Evaluating Preoperative Imaging in Patients with CTEPH: Is CTPA a Reliable Alternative to Pulmonary Angiography?

Objectives Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension, with pulmonary endarterectomy (PEA) serving as a key surgical treatment option. Accurate preoperative imaging is critical for determining surgical candidacy and optimizing operative outcomes. While digital subtraction pulmonary angiography (DSPA) remains the gold standard, computed tomography pulmonary angiography (CTPA) has emerged as a non-invasive alternative. This study compares the concordance of CTPA and DSPA with intraoperative specimen findings to determine their diagnostic accuracy. Methods We conducted a retrospective cohort study of patients who underwent PEA for CTEPH at a single Canadian center between 2014 and 2017. All patients underwent preoperative CTPA and DSPA as part of their routine evaluation. Imaging findings were compared with operative findings using a territory-based anatomical assessment across major pulmonary artery segments. Functional and hemodynamic outcomes were also assessed before and after surgery. Results Seventeen patients (mean age 52.8 years (± 3.7); 53% female) were included. CTPA demonstrated greater agreement with operative findings in the right main pulmonary artery, left upper lobe, and lingula. DSPA demonstrated greater agreement in the right upper lobe, while both modalities showed similar agreement in the left main pulmonary artery and left lower lobe. Patients experienced postoperative improvements in New York Heart Association functional class, pulmonary artery pressures, and cardiac index. Despite overall agreement between imaging and operative findings, discrepancies persisted across several vascular territories. Conclusions CTPA demonstrated substantial agreement with operative findigns in central and lobar pulmonary arterial territories, supporting its role as an important frontline imaging modality in the evaluation of CTEPH. However, persistent discrepancies between imaging and operative assessment, particularly in more distal territories, support the continued use of a multimodal approach integrating both CTPA, DSPA, hemodynamic assessment, and multidisciplinary evaluation when determining operability and treatment strategy.