Surgical treatment of primary pulmonary artery sarcoma
Valentina GrazioliNicola VistariniMarco MorsoliniCatherine KlersyG OrlandoniRoberto DoreAndrea Maria D’Armini
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Pulmonary thromboendarterectomy
Endarterectomy
Endarterectomy
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Pulmonary artery pressure (PAP) is reduced dramatically after pulmonary thromboendarterectomy in patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, it is unclear whether pulmonary artery compliance increases in conjunction with the reduction in PAP. Pulmonary artery compliance may affect right ventricular afterload and prognosis.In 33 patients with CTEPH (9 men, 22-76 years), changes in the tricuspid regurgitation pressure gradient (TRPG) and the acceleration time (ACT) of pulmonary artery flow (a surrogate parameter of pulmonary artery compliance) were examined before and after pulmonary thromboendarterectomy using echocardiography to clarify factors affecting the changes. At 6 months, both TRPG and ACT normalized (or=100 ms, respectively) in 25 patients (group A) but not in 8 (group B). In group B, there were 5 with normal TRPG and shortened ACT at 6 months that normalized at 17+/-3 months. Group A patients showed shorter disease period and shorter period without anticoagulation than group B patients (p=0.04, 0.02 respectively). All patients in group A had the proximal type, and 2 patients of group B had the distal type (p=0.05). Clinical improvement was more remarkable in group A.The recovery of PAP and the ACT of pulmonary artery flow was not always concordant after pulmonary thromboendarterectomy, suggesting a presence of a time lag in the recovery between pressure and compliance in some patients. A long period of CTEPH, a long period without anticoagulation and the distal embolism type may be predictive factors of an unfavorable operative result with reduced pulmonary artery compliance, and hence poor recovery of clinical performance.
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to assess effect of thromboendarterectomy from pulmonary artery branches on clinical functional state of patients with chronic thromboembolic pulmonary hypertension (CTEPH) in dependence on degree of pulmonary hypertension and disease duration.Patients (n=152) were divided into 3 groups: (1) with systolic pulmonary artery pressure (SPAP) less or equal 50 mm Hg (n=20), (2) with SPAP>50- less or equal 80mm Hg (n=46), (3) with SPAP >80mm Hg (n=86).Examination included registration of dynamics of general clinical state and character of complaints, six-minute walk test, transthoracic echocardiography with measurement of SPAP and right ventricular ejection fraction, pulmonary perfusion scintigraphy with calculation of index of perfusion deficit.Pulmonary thromboendarterectomy from pulmonary artery branches was associated with stable improvement of clinical functional state of patients with CTEPH and regression of symptoms irrespective of preoperative level of pulmonary hypertension.
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Fifty-three patients underwent emergency carotid thromboendarterectomy under surgical indications consisting of spontaneous cerebrovascular accident, stroke following carotid arteriography, stroke following successful carotid endarterectomy, and persistent transient ischemic attacks. Nearly 60% of the patients came to the operating room with some degree of neurologic deficit. There were six hospital deaths, five of whom were in the latter group. Based on immediate and late results of the operation, it is concluded that emergency carotid thromboendarterectomy is indicated (1) in patients with transient ischemic attacks who present with extremely severe narrowing of one or both internal carotid arteries, (2) when there is spontaneous stroke in selected patients (after angiography, disappearance of bruit) and, finally, (3) in patients who initially recover from carotid endarterectomy but go on to develop stroke as the result of thrombosis of the endarterectomized vessel.
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Endarterectomy
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Left pulmonary artery
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Pulmonary hypertension as a result of chronic thromboembolic disease (CTEPH) is potentially curable with pulmonary endarterectomy surgery. Consequently, correctly diagnosing patients with this type of pulmonary hypertension and evaluating these patients with the goal of establishing their candidacy for surgical intervention is of utmost importance. And as advancements in surgical techniques have allowed successful resection of segmental‐level chronic thromboembolic disease, the number of CTEPH patients that are deemed suitable surgical candidates has expanded, making it even more important that the evaluation be conducted with greater precision. This article will review a diagnostic approach to patients with suspected chronic thromboembolic disease with an emphasis on the criteria considered in selecting patients for pulmonary endarterectomy surgery.
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