Pulmonary thromboendarterectomy (PTE) for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH) is an uncommon surgical procedure; however, it is the only curative option that provides immediate and permanent cure for this devastating disease. The condition is remarkably underdiagnosed, and as a result the procedure is uncommonly applied. Patients with chronic pulmonary hypertension secondary to thromboembolic disease may present with a variety of debilitating cardiopulmonary symptoms. However, once it is diagnosed, there is no curative role for medical management, and surgical removal of the thromboembolic material is the only therapeutic option.

The exact incidence of pulmonary embolism (PE) is unknown, but there are some valid estimates. Acute PE is the third most common cause of death (after heart disease and cancer). Approximately, 75% of autopsy-proven PEs are not detected clinically. It is estimated that PE results in approximately 700,000 symptomatic episodes in the United States yearly. The disease is particularly common in hospitalized elderly patients. Of the hospitalized patients who develop PE, 12% to 21% will die in the hospital, and another 24% to 39% die within 12 months. Thus, approximately 36% to 60% of the patients who survive the initial episode live beyond 12 months, and they may present later in life with a wide variety of symptoms.

The mainstay of treatment of patients with deep vein thrombosis (DVT) and acute PE is medical management. In general, cardiac surgeons rarely intervene in hospitalized patients who suffer a massive embolus that causes life-threatening acute right heart failure and severe hemodynamic compromise. In contrast, the only treatment for patients with chronic pulmonary thromboembolic disease is the surgical removal of the disease by means of PTE. Medical management in these patients is only palliative, and surgery by means of transplantation is an inappropriate use of resources with less than satisfactory results.

The prognosis for patients with pulmonary hypertension is poor, and it is worse for those who do not have intracardiac shunts, since the shunt will reduce right-sided pressures. Thus, patients with primary pulmonary hypertension and those with pulmonary hypertension secondary to pulmonary emboli fall into a higher risk category than those with Eisenmenger syndrome and have a higher mortality rate. In fact, once the mean pulmonary pressure in patients with thromboembolic disease reaches ≥50 mmHg, the 3-year mortality approaches 90%.

Surgical preferences are dependent on both the principal disease process and the reversibility of the pulmonary hypertension. With the exception of thromboembolic pulmonary hypertension, lung transplantation is the only effective therapy for patients with end-stage pulmonary hypertension. Although it has been performed less frequently in the last few years, pulmonary transplantation is still used in some centers as the treatment of choice for patients with thromboembolic disease. However, a true assessment of the effectiveness of any therapy should take into account the total mortality after the patient has been accepted and put on the waiting list. Thus, the mortality for transplantation (and especially double-lung or heart-lung transplantation) as a therapeutic strategy is much higher than is generally appreciated because of the significant loss of patients awaiting donors. Bearing in mind, in addition, the long-term use of immunosuppressants with their associated side effects, the higher operative morbidity and mortality, the inferior prognosis even after successful transplantation, and the long waiting period, one can see that transplantation is clearly an inferior alternative to PTE and should be considered an inappropriate and outdated form of therapy.