Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension

Abstract

Chronic thromboembolic pulmonary hypertension (CTEPH) is thought to result from incomplete resolution of pulmonary thromboemboli that undergo organisation into fibrous tissue within pulmonary arterial branches, filling pulmonary arterial lumina with collagenous obstructions. The treatment of choice is pulmonary endarterectomy (PEA) in CTEPH centres, which has low post-operative mortality and good long-term survival. For patients ineligible for PEA or who have recurrent or persistent pulmonary hypertension after surgery, medical treatment with riociguat is beneficial. In addition, percutaneous balloon pulmonary angioplasty (BPA) is an emerging option, and promises haemodynamic and functional benefits for inoperable patients. In contrast to conventional angioplasty, BPA with undersized balloons over guide wires exclusively breaks intraluminal webs and bands, without dissecting medial vessel layers, and repeat sessions are generally required. Observational studies report that BPA improves haemodynamics, symptoms and functional capacity in patients with CTEPH, but controlled trials with long-term follow-up are needed. Complications include haemoptysis, wire injury, vessel dissection, vessel rupture, reperfusion pulmonary oedema, pulmonary parenchymal bleeding and haemorrhagic pleural effusions. This review summarises the available evidence for BPA, patient selection, recent technical refinements and periprocedural imaging, and discusses the potential future role of BPA in the management of CTEPH.

The changing landscape of chronic thromboembolic pulmonary hypertension management

“…During BPA, a guide wire inserted via the femoral or jugular vein [56] is used to accurately place a balloon at the site of a lesion or occlusion [55], with the assistance of imaging techniques such as selective pulmonary angiography, intravascular modalities, pressure wires or advanced CT [22,56]. Inflation of the balloon widens stenotic lesions and breaks intraluminal webs and bands in the distal pulmonary vasculature and restores vascular blood flow [56]. The lobe with the worst perfusion is often targeted first and more than one lobe may be treated in a single session in patients with permissive haemodynamics (mPAP <40 mmHg) [55,56].…”

“…The lobe with the worst perfusion is often targeted first and more than one lobe may be treated in a single session in patients with permissive haemodynamics (mPAP <40 mmHg) [55,56]. Depending on the number and severity of the lesions, patients generally require multiple BPA sessions to adequately manage their disease [56].…”

“…These include severe renal dysfunction or an allergic reaction to iodine-based contrast medium. For the latter, the use of gadolinium-based contrast agents may help to avoid allergic reactions [56].…”

“…Outcomes after BPA BPA has been shown to improve symptoms, function and haemodynamic parameters in patients [21,22,[56][57][58][59][60]. Results from one experienced centre have shown an average reduction in PVR of 57% [22], as well as improvements in functional class, exercise capacity and brain natriuretic peptide levels, at 3 months post-BPA [21,22].…”

An epidemiological analysis of the burden of chronic thromboembolic pulmonary hypertension in the USA, Europe and Japan

“…An emerging interventional technique for the management of inoperable CTEPH is percutaneous balloon pulmonary angioplasty (BPA), which aims to dilate the pulmonary artery branches through the inflation of a small balloon inserted into the artery. While BPA is still in its infancy and can only be performed at specialist centres by physicians experienced in the technique, it may provide a potential treatment option for patients with inoperable CTEPH [29][30][31][32][33].…”