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Pulmonary Endarterectomy (PEA)

There is a potential cure for CTEPH through pulmonary endarterectomy (PEA) surgery. Approved medical treatment may also slow disease progression and alleviate symptoms.

Pulmonary Endarterectomy (PEA) Surgery 

 
The standard and potentially curative treatment for patients who have developed CTEPH and are suitable for surgery is a procedure called pulmonary endarterectomy (PEA). PEA is a major surgery that clears the blood vessels of the lungs of clots and scar material present in the disease.

To determine whether you are a suitable candidate for surgery, you need to be thoroughly assessed at a centre specialized in the treatment of CTEPH.

CTEPH specialists will assess:
  • If the blockage is reachable through surgery - if the blockage is too deep within the lungs, it may not be reachable;
  • Your overall suitability to undergo surgery. 
  • Preparing for your surgery
    Your surgeon has scheduled you for pulmonary thromboendarterectomy (PEA) surgery. You and your healthcare providers have decided that this surgery is the best treatment for your chronic thromboembolic pulmonary hypertension (CTEPH).
     
    PEA surgery has 2 goals:
     
    1. To improve the blood flow in your lungs and treat your shortness of breath.
     
    If you use oxygen, you may slowly reduce the amount you use over many weeks or months after surgery. You may also be able to return to your normal activities and become more active. This will improve your quality of life.
     
    2. To prevent the right side of your heart from weakening because of high blood pressure in your lung (pulmonary) vessels.
     
    Removing clot and scar tissue in your vessels lowers the pressure in your lungs. This reduces how hard the right side of your heart has to work.
     
    How Long Will I Need to Stay in the Hospital?
    Be prepared to stay in the hospital for about 10–14 days. When you can go home will depend on how you are recovering.
     
    Can the Time for my Surgery Change?
    Yes, but it is unlikely. Your healthcare team will do its best to do your surgery at the scheduled time. However, your surgery may be rescheduled if your surgeon needs to do emergency surgery.
     
    Choosing a Support Person
    Before your surgery, you need to choose a support person. This is a person who will be available to help you at the end of your hospital stay and take you home.
     
    Your support person can be a family member or a friend. They will need to agree to come to the hospital when you are discharged and take you home. Give your support person’s name and phone number to the CTEPH clinic office before your surgery.
     
    What About my Medicines?
    If you are taking a blood thinner medicine by mouth or by needle, it’s important to keep taking it. Your doctor or nurse practitioner will stop your medicine once you are admitted to the hospital.
  • Your Hospital Stay
    When Should I Come to the Hospital?
    Follow your healthcare team’s instruction regarding your hospital admittance.
     
    What Happens After I Arrive?
    You stop taking your warfarin (Coumadin®), new oral anticoagulant such as rivaroxaban (Xarelto®), or blood thinner by needle, such as tinzaparin (Innohep®).
    Your health care team will start to give you a medicine called heparin through an intravenous (IV). Your body will need 2 days before your surgery to reverse the effects of the blood thinner medicine you were taking.

    Your healthcare team may have you do more medical tests. These tests help your surgeon plan your surgery. These tests may include:
    • echocardiogram (ECHO)
    • electrocardiogram (EKG or ECG)
    • CT scan
    • pulmonary angiogram
    • right and left heart catheterization
    • ventilation/perfusion scan (V/Q scan)
    • pulmonary function test (PFT) and arterial blood gases (ABGs)
    • blood work
    • femoral and carotid Doppler ultrasound
     
    You will speak with your surgeon and other members of your surgical team. They will answer any questions you have, give you more information about the surgery and provide support.
    You will have an enema the evening before your surgery so your bowel is empty for the long procedure.
     
    You are not allowed to eat or drink anything as of midnight before your surgery.
  • During the Surgery
    What Happens on the Day of my Surgery?
    During your surgery, your family and close friends can wait in a designated area, where someone will be able to provide help if needed.
     
    Just before your surgery, you will be asked to shower using a special (antimicrobial) soap. This will help get rid of any germs on your body.
     
    Your surgery will take about seven to eight hours. During this time, a nurse may come out of the operating room to update your family and friends. At the end of your surgery, your surgeon may also come to the waiting room to give them an update.
     
