Elsevier

Human Pathology

Volume 34, Issue 12, December 2003, Pages 1290-1298
Human Pathology

Original contribution
Surgical pathology of pulmonary thromboendarterectomy: a study of 54 cases from 1990 to 2001

Accepted for poster presentation at the 92nd Annual Meeting of the United States-Canadian Academy of Pathology, Washington DC, March 26, 2003.
https://doi.org/10.1016/j.humpath.2003.07.003Get rights and content

Abstract

Thromboendarterectomy is performed to treat chronic thromboembolic pulmonary hypertension with obstruction of main, lobar, or segmental pulmonary arteries. The present study evaluated surgical specimens removed between 1990 and 2001. Medical histories and microscopic slides were reviewed in each case. Study slides were stained with hematoxylin and eosin and Verhoeff-van Gieson and evaluated for thrombus, collagen, elastin, atherosclerosis, hemosiderin, calcification, and inflammation. The study group comprised 54 patients (30 women and 24 men), ranging in age from 33 to 77 years (mean, 58 years). Clinically, 28 (52%) had a history of deep leg vein thrombosis and 42 (78%) had a history of pulmonary embolism; 24 (44%) had both events. Coagulation abnormalities were documented in 15 (28%); autoimmune or hematologic disorders, in 8 (15%). Pulmonary thromboendarterectomy was bilateral in 52 patients (96%) and right-sided in 2. Six patients also had obstructions resected from the main pulmonary arteries. Obstruction limited to segmental arteries occurred only in women. Grossly, right-sided specimens were larger than left-sided ones (P = 0.003). Microscopically, ages of thrombi were uniform in 72% and variable in 28%. Intima was thickened in all patients and consisted of collagen (100%), elastin (67%), hemosiderin (56%), inflammation (53%), atherosclerosis (32%), and calcification (15%). We determined that pulmonary thromboendarterectomy was performed most often in middle-aged and elderly patients with a history of deep venous thrombosis or pulmonary embolism. Less than 50% of the patients had an identifiable coagulation, autoimmune, or hematologic abnormality. Most patients had bilateral disease and resections. Right-sided specimens were significantly larger than left-sided specimens, and lower lobe involvement was more common than involvement elsewhere. Resected tissues most commonly exhibited old organized thrombus.

Section snippets

Study group

The authors reviewed medical records, operative reports, and surgical specimens from all patients who underwent pulmonary thromboendarterectomy procedures performed by G.C.A.M. at Mayo Clinic Rochester between January 1, 1990 and December 31, 2001. The study was approved by the Mayo Clinic Institutional Review Board.

Clinical findings

For each patient, gender and age at operation were recorded from the medical record, as well as a history of DVT, pulmonary embolism (PE), coagulation abnormality, autoimmune

General findings

Of the 54 patients, 30 (56%) were women and 24 (44%) were men. At the time of operation, patients ranged in age from 33 to 77 years (mean, 58 years).

Thrombosis and embolism

A history of DVT was present in 28 patients (52%), 16 (58%) of whom were men. Another man had a history of subclavian vein thrombosis. Of the 42 patients (78%) with a history of PE, 23 (55%) were women. Twenty-four patients (44%) had a history of both DVT and PE, 14 (58%) of whom were men.

Coagulopathy

All patients were evaluated for an underlying coagulation

Discussion

CTEPH is an insidious and often unrecognized disease. Diagnosis is often delayed or overlooked. In general, prognosis is poor; the 5-year survival in patients with a mean pulmonary artery pressure >30 mm Hg is only 30%, and that for patients with a mean pulmonary artery pressure >50 mm Hg is only 10%.15 Other than lung transplantation, PTE is the only effective therapeutic option for this disease. For selected patients, PTE offers the possibility for substantial improvement in symptoms,

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