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Alexander Marmureanu

Alexander Marmureanu

Pulmonary Embolic Diseases

Pulmonary Embolism: Acute Blockage

A sudden blockage in the arteries of the lung, known as an acute pulmonary embolism (PE), begins as a clot in a vein elsewhere in the body that travels to the lung. Pulmonary emboli are life threatening, with 25-30% of patients dying unless treated immediately. Acute pulmonary emboli are treated by our pulmonary medicine colleagues with medication to thin the blood or dissolve the clot. For patients at risk for repeat pulmonary emboli, a filter may be placed in the inferior vena cava, the large vein carrying de-oxygenated blood from the lower portion of the body to the heart. In rare cases, medical management of acute pulmonary emboli fails to adequately treat these clots, or a patient may have severe hemodynamic instability from a very large embolus. In these cases, a surgeon can remove the offending clot and restore proper blood flow to the lungs. Our surgeons have expertise in all procedures involving pulmonary artery conditions.

Pulmonary Embolism: Chronic Blockage

Ongoing blockage of the pulmonary arteries occurs when clots and other matter from the blood builds up in the vessels, inhibiting or blocking the path of blood flow. The causes of these blockages are multivariate, and many are not well understood, but are thought to include 1) a part of a blockage remaining after the clearing of an acute pulmonary embolism, or 2) a clot remaining from an undetected, and therefore untreated, acute pulmonary embolism.  

A chronic pulmonary blockage curtails the flow of blood through the lungs, which receive blood from the right side of the heart and deliver oxygenated blood to the left side of the heart, causing a situation of high blood pressure in the lungs (pulmonary hypertension). The resulting disease state is known as chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH may be mild or severe depending on the position and size of the blockage, which may grow over time.

CTEPH is initially difficult to diagnose because its main symptom in its early stages, shortness of breath, can signify a variety of conditions. As the size of the pulmonary blockage progresses, and the CTEPH increases, additional symptoms may appear due to stress placed on the right side of the heart as it struggles to push blood through the blocked area. As the flow of blood through the lungs is diminished, so is the oxygenation of the blood. Symptoms may include: difficulty breathing, water retention in the limbs (edema) due to the heart's reduced ability to move fluid through the body's blood vessels, chest pain, light-headedness and faintness (syncope).

The physician can diagnose the condition using a series of tools, including an echocardiogram (sound wave picture of the heart) and a pulmonary angiogram, an X-ray image of the pulmonary arteries.

Treatment

Treatment of CTEPH is not always necessary and depends upon a variety of factors including the location and severity of the blockage. Pulmonary thromboendarterectomy (PTE), the surgical procedure used to treat CTEPH, restores blood flow through the lungs by means of surgical removal of accumulated clots and material from the pulmonary arteries.

The procedure involves "open-heart" surgery so that the surgeon may view the pulmonary arteries, which connect the lungs to the heart. In order to achieve this, the patient is connected to the heart-lung bypass machine, which mimics the actions of the heart and lungs, oxygenating the blood and pumping it throughout the body. The heart is stopped to control the blood flow to the heart and lungs.

The patient's body is cooled significantly, reducing the need for oxygen, with the purpose of allowing surgeons to halt the bypass machine periodically to view the vessels they are clearing. Bit by bit they gently loosen the clots and remove them. Clots may be as long as 10 inches, extending from the main arteries into the smaller arteries of the lung.