Patient selection for balloon pulmonary angioplasty: Six‐year results from a high volume PTE surgical center

Abstract

Chronic thromboembolic pulmonary hypertension (CTEPH) is the result of incompletely resolved pulmonary emboli (PE) that lead to chronic right heart failure. The two mechanical treatment options are pulmonary thromboendarterectomy (PTE) and balloon pulmonary angioplasty (BPA). There are no formal criteria for BPA patient selection and treatment decisions vary according to a center's experience with BPA and PTE. We performed a retrospective review of consecutive patients treated with PTE and BPA at UCSD from March 2015 to 2021. Clinical and hemodynamic data were collected. Patients were categorized according to the rationale for BPA. One hundred fifty three patients underwent 643 BPA sessions, and 1104 patients underwent PTE. Patients selected for PTE had worse baseline hemodynamics with mean pulmonary artery pressure 41.1 ± 11.7 versus 34.6 ± 11.2 mmHg, p < 0.001. 59% of patients selected for BPA had surgically inaccessible disease, 21% had residual CTEPH after PTE, 10% had a discordance between disease burden and symptoms/hemodynamics, 7% had comorbidities that prevented PTE and 3% refused PTE surgery. 28% of patients who underwent PTE had exclusively level III or IV disease based on surgical specimen. There were no BPA procedure‐related mortalities and minor pulmonary vascular complication rates during BPA were 9.2%. The most common reason for BPA selection was surgically inaccessible disease followed by residual CTEPH after PTE. Almost one third of patients who underwent PTE had exclusively distal disease by surgical criteria and might have been directed to BPA at a less experienced surgical center.

Distal vessel pulmonary thromboendarterectomy: Results from a single institution

“…In the experience of our multidisciplinary team in selecting patients for BPA, 59% of patients who underwent BPA at UCSD were referred for surgically inaccessible distal CTEPH while 7% were referred for BPA due to comorbidities precluding PTE surgery. 23 Therefore, we can comment that the patients deemed by the multi-specialty team to be of acceptable risk with operable disease do well with distal PTE.…”

“…Throughout in this study, our team conducted a weekly multi-specialty conference including radiologists, pulmonary vascular medicine specialists, and cardiothoracic surgeons who review all cases to determine the best course for management. The BPA program 22,23 and riociguat medical therapy 18 were both available alternatives since the inception of this study so there were management options for patients deemed not to be candidates for distal endarterectomy. Many factors go into the decision for a distal endarterectomy including the hemodynamics, extent of chronic clot burden and the patient's comorbidities.…”

Balloon pulmonary angioplasty in the current era of CTEPH treatment: How did we get here?

“…Both upfront unilateral BPA followed by subsequent PTE in the contralateral lung, as well as initial bilateral PTE followed by BPA and medical therapy for distal residual disease, have been reported. 21,32 Additionally, residual PH after PTE is common. 33 While re-do or second PTE surgery is possible in select cases at experienced centers, 34 these patients may also now be candidates for combination of medical therapy and BPA.…”

“…Similarly, at UCSD, the most common reason patients were chosen for BPA was also a surgically inaccessible disease (59%). Other reasons included post‐PTE (21%), hemodynamic impairment or symptoms disproportionate to degree of visible disease (10%), comorbidities (7%), and patient refusal (3%) 21 . Importantly, the definition of surgical accessibility is subjective and can change depending on institutional expertise.…”

“…There are also reports of a stepwise approach to asymmetric disease. Both upfront unilateral BPA followed by subsequent PTE in the contralateral lung, as well as initial bilateral PTE followed by BPA and medical therapy for distal residual disease, have been reported 21,32 . Additionally, residual PH after PTE is common 33 .…”