[Successful pulmonary thromboendarterectomy in a patient with chronic pulmonary thromboembolism]

A 63-year-old patient had been diagnosed with angina pectoris for 5 months and came to us complaining of progressive exertional dyspnea. Echo cardiography showed remarkable pulmonary hypertension and we were prompted to do cardiac catheterization. The catheterization showed the pressure of the main pulmonary artery (PA) as 84/14 (36) mmHg and PA angiography showed a massive embolus in the right main PA. Chest computed tomography and lung perfusion scintigraphy were also compatible with pulmonary embolism. The patient had been treated with anticoagulant for 1 month, but he was not doing well. We decided to remove the embolus surgically. In a median sternotomy, a cardiopulmonary bypass was established with ascending aortic and two caval cannulae. During cooling, the right PA was mobilized within the pericardial reflection. An incision was made in the right PA. An organized thrombus was located at the central PA and extended to the distal segmental PA. Thromboendarterectomy was carried out carefully. To obtain a better operative view, circulatory arrest was introduced intermittently. The left PA was opened and the organized thrombus, located at the bifurcation between the upper and lower branch, was removed. Post-operative PA angiography showed remaining thrombus in the right lower PA, but the pressure of the main PA fell to 27/12 (18) mmHg. Pulmonary thromboendarterectomy by median sternotomy with the aid of deep hypothermia and circulatory arrest was useful to remove the thrombus in the bilateral PA, and to obtain good hemodynamic and symptomatic results.