Let's learn about the surgery to remove blood clots in the lungs (Pulmonary Thromboendarterectomy - PTE)

You may have been having difficulty breathing for some time, or even feeling short of breath when walking. Your doctor may have told you that you have pulmonary hypertension, which is a buildup of old blood clots in your lungs. When this condition cannot be controlled with medication, we are talking about a special surgery that can save your life.

Simply put, what is this PTE surgery?

Don't be intimidated by the long name Pulmonary Thromboendarterectomy. We'll call it PTE for short. PTE is a very complex procedure performed by specialist surgeons. It involves surgically removing old blood clots and scar tissue that have become stuck to the walls of the main blood vessels that carry blood to your lungs (the Pulmonary Arteries).

Imagine that a water pipe in your home has become clogged with dirt and water is not flowing. PTE surgery is like cleaning the inside of the pipe and making the water flow smoothly again. This is the best way to remove these old and hardened blood clots that cannot be dissolved with medication. Sometimes, this surgery can even cure the condition completely.

What conditions are treated with PTE surgery?

This surgery is mainly performed on people with a condition called Chronic Thromboembolic Pulmonary Hypertension (CTEPH) . This is a bit of a complicated name, so let's understand it.

• Chronic: means "lasting for a long time."
• Thromboembolic: means "caused by a blood clot."
• Pulmonary Hypertension: This means "high blood pressure in the lungs."

Simply put, CTEPH is when a blood clot (Pulmonary Embolism - PE) that has previously formed in the lungs does not dissolve properly, but instead sticks to the walls of the blood vessels in the lungs, forming scar tissue over time, obstructing blood flow, causing pressure to increase in the lungs.

Usually, when someone has a blood clot (PE) in the lungs, doctors give them blood thinners. Most of the time, these medications dissolve the blood clots. But in a very small number of people, about 2% - 4%, these blood clots do not dissolve completely. They become old, stick to the walls of the blood vessels, and block the way for blood to flow. This puts a lot of strain on the right side of the heart, which pumps blood to the lungs. Over time, this can lead to heart failure , lung damage, and even life-threatening complications.

Who needs this surgery? Can everyone have it?

If you have CTEPH, several factors will be considered to determine whether you can have this surgery.

• The severity of your symptoms.
• Where the blood clots are located, how far they have spread, and how much they have blocked the blood vessels.
• Your age, overall health, and how your heart and lungs are working.

According to surgeons, if these blood clots can be safely removed, the treatment of choice for CTEPH is PTE surgery.

However, not everyone with CTEPH can undergo this surgery. Approximately 40%, or four out of ten people, are not suitable for this surgery. The main reason for this is that it is a very complex surgery.

Why is this surgery so complicated?

During this surgery, the medical team temporarily transfers the work of your heart and lungs to a cardiopulmonary bypass machine . This means that this machine supplies your body with oxygen and pumps blood during the surgery.

Even more importantly, during the operation, the surgeon needs to clearly see the delicate blood vessels in the lungs. To do this, a special method is used to lower your body temperature to 18 degrees Celsius (65 Fahrenheit), completely stopping blood circulation for a while (Deep Hypothermic Circulatory Arrest). The body is cooled in this way to prevent damage to the brain. This method allows the surgeon to very carefully remove blood clots and scar tissue in a clear, bloodless surgical field.

If surgery is not possible, what other options are there?

If doctors decide that you are not suitable for PTE surgery for any reason, they will recommend other treatments.

• Oral Medication: There are special medications that can control blood pressure in the lungs.
• Balloon Pulmonary Angioplasty (BPA): This involves using a thin tube inserted through a vein in the leg to reach the blocked blood vessels in the lungs, and inflating them with a balloon-like device to open up the blood flow.

How do you prepare before surgery?

Your doctor will give you clear instructions on how to prepare for surgery. It is very important to follow those instructions exactly.

What happens during the surgery?

This surgery usually starts in the morning and takes about 6 hours. You will be fully anesthetized so you won't feel anything.

1. Help with breathing: First, a thin tube (Endotracheal Tube - ETT) is inserted through your mouth or nose, down your windpipe, and connected to an oxygen machine (ventilator). This machine will help you breathe throughout the surgery.

2. Opening the chest: Next, the surgeon will cut through your breastbone (sternum) to reach the heart and lungs.

3. Connection to the bypass machine: You will then be connected to the Cardiopulmonary Bypass Machine. This machine will do the work of the heart and lungs during the surgery.

4. Body cooling: Next, your body temperature is gradually lowered to 18 degrees Celsius.

5. Removing blood clots: After cooling the body and temporarily stopping blood circulation, the surgeon carefully removes the blood clots and scar tissue from inside the blood vessels of the lungs using special instruments.

6. Rewarming: After the blood clots are removed, your body temperature is brought back to normal and you are disconnected from the bypass machine. But you remain connected to the ventilator.

7. Chest closure:Finally, the surgeon will close your chest and insert several thin tubes to drain any excess fluid that may be accumulating inside your body.

What happens after the surgery?

After surgery, you will be admitted to the intensive care unit (ICU) . You will stay in the ICU that night. The next morning, the medical team will check your breathing. If you can breathe on your own, the ventilator will be removed.

You will usually have to stay in the hospital for 7 to 10 days. You will first be in the ICU, and then you will be transferred to a regular ward as your condition improves.

The recovery process is much like recovering from open heart surgery. You will be able to walk within a few days and gradually be able to do some work. Before you go home, you will also have some tests to see if you need oxygen.

What are the benefits and risks of PTE surgery?

Advantages

• This is the only way to completely cure CTEPH.
• For many people, the surgery is successful, and breathing and lung function improve significantly.
• Many people who were dependent on oxygen before surgery will no longer need oxygen after surgery.
• The damage caused to the right side of the heart by the disease is often reversed.
• The chance of long-term survival after surgery is very high.

Risks and Complications

Since this is a major surgery, there are some risks. However, with the advancement of technology over the past few years, these risks have been greatly reduced.

• The risk of death during surgery is now as low as 1%.
• The risk of stroke is about 1% - 2%.
• Some people may still have some level of pulmonary hypertension after surgery. They will need to continue taking medication.
• Sometimes, fluid accumulation around the heart (pericardial effusion) can occur.

If you experience the following symptoms, call 1990 immediately or go to the nearest hospital Emergency Department (ETU):

• Severe chest pain
• Fainting
• Sudden severe shortness of breath

How long does it take to heal?

Over time, you can return to normal life. But, you have to be a little patient.

• First 6 weeks: You cannot drive, go to work, or lift more than 10 pounds (about 4.5 kg).
• Weeks 7 to 12: Can lift up to 25 pounds (about 11 kg).
• After 12 weeks: Weight-lifting restrictions are usually lifted.

Most people can return to their normal activities within 3 months. Your breathing and ability to exercise will gradually improve, and you may see improvements for up to 4 years.

How is the medical supervision after the surgery?

After the surgery, you will have to continue seeing the doctor.

• You will have several special tests to check your lungs 6 weeks after surgery and again between 3-6 months later.
• The most important thing is that you will have to take anticoagulants/blood thinners for the rest of your life to prevent new blood clots from forming.

If you have these symptoms, talk to your doctor.

• If the pain is unbearable, or if the pain decreases and then increases again.
• If the heartbeat is fast or irregular.
• If the surgical wound is red, swollen, oozing pus, or has a fever (these are signs of infection).

PTE is a very valuable surgery that can give a second life to someone suffering from CTEPH. Although it is a complex surgery and takes a long time to recover, the result of it, which is the opportunity to live freely without suffocation again, is priceless.