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Revisiting Balloon Pulmonary Angioplasty for the Treatment of Non-Operable Chronic Thromboembolic Pulmonary Hypertension

Mithun Chakravarthy
Allegheny General Hospital
Pittsburgh, PA, USA

Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially curable condition [1]. The current treatment of choice for CTEPH is pulmonary endarterectomy (PEA) in patients who are considered candidates for surgical therapy. However, some CTEPH patients have thrombotic disease that affects the distal segmental pulmonary artery branches, while others have major medical co-morbidities which make them less than optimal candidates for surgical PEA. So, what are the alternatives when there is an inadequate response to medical therapy with pulmonary vasodilating agents such as Riociguat?

Angioplasty has been performed in most vascular beds with excellent results since Dr. Andreas Gruentzig paved the way for balloon angioplasty. However, experience with angioplasty in the pulmonary vasculature has been mostly limited to pediatric patients with congenital pulmonary artery stenosis.

A group from Boston had explored the possibility of performing pulmonary angioplasty to treat patients with CTEPH in the early 2000s with limited success due to significant complication rates [2]. These patients could develop reperfusion pulmonary edema, hemoptysis and other vascular complications, and experience with this procedure in the United States has been very limited.

However, over the last several years, Japanese investigators have revisited the use of balloon pulmonary angioplasty (BPA) in CTEPH patients and have gradually refined the interventional technique for this procedure. [3] Indeed, the recent Japanese experience has shown that BPA can be performed with success in terms of reducing pulmonary artery pressures and PVR without the major complications rates which had previously been associated with this procedure.

They have achieved this, in part, by being very meticulous in technical aspects of the procedure, including use of smaller balloons and also by avoiding performing BPA to all the involved segments at one session. BPA performed in four to five sessions over a course of weeks has significantly minimized the complications that are unique to BPA, including rates of reperfusion pulmonary edema. Inami et al. went so far as to devise a scoring system to predict the risk of reperfusion pulmonary edema (Pulmonary Edema Predictive Scoring Index, PEPSI score) [4] in patients undergoing BPA for CTEPH.

I recently had the opportunity to travel to Japan and visit one of the premier centers in Osaka to learn their techniques for BPA. What was particularly enlightening was that chronic thromboembolic disease that we would consider non-operable in the United States could frequently be addressed by BPA in experienced hands. As such, BPA has a huge potential in treating and palliating very sick patients with CTEPH who are otherwise not good candidates for PEA and who may have limited response to drug therapy. With the lessons learned in Japan, we recently performed the first BPA procedure in a non-operable CTEPH patient at our institution (see figure).

Given promising results from several Japanese series (from multiple centers) using BPA in non-operable CTEPH patients, we should consider offering this promising alternative therapy to our patients with non-operable CTEPH, albeit with several caveats. We should note that there is no large scale or long-term data with BPA therapy in terms of PVR reduction, reduction and PA pressures or outcomes in CTEPH patients 5. BPA should only be considered in those PH centers where there is enough expertise to treat CTEPH patients in a multi-disciplinary fashion, including the providing the option of evaluation for PEA surgery [5]. Lastly, the results of BPA are operator dependent and interventionalists in the United States and Europe need to gain greater familiarity with this procedure in order to replicate the results achieved in the Japanese experience. ■

Disclosure Statement: The author has no conflicts of interest to disclose.

1. Lang IM, Madani M. Update on Chronic Thromboembolic Pulmonary Hypertension. Circulation. 2014; 130:508-518.

2. Feinstein JA, Goldhaber SZ, Lock JE, Ferndandes SM, Landzberg MJ. Balloon pulmonary angioplasty for treatment of chronic thromboembolic pulmonary hypertension. Circulation. 2001; 103:10-13.

3. Kataoka M, Inami T, Hayashida K, Shimura N, Ishiguro H, Abe T, Tamura Y, Ando M, Fukuda K, Yoshino H, Satoh T. Percutaneous transluminal pulmonary angioplasty for the treatment of chronic thromboembolic pulmonary hypertension. Circ Cardiovasc Interv. 2012; 5:756-762.

4. Inami T, Kataoka M, Shimura N, Ishiguro H, Yanagisawa R, Taguchi H, Fukuda K, Yoshino H, Satoh T. Pulmonary Edema Predictive Scoring Index (PEPSI), a new index to predict risk of reperfusion pulmonary edema and improvement of hemodynamics in percutaneous transluminal pulmonary angioplasty. J Am Coll Cardiol Cardiovasc Interv. 2013; 6:725-736.

5. Hoeper MM. Chronic thromboembolic pulmonary hypertension at the crossroad. Eur Respir J. 2014; 43:1230-1232.

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