Pulmonary Endarterectomy

A pulmonary endarterectomy, also known as pulmonary thromboendarterectomy (PTE), is surgery to remove old blood clots and scar tissue from the pulmonary arteries in the lungs.

What is a pulmonary endarterectomy?
Why do I need a pulmonary endarterectomy?
What are the risks of having a pulmonary endarterectomy?
How do I prepare for a pulmonary endarterectomy?
What happens during a pulmonary endarterectomy?
What happens after a pulmonary endarterectomy?

What is a pulmonary endarterectomy?

A pulmonary endarterectomy is an operation to remove old blood clots and scar tissue from the pulmonary arteries in the lungs.

Why do I need a pulmonary endarterectomy?

In some patients, blood clots may lodge in the pulmonary arteries (pulmonary embolism or PE). A PE is treated with blood thinning medication (anticoagulants) to allow the clots to dissolve.

Sometimes, these clots persist and remain adherent to the artery wall. With time, the clots are replaced by scar tissue resulting in chronic obstruction of the pulmonary arteries, causing restricted blood flow and high blood pressure through the lungs. This rare condition is called chronic thromboembolic pulmonary hypertension (CTEPH). 

When you have pulmonary hypertension, the right side of the heart is more strained than normal. This means you often feel breathless and tired. You may also have swelling in your stomach and legs.

A pulmonary endarterectomy will remove the blood clot and scar tissue that blocks the arteries, helping to restore blood flow and normal blood pressure in the lungs and take the strain off the right side of the heart. When these clots are removed from the arteries, the heart and the lungs will work together better and your overall health and wellbeing should improve.

What are the risks of having a pulmonary endarterectomy?

As with any surgery, there are some risks associated with a pulmonary endarterectomy. Some of these risks might include:

• Abnormal heart rhythms (arrhythmias)
• Bleeding
• Fluid in the lungs (pulmonary oedema)
• Infection
• Kidney problems.

In extremely rare cases, there may be:

• Death
• Stroke - only seen in 2-3% of patients.

Speak to your doctor if you would like to know more about the specific risks.

How do I prepare for a pulmonary endarterectomy?

Around two weeks before your surgery, you’ll need to:

• Check with your doctor about taking your medications – some may need to be stopped before the surgery
• Plan your transport home – it is your responsibility to arrange how you will get home after surgery
• Prepare your home for when you return from hospital – find someone to collect you from the hospital to help you return home after surgery and to help you with shopping, meals, cleaning and driving.

For information, including guidelines and tips for travelling home by car or plane after heart surgery, you can visit our travel page.

• Have some important tests – including an ECG, chest X-ray, blood tests, nose and groin swabs and carotid dopplers (which is an ultrasound of the blood vessels in your neck that supply the brain)
• Shower with antibacterial soap – your doctor will recommend one for you.

On the day before surgery, you’ll need to:

• Ensure your bowels are opened – ask  for a laxative, if required
• Pack a small bag of essentials, like toiletries and glasses – these will be taken to Intensive Care after your surgery
• Stop eating and drinking – from midnight before your surgery.

On the day of surgery:

• A member of hospital staff will clip off any hair from your chest, arms, legs, groins – to reduce the potential of infection
• Remember not to eat or drink anything – from midnight before surgery
• Shower with antibacterial soap – this will be provided by the hospital
• Wear a hospital gown – and remove any makeup, nail polish and jewellery (dentures can be left in).

What happens during a pulmonary endarterectomy?

Pulmonary endarterectomy surgery is performed under general anaesthetic, which means that you will be asleep throughout your surgery. When you are asleep:

• A breathing tube is put down your throat into your lungs – this is connected to a breathing machine called a ventilator
• Two catheters are inserted in your neck – one is connected to a drip to give fluids and medicines, the other measures the pressures in your heart and lungs
• One catheter is inserted into an artery in your wrist – to monitor your blood pressure and oxygen levels
• One catheter is inserted into your bladder – to monitor your urine and kidneys.

Your doctor will:

• Access your lungs by a cut through your breastbone (sternum)
• Stop your heart for a short time - your body will be connected to a heart-lung machine which will take over the work of your heart and lungs
• Your body will be cooled to 20 degrees
• The blood will be drained from your lungs and heart
• The heart lung machine will be stopped for a period
• The surgeon will open your pulmonary arteries - one at a time
• The surgeon will carefully clean out the blood clots and scar tissue from your pulmonary arteries
• Your body temperature will be warmed to 37 degrees
• Your heart will start again
• The surgeon will close your chest using wires to hold your breastbone together and dissolvable stitches on your skin.

