Percutaneous Transluminal Pulmonary Angioplasty for the Treatment of Chronic Thromboembolic Pulmonary Hypertension

Abstract

C hronic thromboembolic pulmonary hypertension (CTEPH) is defined as a progressive disease of increasing pulmonary vascular resistance because of chronic thromboembolism in the pulmonary arteries that leads to pulmonary hypertension (PH), right-sided heart failure, and a grave prognosis. [1][2][3][4][5][6][7][8][9] Several studies have demonstrated the efficacy of medical therapies using anticoagulation and pulmonary vasodilators, including several newly developed agents. 1,10,11 The most powerful conventional therapeutic strategy for CTEPH is invasive surgical pulmonary endarterectomy (PEA).12-16 Surgical therapy is indicated when the thromboembolic lesions are located in the proximal pulmonary arteries or lobar branches.9 Thus, there are some patients in whom PEA is not indicated; furthermore, some patients continue to suffer from severe PH despite treatment with PEA. Editorial see p 744A few reports have demonstrated the efficacy of balloon pulmonary angioplasty. In 1988, 1 case report demonstrated the efficacy of pulmonary angioplasty after acute pulmonary embolism.17 In 2001, Feinstein et al 18 showed that pulmonary hemodynamics were markedly improved by pulmonary angioplasty in 18 patients with CTEPH, and that 11 of 18 patients developed reperfusion pulmonary edema. However, this therapy has not been developed further since then, and is rarely performed now. Thus, it is important to take into account the experiences of this therapy and the data regarding its complications, to consider the possibility of pulmonary angioplasty as an alternative therapy for selected patients with CTEPH.Therefore, the objectives of this study were (1) to investigate the clinical efficacy of percutaneous transluminal pulmonary Background-Chronic thromboembolic pulmonary hypertension leads to pulmonary hypertension and right-sided heart failure. The purpose of this study was to investigate the efficacy of percutaneous transluminal pulmonary angioplasty (PTPA) for the treatment of chronic thromboembolic pulmonary hypertension. Methods and Results-Twenty-nine patients with chronic thromboembolic pulmonary hypertension underwent PTPA. One patient had a wiring perforation as a complication of PTPA and died 2 days after the procedure. In the remaining 28 patients, PTPA did not produce immediate hemodynamic improvement at the time of the procedure. However, after follow-up (6.0 ± 6.9 months), New York Heart Association functional classifications and levels of plasma B-type natriuretic peptide significantly improved (both P<0.01). Hemodynamic parameters also significantly improved (mean pulmonary arterial pressure, 45.3 ± 9.8 versus 31.8 ± 10.0 mm Hg; cardiac output, 3.6 ± 1.2 versus 4.6 ± 1.7 L/min, baseline versus followup, respectively; both P<0.01). Twenty-seven of 51 procedures in total (53%), and 19 of 28 first procedures (68%), had reperfusion pulmonary edema as the chief complication. Patients with severe clinical signs and/or severe hemodynamics at baseline had a high risk of reperfusion pulmonary edema. Conclusions-PTPA imp...

Pulmonary Artery Diameter Predicts Lung Injury After Balloon Pulmonary Angioplasty in Patients With Chronic Thromboembolic Pulmonary Hypertension

“…5,14,15) Although the mechanism of lung injury has been considered to be reperfusion injury by cytokine release or pressure overload, recent reports have demonstrated that mechanical damage by the guide wire or balloon is also one of the causes. 5,9) However, in the present study, lung injury did not depend on the increasing frequency of BPA sessions or treated vessels, technique of the operator, balloon size, pressure of the balloon inflation, or guide wires.…”

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

“…Both reports mentioned specific complications related to this procedure. Meanwhile, several Japanese centres gained their own experience in BPA using slightly different methodologies and claimed reduced complication rates while maintaining high efficacy [7][8][9][10][11][12][13][14]. We started to perform BPA in non-operable CTEPH patients in 2013 [15,16], motivated by their expected poor survival compared with those offered surgical PEA [2].…”

Sequential Hybrid Therapy With Pulmonary Endarterectomy and Additional Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension

“…Pulmonary endarterectomy (PEA) is a gold standard therapy7, 8; however, PEA for organized thrombus located peripherally in subsegmental pulmonary arteries was less effective and had a high perioperative mortality rate 7, 9. Presently, balloon pulmonary angioplasty (BPA) can be recommended as an established treatment for nonoperable CTEPH patients 10, 11, 12, 13, 14, 15, 16…”