Pulmonary Thromboendoarterectomy at Leading High-Volume Centers: International Perspectives

Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious yet potentially curable form of pulmonary hypertension (PH), characterized by persistent obstruction of the pulmonary arteries due to organized thromboembolic material.Pulmonary thromboendarterectomy (PTE) remains the gold standard treatment for eligible patients, offering the possibility of significant symptomatic relief, improved hemodynamics, and long-term survival.Recent advances in surgical and interventional therapies-most notably pulmonary endarterectomy and balloon pulmonary angioplasty-have markedly improved patient outcomes.Additionally, emerging medical treatments such as pulmonary vasodilators provide promising options for patients deemed inoperable.As a complex surgical procedure requiring cardiopulmonary bypass (CBP) and deep hypothermic circulatory arrest (DHCA), management of PTE demands a highly specialized, multidisciplinary approach.This article represents a collaborative effort by four leading medical centers across the globe with extensive experience in the management of CTEPH.It aims to provide a comprehensive and practical overview of current best practices in patient selection, surgical technique, anesthetic management, and postoperative care, while also highlighting institutional nuances and emerging innovations in the field.Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension (PH), and pulmonary thromboendarterectomy (PTE) remains the definitive treatment for operable disease at experienced centers.Given the complex high-risk physiology and the potential for life-threatening perioperative complications, outcomes depend not only on surgical expertise but also on highly coordinated anesthetic and critical care management.This review presents a collaborative, practice-based synthesis from four high-volume leading international PTE centers focusing on perioperative strategies spanning preoperative optimization, intraoperative management including induction and hemodynamic monitoring, cardiopulmonary bypass and deep hypothermic circulatory arrest considerations relevant to anesthesia, and postoperative ICU management.In addition to outlining shared principles, we compare areas of institutional variation, including anticoagulation approaches, monitoring practices, neuroprotection techniques, blood conservation strategies, and postoperative ventilation and hemodynamic management. J o u r n a l P r e -p r o o fWe discuss how these differences reflect local protocols developed in the context of limited comparative evidence.By presenting both area of consensus and domains of practice variability, we aim to provide a pragmatic reference for multidisciplinary teams caring for patients undergoing PTE and to identify priorities for future multicenter evaluation and quality improvement initiatives