Changing the strategy of balloon pulmonary angioplasty resulted in a reduced complication rate in patients with chronic thromboembolic pulmonary hypertension. A single-centre European experience

Abstract

A b s t r a c t Background and aim:To assess the safety and efficacy of a refined balloon pulmonary angioplasty (BPA) strategy in patients with chronic thromboembolic pulmonary hypertension (CTEPH).Methods: There were 157 BPA sessions performed in 56 CTEPH patients (47 non-operable, nine after pulmonary endarterectomy; aged 58.6 ± 17.9 years; 28 females) with severely impaired pulmonary haemodynamics (mean pulmonary artery pressure [mPAP]: 51.3 ± 12.2 mm Hg, pulmonary vascular resistance [PVR]: 10.1 ± 3.9 Wood Units). The first 50 sessions aimed to recanalise chronic occlusions and prevent reocclusion with aggressive anticoagulation. The next 107 sessions aimed to relieve "web" and "ring" lesions using reduced tip load guidewires and less intensive anticoagulation.Results: There was significant reduction in haemoptysis (22% vs. 7%, p = 0.01), vessel injury (30% vs. 13%, p = 0.01), and reperfusion pulmonary injuries (22% vs. 4%, p = 0.01) after changing the BPA strategy. Mortality at 14 days was also reduced (6% vs. 0%; p = 0.05). The cumulative survival rate was 94.6% at 24 months after the first BPA, which was more favourable than medically treated historic controls. In the 31 patients with > 3 BPA sessions, there was significant reduction of PVR (10.3 ± 3.7 vs. 5.9 ± 2.8 Wood Units; p = 0.01), mPAP (50.7 ± 10.8 vs. 35.6 ± 9.3 mm Hg; p = 0.01) and improvement in World Health Organisation functional class (3.19 ± 0.48 vs. 1.97 ± 0.80; p < 0.001).Conclusions: Balloon pulmonary angioplasty improves haemodynamics and outcome but requires refined strategy to limit early complication rate.

Impact of Balloon Pulmonary Angioplasty on Hemodynamics and Clinical Outcomes in Patients with Chronic Thromboembolic Pulmonary Hypertension: the Initial Korean Experience

“…This complication rate is lower than those of previous reports, particularly when considering that of reperfusion edema. 17 18 19 As most of the complications reported in previous studies originated from vascular injury caused by wires or balloons, we focused on refining the BPA techniques, such as using wires with a tip load of < 1 g, using undersized balloons, and limiting the number of dilated segments. We suspect that this practice strategy will result in low complication rates.…”

Comparison of Balloon Pulmonary Angioplasty and Pulmonary Vasodilators for Inoperable Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review and Meta-Analysis

“…1). Of these, 11 studies presented outcomes for 755 patients with inoperable CTEPH treated with BPA (Table 1) 8,[22][23][24][25][26][27][28][29][30][31] . Twenty-three studies reported outcomes in 849 patients with inoperable CTEPH treated with pulmonary vasodilators (Table 1) 10-12,32-51 .…”

“…This is consistent with our results. However, Phan et al 's investigation did not include several key studies pertaining to BPA 8,[22][23][24][25][26][27][28][29] and pulmonary vasodilators 12,33,34,39,43,46 . Wang et al also compared riociguat to BPA in patients with inoperable CTEPH 58 .…”

Contemporary methods for the treatment of pulmonary embolism — is it prime-time for percutaneous interventions?

“…However, a technique suggested by Okayama group [31] and other Japanese centres [26] involving performance of dilations in lesions with easier morphology (rings and webs) and the use of undersized balloon catheters of maximum diameter 2.0-2.5 mm at the time of first procedure when pressure in the pulmonary artery is still high seems to have an impact on reduction of perioperative complications (Fig. 2) [32]. Supplementing initial dilations optimises the effect with catheters of a size being 100% up to 110% of vessel diameter in situations when mean pulmonary arterial pressure drops below 35 mm Hg, as well as attempting to recanalise lesions of the type of subtotal or total occlusion.…”

“…3). However, even procedures not leading to normalisation of pressure in the pulmonary artery but rather, characterised by reduction of pulmonary vascular resistance comprising about 50%, in a significant way improves patients' quality of life [38] and provides for survival at the level of 94% over a two-year observation -comparable with PEA procedures [32]. The impact of the choice of procedural technique and treatment goals for long-term follow-up requires further studies.…”