Emerging Role of Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Disease—Insights from the 2022 ESC Guidelines

Abstract

In this article, we discuss the topic of chronic thromboembolic pulmonary disease (CTEPD) and the growing role of balloon pulmonary angioplasty (BPA) in its treatment. We present the pathophysiology of CTEPD which arises from an incomplete resolution of thrombi in the pulmonary arteries and leads to stenosis and occlusion of the vessels. The article focuses mainly on the chronic thromboembolic pulmonary hypertension (CTEPH) subpopulation for which prognosis is very poor when left untreated. We describe a multimodal approach to treating CTEPH, including pulmonary endarterectomy (PEA), BPA, and pharmacological therapies. Additionally, the benefits of pharmacological pre-treatment before BPA and the technical aspects of the procedure itself are outlined. It is emphasized that BPA does not replace PEA but serves as a complementary treatment option for eligible patients. We summarized efficacy and treatment goals including an improvement in functional and biochemical parameters before and after BPA. Patients who received pre-treatment with riociguat prior to BPA exhibited a notable reduction in the occurrence of less severe complications. However, elderly patients are still perceived as an especially vulnerable group. It is shown that the prognosis of patients undergoing BPA is similar to PEA in the first years after the procedure but the long-term prognosis of BPA still remains unclear. The 2022 ESC/ERS guidelines highlight the significant role of BPA in the multimodal treatment of CTEPH, emphasizing its effectiveness and recommending its consideration as a therapeutic option for patients with CTEPD, both with and without pulmonary hypertension. This review summarizes the available evidence for BPA, patient selection, procedural details, and prognosis and discusses the potential future role of BPA in the management of CTEPH.

Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension with bronchial obstruction by a carcinoid tumor

“…These complications are serious, and the risk is significantly higher when BPA is performed for proximal lesions. 8 Therefore, in our patient, subsequent BPA after endobronchial resection of the tumor was not considered to provide a better long‐term prognosis or lower the operative risks compared with subsequent PEA.…”

“…Pulmonary injury and hemoptysis are the most commonly reported complications, accounting for up to 10% of cases after BPA, and PA perforation, dissection, and rupture have been reported in <3% of cases. These complications are serious, and the risk is significantly higher when BPA is performed for proximal lesions 8 . Therefore, in our patient, subsequent BPA after endobronchial resection of the tumor was not considered to provide a better long‐term prognosis or lower the operative risks compared with subsequent PEA.…”

“…BPA is another well‐established interventional treatment for patients with CTEPH that provides effective improvements in pulmonary hemodynamics and long‐term prognosis. 8 However, whereas the long‐term prognosis after PEA in operable CTEPH patients is established, 6 recent evaluation of the long‐term prognosis after BPA has been performed only for patients with inoperable CTEPH, chiefly involving peripheral distribution of lesions in the pulmonary arteries. 8 In addition, BPA carries the risk of interventional complications.…”

“… 8 However, whereas the long‐term prognosis after PEA in operable CTEPH patients is established, 6 recent evaluation of the long‐term prognosis after BPA has been performed only for patients with inoperable CTEPH, chiefly involving peripheral distribution of lesions in the pulmonary arteries. 8 In addition, BPA carries the risk of interventional complications. Pulmonary injury and hemoptysis are the most commonly reported complications, accounting for up to 10% of cases after BPA, and PA perforation, dissection, and rupture have been reported in <3% of cases.…”

Sarcoidosis-associated pulmonary hypertension due to pulmonary arteries stenosis – a case report

“…In case of active disease, corticosteroid and immunosuppressive treatment, are recommended [ 31 , 41 ]. Otherwise, balloon pulmonary angioplasty, which is currently recommended for the therapy of inoperable chronic thromboembolic pulmonary hypertension, or pulmonary artery stenting performed in PH expert centre may be considered [ 23 , 42 – 44 ]. In case of failure or insufficient response to treatment and deterioration of lung function, early referral for lung or lung and heart transplantation is recommended.…”