    What Happens During my PEA Surgery?
    1. Your healthcare team takes you to the operating room and gives you an intravenous (IV).
    2. Your healthcare team gives you pain medicine and a medicine to help you relax while doctors put a large intravenous catheter (tube) and arterial catheter into your body.
    3. Your surgeon makes an incision (cut) through your chest bone, called a median sternotomy (see Median Sternotomy image). This allows him to reach your heart and major blood vessels.
    4. Your heart and major blood vessels are connected to a heart-lung bypass machine. The bypass machine takes the blood away from your heart so your surgeon can clearly see the clot in your arteries.
    5. The machine also protects your body by cooling it to half its normal temperature. Once your body is cooled down, the heart-lung bypass machine can be stopped temporarily. This makes it safer to remove the scar tissue from your lung vessels.
    6. Your surgeon makes incisions in your lung vessels so they can reach the scar tissue. They carefully remove the scar tissue from the inside of the artery walls on both sides of your lungs (see the image below).
    7. Once they remove the scar tissue, your chest bone is wired back together so it can heal. The wires won’t need to be taken out and are safe for your body. They won’t cause any problems with metal detectors in an airport.
    8. After your surgery is done, your health care team moves you out of the operating room and continues to give you medicine so you stay asleep overnight.
  • After the Surgery
    Where Will I Go After the Surgery?
    After surgery, you will be moved to the Medical Surgical Intensive Care Unit (MSICU). You will stay there for about two to four days.
     
    When you wake up, it may seem noisy and busy. This is a normal part of your care. Try to stay calm and don’t pull on any tubes.
     
    What Can I Expect to Have on My Body?
     After your surgery, you will have:
     
    Incisions
    You will have an incision called a sternotomy down the middle of your chest. It will be about 20 centimeters (seven to eight inches) long.
     
    Your surgeon uses dissolvable stitches to close the incision. This means they go away on their own. Bandages will cover your incisions; they will be removed two days after your surgery.
     
    Endotracheal Tube (ETT) Ventilator 
    An endotracheal tube is also called a breathing tube. The tube is attached to a ventilator. Together, they help you breathe until your body recovers. Your healthcare team will remove the tube when it’s safe for you to breathe on your own.
     
    When you first wake up, the breathing tube may make you feel like you are choking. Try to stay calm. You won’t be able to talk while you have the tube, but we will give you a writing pad. You will still be able to let your healthcare team know your needs.
     
    Chest Tubes
    You will have 3 chest tubes coming out of your sides. These tubes remove air and fluid from the inside of your chest area. The tubes are attached to a machine that helps suck the air and fluid out.
     
    Stitches are used to keep the chest tubes in place. These are not dissolvable. Your healthcare team will remove your chest tubes once it is safe and will remove the stitches 24 hours after the tubes are taken out.
     
    Pacer Wires Connected to a Pacemaker Box
    You will have pacer wires attached to your heart. These wires are connected to a pacemaker box.
     
    After your surgery, your heart rate may slow down. The pacemaker will use electric current to help your heart beat faster. Once it is safe, your healthcare team will remove these wires at the same time as your chest tubes.
     
    Intravenous (IV) 
    You will have one IV line in your arm so your healthcare team can give you fluids and pain medicines. These medicines will help you relax and manage any pain you may feel.
     
    Central Lines
    You will have two central lines. One line (like a big IV catheter) will be in the right side of your neck and 1 will be in the upper left side of your chest. These lines are used to give you medicines and take blood samples. Your healthcare team will also use them to continuously check your blood pressure on the right side of your heart and pulmonary (lung) artery.
     
    The central line from your neck will come out at the same time as your chest tubes and pacer wires. The central line in your upper chest will come out within one week after surgery.
     
    Arterial Lines
    You will have tow arterial lines. One will be in your wrist and one will be in your groin area. These tubes will look like your IV, and your health care team will use them to take blood samples without having to poke you with needles. They will also continuously check your blood pressure.
     
    Urinary Catheter
    You will have a tube draining your bladder for up to seven days. While you are in the hospital, the nurse will measure how much you urinate (pee).
     
