Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: a clinical consensus statement of the ESC working group on pulmonary circulation and right ventricular function

Abstract

The current treatment algorithm for chronic thromboembolic pulmonary hypertension (CTEPH) as depicted in the 2022 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines on the diagnosis and treatment of pulmonary hypertension (PH) includes a multimodal approach of combinations of pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA) and medical therapies to target major vessel pulmonary vascular lesions, and microvasculopathy. Today, BPA of >1700 patients has been reported in the literature from centers in Asia, the US, and also Europe; many more patients have been treated outside literature reports. As BPA becomes part of routine care of patients with CTEPH, benchmarks for safe and effective care delivery become increasingly important. In light of this development, the ESC Working Group on Pulmonary Circulation and Right Ventricular Function has decided to publish a document that helps standardize BPA to meet the need of uniformity in patient selection, procedural planning, technical approach, materials and devices, treatment goals, complications including their management, and patient follow-up, thus complementing the guidelines. Delphi methodology was utilized for statements that were not evidence based. First, an anatomical nomenclature and a description of vascular lesions are provided. Second, treatment goals and definitions of complete BPA are outlined. Third, definitions of complications are presented which may be the basis for a standardized reporting in studies involving BPA. The document is intended to serve as a companion to the official ESC/ERS guidelines.

Chronic Pulmonary Artery Stenosis: Time to Think as a Disease Entity

“…[39] Percutaneous transluminal pulmonary artery (PTPA) intervention is a crucial therapeutic approach for inoperable CTEPH and persistent/recurrent PH after PEA. [40] A multicenter study from Poland that included 236 patients with CTEPH showed a 3-year survival rate of 92.4% after initial balloon pulmonary angioplasty (BPA). [41] In patients with TA-PH, the mPAP decreased significantly from 51 to 38 mmHg over an average follow-up of 37 months after PTPA; this group also demonstrated a 3-year survival rate of 93.7%, compared with 76.2% in the non-PTPA group.…”

Balloon pulmonary angioplasty in the current era of CTEPH treatment: How did we get here?

“…The current BPA technique is well documented, 10,17,24 but briefly, vascular access is obtained via the femoral or internal jugular vein. A right heart catheterization is performed to obtain baseline hemodynamics to assess PH severity, and subsequently, a 6F 90-cm sheath is placed into the target pulmonary artery through a series of wire and catheter exchanges.…”

“…However, over the last 20 years, balloon pulmonary angioplasty (BPA) has emerged as a viable alternative, and it is now an established class I treatment option in select inoperable CTEPH cases with consensus BPA guidelines recently published. 9,10 In this manuscript, we review the history and evolution of BPA, as well as the landmark studies that have solidified BPA as an integral treatment modality for CTEPH, and how our understanding of the role of BPA in the treatment of CTEPH continues to evolve.…”

Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension due to septic emboli

“…1A,C). 2,4 Her pulmonary hypertension remained severe despite riociguat and ambrisentan (Table 1). The patient was previously turned down for both surgical pulmonary thromboendarterectomy (PTE) and transcatheter intervention at an outside institution due to high risk and unclear benefit in the setting of prior septic emboli.…”

“…Workup, including nonselective pulmonary angiography, led to a diagnosis of CTEPH with a type D, ostial CTO in left lower posterior branch (A9 and A10) and a type D, pouch CTO in the right truncus anterior (A1 and A3) (Figure 1A,C). 2,4 Her pulmonary hypertension remained severe despite riociguat and ambrisentan (Table 1). The patient was previously turned down for both surgical pulmonary thromboendarterectomy (PTE) and transcatheter intervention at an outside institution due to high risk and unclear benefit in the setting of prior septic emboli.…”