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BPA for inoperable or recurrent CTEPH

BPA is an emerging medical intervention

Percutaneous balloon pulmonary angioplasty (BPA) may be an option for some patients who are not eligible for pulmonary thromboendarterectomy (PTE) surgery or have recurrent/persistent pulmonary hypertension following PTE.1 BPA is an emerging technique and should be reserved for expert centers with extensive training and experience.2

 

BPA opens obstructed vessels or widens stenotic lesions using a catheter-based intervention in order to restore pulmonary blood flow.1,2

 

BPA has been reported to improve2

  • Hemodynamics

  • Symptoms

  • Exercise capacity

  • Right ventricular function

 

ESC/ERS guidelines suggest BPA may be considered in patients who are technically non-operable or carry an unfavorable risk-benefit ratio for PTE.3

balloon pulmonary angioplasty image

Pulmonary arterial imaging before and after percutaneous balloon pulmonary angioplasty (BPA).

a) Pre-procedure pulmonary angiogram demonstrating an intra-arterial fibrous “web” lesion; b) the corresponding intravascular ultrasound image showing the intravascular filling defect; c) the BPA balloon in place; d) pulmonary angiogram after the BPA procedure, showing the patent arterial lumen. Image from Lang et al 2017.1

Patients should be evaluated for BPA only at an expert center

BPA is a complex procedure that includes risk of complications and often requires multiple sessions. BPA requires extensive training and case experience, and should be reserved for expert centers with a CTEPH team.1,2

 

BPA can be considered for symptomatic CTEPH patients who are ineligible for PTE.2

 

BPA should not be considered for patients with large central clots or unilateral total occlusion.1

Sixth World Symposium on Pulmonary Hypertension CTEPH Treatment Algorithm

Complications with BPA

Complications include1:

  • Hemoptysis

  • Wire injury

  • Vessel dissection

  • Vessel rupture

  • Reperfusion pulmonary edema

  • Pulmonary parenchymal bleeding

  • Hemorrhagic pleural effusions

 

Investigators have refined BPA by using smaller balloons and limiting the number of balloon inflations per session to 1 to 2 pulmonary vascular segments. Targeting only one lobe during each session and cautious balloon sizing have reduced the incidence of RPE to 2% in individual centers.3
 

Multidisciplinary Team

References:

1. Lang I, Meyer BC, Ogo T, et al. Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension. Eur Respir Rev. 2017;26:160119. 2. Kim NH, Delcroix M, Jais X, et al. Chronic thromboembolic pulmonary hypertension. Eur Respir J. 2019;53:1801915. 3. Galie N, Humbert M, Vachiery J, et al. 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2016;37(1):67-119.