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ORIGINAL ARTICLE

Surgical treatment of chronic pulmonary embolism: analisys of initial experience

Fábio B JateneI; Paulo M Pêgo-FernandesI; Sérgio PovedaI; Rosangela MonteiroI; Alberto CukierI; Charles MadyI; Adib D JateneI

DOI: 10.1590/S0102-76381995000200002

ABSTRACT

After the acute pulmonary embolism, in the majority of the cases lysis occurs with recanalization of the pulmonary branches. However, in a small but undetermined number of patients (pts) with chronic pulmonary embolism (PE) the incomplete resolution of the embolic material may result in a severe pulmonary hypertension. The pulmonary thromboendarterectomy is an option, specially when the obstruction is proximal and the patient presents failure of the clinical treatment. Many surgical techniques have been used, but the utilized sternotomy, extracorporeal circulation and hypothermic circulatory arrest presented best results. Until January 95,15 pts with PE were operated upon. The pulmonary angiography showed pulmonary embolism at both lungs in 66.7% of the cases. Sternotomy was realized in 73.3%. Endarterectomy by retrograde traction of thrombus was used in these pts. Extracorporeal circulation was utilized in all pts, with medium time of 124.8 min. In 66.7% of the cases hypothermic circulatory arrest was realized with medium time of 34.2 min. The pulmonary artery pressure was 91/32/55 mmHg in the pre and presented reduction by 52/15/ 27 mmHg in the postoperative period. One hospitalar death due to coagulopathy, and one later death due to complications not related to surgery were registered. Of the 13 survivors, 1 (7.7%) presented reobstruction and 12 (92.3%) had good evolution and now are free of symptoms, with oral anticoagulation in a period of until 165 months (47mo). In conclusion, the pulmonary thromboendarterectomy realized by sternotomy and with help of the hypothermic circulatory arrest is a safe procedure for resolution of pulmonary embolus and symptoms, and maintenance of the results at longterm follow-up.

RESUMO

Após a tromboembolia pulmonar aguda, na maioria dos casos, ocorre lise com recanalização dos ramos pulmonares. Entretanto, em pequeno, mas indeterminado número de pacientes (pts) com embolia pulmonar (EP) crônica, a incompleta resolução do material embólico pode resultar em grave hipertensão pulmonar. A tromboendarterectomia pulmonar (TP) é uma opção, especialmente quando a obstrução é proximal e os pts apresentam falência ao tratamento clínico. Dentre as técnicas cirúrgicas já empregadas, a que utiliza, atualmente, a esternotomia com circulação extracorpórea (CEC) e parada circulatória total (PCT) é a que tem apresentado melhores resultados. Até janeiro/95 foram operados 15 pts portadores de EP recurrente. A arteriografia pulmonar mostrou comprometimento bilateral em 66,7% dos casos. Esternotomia foi realizada em 73,3% dos pts. Nestes pts, a técnica utilizada foi a TP por tração retrógrada dos trombos. Circulação extracorpórea foi utilizada em todos os pts, com tempo médio de 124,8 min, sendo em 66,7% dos casos realizada PCT, com tempo médio de 34,2 min. Os valores pressóricos médios na artéria pulmonar eram 91/32/55 mmHg no pré e apresentaram queda para 52/15/27 mmHg no pós-operatório.Houve 1 (6,7%) óbito hospitalar por coagulopatia e 1 tardio devido a problemas não relacionados à operação. Dos 13 pts vivos, 1 (7,7%) apresentou reobstrução e 12 (92,3%) encontram-se assintomáticos sob anticoagulação oral, tendo retornado às atividades habituais, em um período de seguimento de até 165 meses (média 47m). Em conclusão, a TP realizada por esternotomia e, quando necessário, com auxílio de PCT é procedimento viável e seguro para resolução de EP crônica, levando à remissão da sintomatologia destes pts e à manutenção do resultado a longo prazo.
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