Refined balloon pulmonary angioplasty driven by combined assessment of intra-arterial anatomy and physiology – Multimodal approach to treated lesions in patients with non-operable distal chronic thromboembolic pulmonary hypertension – Technique, safety and efficacy of 50 consecutive angioplasties

Roik, Marek; Wretowski, Dominik; Łabyk, Andrzej; Kostrubiec, Maciej; Irzyk, Katarzyna; Dzikowska-Diduch, Olga; Lichodziejewska, Barbara; Ciurzyński, Michał; Kurnicka, Katarzyna; Gołębiowski, Marek; Pruszczyk, Piotr

doi:10.1016/j.ijcard.2015.10.116

Cited by 63 publications

(41 citation statements)

References 29 publications

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“…After 51 months' follow-up, 85% of patients were still alive. Three further publications from European centres, one in 37 patients [9] and two others, each in nine patients [24,25], described improvements in mPAP, exercise capacity and functional class after BPA, with low rates of complications.…”

Section: History Evolution and Evidence For Bpamentioning

confidence: 99%

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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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Section: History Evolution and Evidence For Bpamentioning

confidence: 99%

“…Published studies of BPA are discussed below and summarised in table 1 [9,[15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32]43]. The first full report was published in 2001 by FEINSTEIN et al [15] in the USA, describing 18 patients with inaccessible or "nonsurgical" CTEPH.…”

Section: History Evolution and Evidence For Bpamentioning

confidence: 99%

Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension

et al. 2017

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“…In subsequent reports, the rate of severe BPA-associated lung injury has declined even further, in the range of 0% to 3.5%, while the incidence of mild BPA-associated lung injury has declined to less than 40%. [42][43][44][45] The improved safety of BPA owes to a steep technical learning curve incorporating improved operator skill, the use of intravascular imaging modalities such as intravascular ultrasound and optical coherence tomography, 46,47 the use of intravascular pressure gradient measurements, 42,48 the characterization of specific lesion types, 49 and the adaptation of interventional technique to the severity of PH. However, BPA requires significant quantities of iodinated contrast and radiation exposure under fluoroscopy.…”

Section: Discussionmentioning

confidence: 99%

“…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: 96%

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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“…Balloon pulmonary angioplasty (BPA) is an emerging therapeutic procedure for CTEPH in patients with distal thrombi or subjects too fragile for PEA [12, 13]. Although there is accumulating evidence on BPA application, its technique, efficacy and safety are still a matter of ongoing intensive research.…”

Section: Introductionmentioning

confidence: 99%

High prevalence of severe coronary artery disease in elderly patients with non-operable chronic thromboembolic pulmonary hypertension referred for balloon pulmonary angioplasty

Roik¹,

Wretowski²,

Kostrubiec³

et al. 2016

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IntroductionBalloon pulmonary angioplasty (BPA) is a new emerging catheter-based alternative treatment option for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH).AimTo show that all elderly CTEPH patients referred for BPA are at higher risk of obstructive coronary artery disease and that, in daily practice, they should undergo invasive coronary angiography.Material and methodsEleven patients at the age of at least 65 years (6 males, 5 females, 77.2 ±5.9 years) with confirmed non-operable type II or type III CTEPH, considered for BPA, underwent elective coronary angiography. Severe obstructive coronary artery disease (CAD) was diagnosed when stenosis of left main coronary artery ≥ 50% or stenosis of ≥ 70% of epicardial arteries was angiographically confirmed. We also screened for CAD consecutive age- and sex-matched 114 PE survivors (52 males, 62 females, 74.8 ±7.2 years) with excluded CTEPH.ResultsSevere CAD was more frequent in elderly patients with non-operable type II or type III CTEPH candidates for BPA than in elderly acute PE survivors with excluded CTEPH (54.5% vs. 16.7%, p < 0.01), and therefore elderly CTEPH patients referred for BPA were at higher risk of CAD (OR = 5.9, 95% CI: 1.64–21.46, p = 0.007) when compared to elderly survivors after acute PE with excluded CTEPH.ConclusionsAll elderly CTEPH patients referred for BPA are at higher risk of severe CAD and should routinely undergo invasive coronary angiography before BPA.

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Cited by 63 publications

References 29 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

High prevalence of severe coronary artery disease in elderly patients with non-operable chronic thromboembolic pulmonary hypertension referred for balloon pulmonary angioplasty

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