SURGICAL-MANAGEMENT OF UNRESOLVED PULMONARY-EMBOLISM - A PERSONAL SERIES OF 72 PATIENTS

Chronic thromboembolic pulmonary hypertension (CT-E PH) is a rare and aberrant outcome of acute pulmonary embolism. Because it has become a potentially curable form of pulmonary hypertension, the frequency of r ecognized cases has increased. We report a case series of 72 patients with CT-E PH evaluated in our institution between 1984 and 1993, and d iscuss diagnostic clues and therapeutic approaches. All patients compl ained of dyspnea on exertion, a history of acute thromboembolic event, and lung murmurs were found in 60% and 17% of patients, respectively. The presence of a disorder of coagulation was found in 30% of the pat ients tested, the most common abnormality being lupus anticoagulant. T he key noninvasive study for diagnosis was the lung perfusion scan whi ch showed at least one segmental or larger perfusion defect in all pat ients. Pulmonary angiography confirmed the diagnosis in all cases, and sometimes associated to intravascular ultrasound imaging, established the feasibility of thromboendarterectomy, Medical therapy included th e use of long-term oral anticoagulant, and in the case of lower limb v enous thrombosis, inferior vena cava filtration. Finally two surgical procedures were discussed in selected patients: thromboendarterectomy and lung transplantation. Since 1988, eight patients have benefited fr om lung transplantation (six patients are still alive), and 11 patient s underwent thromboendarterectomy which was successful in 9 patients w ith a dramatic functional and hemodynamic improvement.