San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California.
San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California; San Diego Health System, Division of Cardiovascular and Thoracic Surgery, University of California, La Jolla, California.
J Heart Lung Transplant. 2023 Aug;42(8):1112-1119. doi: 10.1016/j.healun.2023.02.1500. Epub 2023 Mar 2.
Chronic thromboembolic pulmonary hypertension (CTEPH) is primarily managed by pulmonary thromboendarterectomy (PTE). As advanced surgical techniques permit resection at the segmental and subsegmental level, PTE can now be curative for CTEPH mostly involving the distal pulmonary arteries.
Between January 2017 and June 2021, consecutive patients undergoing PTE were categorized according to the most proximal level of chronic thrombus resection: Level I (main pulmonary artery), Level II (lobar), Level III (segmental) and Level IV (subsegmental). Proximal disease patients (any Level I or II) were compared to distal disease (Level III or IV bilaterally) patients. Demographics, medical history, preoperative pulmonary hemodynamics, and immediate postoperative outcomes were obtained for each group.
During the study period, 794 patients underwent PTE, 563 with proximal disease and 231 with distal disease. Patients with distal disease more frequently had a history of an indwelling intravenous device, splenectomy, upper extremity thrombosis or use thyroid replacement and less often had prior lower extremity thrombosis or hypercoagulable state. Despite more use of PAH-targeted medications in the distal disease group (63.2% vs 50.1%, p < 0.001), preoperative hemodynamics were similar. Both patient groups exhibited significant improvements in pulmonary hemodynamics postoperatively with comparable in-hospital mortality rates. Compared to proximal disease, a lower percentage of patients with distal disease showed residual pulmonary hypertension (3.1% vs 6.9%, p = 0.039) and airway hemorrhage (3.0% vs 6.6%, p = 0.047) postoperatively.
Thromboendarterectomy for distal (segmental and subsegmental) CTEPH is technically feasible and may result in favorable pulmonary hemodynamic outcomes, without increased mortality or morbidity.
慢性血栓栓塞性肺动脉高压（CTEPH）主要通过肺动脉血栓内膜切除术（PTE）治疗。随着先进的外科技术允许在段和亚段水平进行切除，PTE 现在可以治愈大多数累及远端肺动脉的 CTEPH。
在 2017 年 1 月至 2021 年 6 月期间，连续接受 PTE 的患者根据慢性血栓切除的最近端水平进行分类：I 级（主肺动脉）、II 级（叶）、III 级（段）和 IV 级（亚段）。近端疾病患者（任何 I 级或 II 级）与远端疾病（双侧 III 级或 IV 级）患者进行比较。为每组患者获得人口统计学资料、病史、术前肺血流动力学和即刻术后结果。
在研究期间，794 例患者接受了 PTE，563 例患者有近端疾病，231 例患者有远端疾病。远端疾病患者更频繁地有留置静脉装置、脾切除术、上肢血栓形成或使用甲状腺替代治疗的病史，较少有下肢血栓形成或高凝状态的病史。尽管远端疾病组更常使用肺动脉高压靶向药物（63.2%比 50.1%，p < 0.001），但术前血流动力学相似。两组患者术后肺血流动力学均显著改善，院内死亡率相似。与近端疾病相比，远端疾病患者术后显示残余肺动脉高压的比例较低（3.1%比 6.9%，p = 0.039）和气道出血（3.0%比 6.6%，p = 0.047）。
对于远端（段和亚段）CTEPH 的血栓内膜切除术在技术上是可行的，可能导致有利的肺血流动力学结果，而不会增加死亡率或发病率。
