Pulmonary embolisms — or blood clots that travel from other parts of the body and block arteries in the lungs — are often successfully treated with blood thinners, but in some people, the clot doesn’t clear completely, leading to a condition called chronic thromboembolic pulmonary hypertension (CTEPH).
“Instead of having an acute, short-term pulmonary embolism, they are left with a chronic condition,” says Michael Cain, MD, assistant professor of cardiothoracic surgery in the University of Colorado Anschutz Department of Surgery. “That blockage that they get in the arteries to the lungs makes it harder for blood to flow through the lungs, so they ultimately get high blood pressure in the arteries that goes to the lungs. It can cause people to be short of breath, to need oxygen, and to not be able to exercise like they used to.”
A surgery to help
The condition also can cause stress to the right side of the heart and, over time, can lead to heart failure. Fortunately, it can be treated with a surgery called a pulmonary thromboendarterectomy (PTE) — an open operation to remove the clots from the pulmonary arteries. At the CU Anschutz Department of Surgery, Cain and Jordan Hoffman, MD, associate professor of cardiothoracic surgery, specialize in the complex procedure.
“Pulmonary hypertension can be challenging to manage ahead of time, so the expertise that we have in our pulmonary hypertension group at the University of Colorado is really helpful,” Cain says. “We're a high-volume center for pulmonary thromboendarterectomy, and the more experience you have, the better your outcomes are.”
Controlling blood flow
Part of the complexity of the operation comes from the fact that it requires circulatory arrest — a temporary stop of blood flow to the body — to clear the blood from the arteries in the lungs.
“Normally when someone is on the heart-lung machine, they have blood that's still circulating through the entirety of their body, but they don't have blood that's flowing to the heart,” Cain says. “Circulatory arrest is where we stop the flow of the blood to the person's body as well. We continue blood flow to the brain, but we stop the blood flow to the body itself, and that allows us to see in the arteries to the lungs in a way that that we otherwise wouldn't be able to see. We do it in two intervals — it's usually 20 minutes for one side, then we take a break and we have blood flowing to the whole body, then we stop the circulation again, so we can do the left side of the lungs.”
Cain says recovery from the operation typically involves two or three days in the intensive care unit, followed by seven to 10 days in the hospital. Because people often have CTEPH for months or years before receiving a pulmonary thromboendarterectomy, they often feel much better after the surgery.
“Many of these people are on oxygen to try to compensate for this elevated pulmonary artery pressure that they have, and the vast majority of people come off of oxygen after this procedure,” says Cain, noting that people who receive the operation have to take blood thinners for the rest of their lives to prevent future clots. “And beyond just coming off oxygen, they feel a lot better. They have a lot more activity tolerance. Their heart has to do a lot less work, and it improves their heart function overall too. Put all that together, and people feel much better.”
Balloon option
In recent years, another procedure has been developed for people with CTEPH who aren’t good candidates for surgery due to frailty or other concerns. Called balloon pulmonary angioplasty, it’s a minimally invasive procedure in which a balloon is inserted into the artery, then inflated to clear the blockage.
“Recovery is easier, but it often requires multiple episodes of angioplasty,” Cain says. “They'll open up a few segments, then they'll let you recover for a few weeks to a month, then they'll come back and do some more. It depends on how much disease somebody has.”
Having both pulmonary thromboendarterectomy and balloon pulmonary angioplasty available for patients underscores the CU Anschutz Department of Surgery’s ability to treat a wide variety of patients, Cain says.
“It really helps us as a program provide care for more people who otherwise may not be able to get that treatment or would have to travel a very long distance to get that treatment,” he says. “It's about picking the right treatment for the right person.”
