization for everyone in the operating room and to enable further review of the procedure.

The recording of a PTE with a rigid endoscope presents an outstanding opportunity for surgeons in training to better understand the technique. Some centers use headcams for the same purpose, but we believe that in small and deep operative fields, such as in this procedure, the long endoscope provides a better visualization of the structures.
The video highlights the different steps of the procedure, from line placement to post-operative care, in order to achieve a good outcome for this complex surgery.

Please provide a 250 word summary of the surgical video being submitted.: A 61-year-old male patient with chronic thromboembolic disease presented to our institution with dyspnea on exertion (NYHA II/III). Right heart catheterization did not show pulmonary hypertension complicating the disease. After meticulous workup, a pulmonary thromboendarterectomy was proposed to alleviate the symptoms.

The procedure was performed with all available monitoring and surgical techniques to minimize circulatory arrest time and prevent any neurological damage. After a standard sternotomy, cannulations (aorta, SVC, IVC, and LV vent) were done, and the patient was cooled to 18°C. We began the removal of the thrombus from the RPA, followed by the LPA, with total circulatory arrest times of 15 and 16 minutes, respectively. For both sides, it was possible to achieve outstanding visualization of the removal of the thrombus and the lumens of the branches free of the disease after the removal. Both arteries were closed with a double-layer prolene suture. During rewarming and after coming off bypass, the details of the hemodynamics were highlighted.

Postoperative management, including the need to avoid pulmonary vasodilators and the importance of early anticoagulation, was also discussed.