PMC9780367_01
Pre- and post-operative selective pulmonary angiography. (a) Selective pulmonary angiography of the right pulmonary arteries identified: eccentric and extended stenoses in the segmental arteries A 1, 2, 4, 5, 6, 7, 8, and occlusion of A 3, 9, 10; (b)
left pulmonary artery: occlusion of the upper lobe branch, roughness of the contours of the lower lobe branch, and eccentric and extended stenoses in the segmental arteries of the lingual segment and lower lobe; (c,d) selective pulmonary angiography after surgery.
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F1
Chest dual-energy CT-angiography and pulmonary angiography confirmed CTEPH (level II according to San Diego pulmonary endarterectomy disease levels) (Figures 1a,b). No stenosis and occlusion of segmental branches were visible (Figures 1c,d).
Pre- and post-operative view of coronary angiography. (a) An intramyocardially located section of the left anterior descending artery (LAD) in the middle third with stenosis in the systole up to 60-70%; (c) the systolic phase of the LAD-MB after the surgery; (b,d) the diastolic phase of the LAD-MB before and after the operation.
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F2
The length of the LAD-MD was ~25 mm, with left anterior descending artery stenosis in the systole reaching 70% (Figures 2a,c, arrowhead). Coronary angiography found no local stenosis of the LAD artery (Figures 2c,d).
Intraoperative view of LAD-MB. The left anterior descending artery myocardial bridge lies at a depth of 4-5 mm with a length of 20-22 mm. LAD-MB was located on the border of the middle and distal thirds of the artery.
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F3
II lesion (San Diego classification of pulmonary endarterectomy disease levels) and a significant myocardial bridge of the left anterior descending artery, a pulmonary thromboendarterectomy in combination with a supracoronary myotomy was performed. Intraoperative revision showed LAD-MB lying at a depth of 4-5 mm for 20-22 mm (Figure 3), suggesting that a supra-arterial myotomy may be performed while the patient was being warmed up.
Intraoperative view of endarterectomized tissues.
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F4
The full view of endarterectomized tissues is shown in Figure 4.