Pulmonary thromboendarterectomy at leading high-volume centers: International perspectives.

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially curable pulmonary hypertension, caused by persistent obstruction of the pulmonary arteries due to organized thromboembolic material. Pulmonary thromboendarterectomy (PTE) remains the gold standard treatment for eligible patients, offering significant symptomatic relief, improved hemodynamics, and long-term survival. As a complex surgical procedure requiring cardiopulmonary bypass and deep hypothermic circulatory arrest, management of PTE demands a highly specialized, multidisciplinary approach. Methods: This review represents a collaborative effort from four leading international centers with extensive experience in CTEPH management. We provide a practical overview of perioperative strategies including patient selection, surgical technique, anesthetic management, cardiopulmonary bypass considerations, and postoperative intensive care management. Institutional variations in practice were also compared. Results: Shared principles across centers included careful hemodynamic optimization, advanced perioperative monitoring, and structured postoperative critical care. Areas of institutional variation included anticoagulation approaches, monitoring practices, neuroprotection techniques, blood conservation strategies, postoperative ventilation, and hemodynamic management. These differences reflected local protocols developed in the setting of limited comparative evidence. Conclusions: PTE remains the definitive treatment for operable CTEPH at experienced centers. Successful outcomes rely not only on surgical expertise but also on coordinated anesthetic and critical care management. This review summarizes current international practice, highlights areas of consensus and variability, and identifies priorities for future multicenter evaluation and quality improvement initiatives.