Combined pulmonary endarterectomy and balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension

Wiedenroth, Christoph B.; Liebetrau, Christoph; Breithecker, Andreas; Guth, Stefan; Lautze, Hans-Jürgen F.; Ortmann, Erik; Arlt, Matthias; Krombach, Gabriele A.; Bandorski, Dirk; Hamm, Christian W.; Möllmann, Helge; Mayer, Eckhard

doi:10.1016/j.healun.2015.10.030

Cited by 107 publications

(72 citation statements)

References 23 publications

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“…A preliminary study in three patients found that this strategy improved pulmonary haemodynamics and functional class [76]. However, at present this strategy remains experimental.…”

Section: Future Perspectives For Cteph Managementmentioning

confidence: 98%

Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension

et al. 2017

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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.

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“…A preliminary study in three patients found that this strategy improved pulmonary haemodynamics and functional class [76]. However, at present this strategy remains experimental.…”

Section: Future Perspectives For Cteph Managementmentioning

confidence: 98%

Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension

et al. 2017

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“…The patients underwent PTE on the operable lung and BPA on the inoperable lung during the rewarming phase of surgery. 50 Ultimately, the number of patients with clot distribution likely to benefit from this approach is small, and as already demonstrated in a previously published series, 42 BPA may emerge as a reliable tool for the treatment of residual PH after PTE. As the collective BPA experience grows, there will assuredly be an interest in comparing BPA directly to PTE in select patient populations.…”

Section: Future Directionsmentioning

confidence: 97%

Treatment of Chronic Thromboembolic Pulmonary Hypertension: The Role of Medical Therapy and Balloon Pulmonary Angioplasty

Fernandes

Poch

Auger

2016

Methodist DeBakey Cardiovascular Journal

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Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially curable disease when treated with pulmonary thromboendarterectomy (PTE). However, even at experienced surgical centers, nearly one-third of patients with CTEPH will be deemed inoperable for reasons including distal disease, comorbidities, or out-of-proportion pulmonary hypertension. It is in these patients with inoperable CTEPH that pulmonary hypertension (PH)-targeted medical therapy and balloon pulmonary angioplasty have potential therapeutic value.Previous unblinded cohort trials have assessed PH-targeted medical therapy in various subpopulations of CTEPH patients using epoprostenol, treprostinil, sildenafil, bosentan, and iloprost, each demonstrating measurable pulmonary hemodynamic effects. However, riociguat, a soluble guanylate cyclase stimulator, is the first FDA-approved therapy for inoperable CTEPH to demonstrate both an improvement in functional capabilities (6-minute walk time) as well as significant gains in secondary pulmonary hemodynamic end points in a large placebo-controlled trial.Balloon pulmonary angioplasty is an interventional procedure using telescoping catheters placed in the pulmonary arteries, through which wires and balloons are used to mechanically disrupt chronic clot material and relieve pulmonary vascular obstruction. Contemporary case series from multiple centers worldwide have demonstrated pulmonary hemodynamic improvement with this approach.As a result of these advances, patients with inoperable CTEPH who had few options as recently as 5 years ago now have alternatives with emerging evidence of therapeutic efficacy.

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“…Such an approach would involve employing combinations of pulmonary endarterectomy, BPA and medical therapy to target proximal, distal and microvascular disease in the same patient. While initial reports have demonstrated that this approach has potential [82][83][84], further prospective studies are warranted to determine the role that hybrid strategies can play in the future management of CTEPH.…”

Section: Future Perspectivesmentioning

confidence: 99%

The changing landscape of chronic thromboembolic pulmonary hypertension management

2017

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For patients with chronic thromboembolic pulmonary hypertension (CTEPH), the current standard of care involves surgical removal of fibro-thrombotic obstructions by pulmonary endarterectomy. While this approach has excellent outcomes, significant proportions of patients are not eligible for surgery or suffer from persistent/recurrent pulmonary hypertension after the procedure. The availability of balloon pulmonary angioplasty and the approval of the first medical therapy for use in CTEPH have significantly improved the outlook for patients ineligible for pulmonary endarterectomy. In this comprehensive review, we discuss the latest developments in the rapidly evolving field of CTEPH. These include improvements in imaging modalities and advances in surgical and interventional techniques, which have broadened the range of patients who may benefit from such procedures. The efficacy and safety of targeted medical therapies in CTEPH patients are also discussed, particularly the encouraging data from the recent MERIT-1 trial, which demonstrated the beneficial impact of using macitentan to treat patients with inoperable CTEPH, including those on background therapy. As the treatment options for CTEPH improve, hybrid management involving more than one intervention in the same patient may become a viable option in the near future.

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Combined pulmonary endarterectomy and balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension

Abstract: The combination of surgical PEA and interventional BPA is a new treatment option for highly selected high-risk CTEPH patients. A multidisciplinary CTEPH expert team is a basic pre-requisite for this complex concept.

Cited by 107 publications

References 23 publications

Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension

Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension

Treatment of Chronic Thromboembolic Pulmonary Hypertension: The Role of Medical Therapy and Balloon Pulmonary Angioplasty

The changing landscape of chronic thromboembolic pulmonary hypertension management

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