The surgery usually takes 6 - 8 hours to complete.

What happens after a pulmonary endarterectomy?

After your pulmonary endarterectomy, you’ll spend a few days in the Intensive Care Unit (ICU). You will be connected to machines to assess your heart, blood pressure, body temperature and breathing.

When you’re ready to leave the ICU, you’ll go to the cardiac ward for another few days.

During your stay, here's what you’ll need to be aware of:   

• Bowel function –  it is easy to become constipated after a big operation. Constipation may be due to your tablets or because you are less active than usual. Drinking fluids and eating foods such as fruit, vegetables and grains may help. There is also medication available to help, so discuss any concerns with your nurse.
• Discomfort – you might feel tightness in your chest and shoulders, and changing your position frequently to maintain good posture can help. Use painkillers regularly so that you can move, take deep breaths and sleep comfortably. Taking painkillers regularly will keep pain under control.
• Fever – some people find that they are sweaty, especially at night in the early days after surgery. Others may find it hard to keep warm. These feelings will improve as your body gets back to normal after the operation. You may have a slight fever in the first few days after your operation which is completely normal, and there is medication to help with this.
• Poor appetite and changes in taste – you may notice that you have a poor appetite and find that food has lost its flavour. Your sense of smell may change and you may also experience a strange metallic taste in your mouth. This can be caused by the operation or your medication and can take three months to fully recover. Try to eat frequent small amounts of cold and simple foods - not spicy or rich in flavour
• Poor memory and concentration – it is quite common to be forgetful and have poor concentration in the early stages of your recovery. This should improve over the first few months.
• Stitches and wires – your medical team will let you know when any stitches and wires will need to be removed, and this will happen before you leave the hospital.
• Vivid dreams and sleeping problems – it may take a few weeks to get back to your normal sleeping pattern. In the early days, you may find that a brief day time nap may help. Try to follow you usual bedtime routine and take pain relief shortly before attempting to sleep. Avoid sleeping on your stomach for the first six weeks.
• Wound care – your nurse will help to make sure your wound is clean and healing well.

Once all tubes are removed, you are walking and your oxygen levels are normal, you will need to have some tests. These include:

• VQ scan – to check for changes to the pulmonary arteries after your surgery
• Echocardiogram – to assess your heart function after your surgery.

Both of these tests should be repeated in six and 12 months’ time.Most people will require oxygen for a period of time after surgery while the lungs recover. Your doctor will discuss a plan for you.

Your medical team will help you with some of the physical aspects of your recovery, including:

• Breathing exercises – you’ll be shown breathing exercises and coughing techniques that don’t harm your recovery
• Mobility – it will take 6-8 weeks for your breastbone to heal, and your nurse will show you the safest ways to lift and move your body, including rolling and sitting in bed
• Physiotherapy routine – you can start to work on your activity levels while still in hospital.

When it’s time to leave the hospital, you’ll need to arrange for a family member or friend to collect you and take you home (please advise the nursing staff of who you have arranged to pick you up and transport you home). For information, including guidelines and tips for travelling by car or plane after heart surgery, you can visit our travel page.

When you are ready to leave the hospital, try and find someone you can rely on to help you at home during those first few weeks. If you need assistance with this, let your medical team know.

As you prepare to return to your normal way of life, you’ll be given detailed instructions for exercise, medications, ongoing wound care and resuming normal activities. We also encourage you to book in to a pulmonary rehabilitation program. Doing this will help you to recover as best you can and live a healthy, fulfilling life.

Before you leave hospital, you will be given contact details for your closest pulmonary rehabilitation program. In your program, you’ll be supported every step of the way as you heal, recover and get back to your normal, everyday life.

After surgery, most people do not suffer shortness of breath and have a much better quality of life.

You will require lifelong blood thinning medication, such as Warfarin, for the rest of your life to prevent clots from returning. Remember: follow your doctor’s advice about medications and any recommended lifestyle changes after your surgery, and attend your regular appointments. If you start to feel unwell or would like to discuss your follow-up care at any time, make an appointment with your doctor.