    Heart Monitor
    Your healthcare team will attach you to a heart monitor. This doesn’t mean there is a problem with your heart; this for all patients who have your type of surgery.
     
    The heart monitor will help your healthcare team see your vital signs like your heart rate, your blood pressure, and how much oxygen is in your blood.
     
    While you are in the MSICU, your body will be recovering. When it’s safe, your healthcare team will remove your breathing tube and some other tubes or drains, and move you from the MSICU.
     
    What Happens After I Leave the MSICU?
    You will be moved to the Thoracic Surgery Step-Down Unit (SDU), where you will stay in for about two to four days.
     
    You will still be connected to a heart monitor and may still have some of the tubes you had in the MSICU. You may also need oxygen for a short time as you recover. But, as your health improves the rest of the tubes will be removed from your body.
     
    When you are ready, you will be moved to a regular ward room, where you will stay until you go home.
     
    During the rest of your hospital stay, you will work closely with a physiotherapist and respiratory therapist. They will help you exercise your body and lungs.
     
    How Can I Manage My Pain?
    Most patients don’t have a lot of pain. After your surgery, you will be given pain medicine through your IV to stay comfortable. Once you are able to eat and drink again, you will be given pain medicine pills. Your healthcare team will work with you to help find the best medicine to manage any pain you feel.
     
    It's important to ask your nurse for pain medicine before your pain becomes very bad.

    Controlling your pain is important. It will help you rest, move, walk, and do breathing exercises like deep breathing and coughing. These are all important to help you recover. 

    When Will I Start Taking My Medicine Again?
    You start taking your warfarin or new oral anticoagulant (for example, rivaroxaban) after all your tubes and drains are removed.
     
    If you are taking warfarin, the Thrombosis Clinic or your family doctor will check your bloodwork and adjust your dose after you leave the hospital. They will be responsible for making sure your INR stays between 2.0 to 3.0.
     
    Before you leave the hospital, your healthcare team will give you a prescription for Warfarin or another type of blood thinner.
     
    Always follow the instructions for taking this medicine. You will need to keep taking your blood thinner for the rest of your life to prevent new blood clots from forming.
     
    To keep information about your blood thinning medicine with you at all times, get a MedicAlert bracelet. You can find an order form at the website: www.medicalert.ca or call 1-800-668-1507.
  • Discharge Checklist
    During your hospital stay, your health care team will help you prepare for discharge (going home). Nurses and other health care professionals will teach you what you need to know how to care for yourself at home.

    Make sure you understand all of these before you go home:
    • caring for your incision
    • protecting your breast bone
    • showering
    • driving
    • other activities
    • new medicines that you started in the hospital
    • managing your pain
    • managing your bowels
    • eating and drinking
    • a follow-up appointment with your surgeon
    • Warfarin and managing INR (clotting time)

    Can I Drive?
    No. You can’t drive until your breast bone is completely healed. Unless your surgeon gives you different instructions, you can ride as a passenger as long as you wear a seatbelt. Your surgeon will talk to you about when you can drive again during your clinic visits.
     
    When Can I Go Back to Work?
    You should expect to be off work for at least 3 months after your surgery. Your health care team will talk more with you at your clinic visits to decide when you can return to work.
     
    What About Sex?
    Wait 6 weeks after your surgery before you have sex. When you can climb 2 flights of stairs comfortably, you are probably ready to have sex.
    Choose positions that won’t stress, irritate, or put pressure on your incision. Stop if you have pain, shortness of breath or feel dizzy. 


    What Problems Should I Look Out For?

    Go to your nearest emergency room or call 911 if you:
    • have trouble breathing;
    • are bleeding;
    • have chest pain;
    • or have fainted
    Call your family doctor or your surgeon's office right away if you:
    • have new redness, warmth or swelling around your incision;
    • have an unusual smell, liquid or pus (thicker yellowish or white liquid) coming from your incision;
    • feel increasing pain at your incision;
    • have a fever higher than 38.5° C or 101° F;
    • see your incision has opened up;
    • feel your heart beating faster or in a different way;
    • feel dizzy or like you will faint;
    • have swelling in a leg or both legs;
    • have shortness of breath that is getting worse;
    • cough up yellow or green mucous with a bad smell;
    • or cough up fresh blood.