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.

Keywords: balloon pulmonary angioplasty; chronic thromboembolic pulmonary disease; chronic thromboembolic pulmonary hypertension; pulmonary endarterectomy; pulmonary hypertension.

Figure 1

Examples of pulmonary angiography for levels I to IV according to the University of San Diego classification (yellow arrows indicate lesions): (A) level I (lesions starting in the main pulmonary artery with level IC corresponding to complete occlusion of one main PA); (B) level II (lesions starting at the level of lobar arteries or in the main descending PAs); (C) level III (lesions starting at the level of the segmental arteries); and (D) level IV (lesions starting at the level of the subsegmental arteries) [14]. The levels I–III are considered surgically accessible lesions whereas level IV is not operable.

Figure 2

(A) Holographic reconstruction of a pulmonary artery created with CarnaLife Holo software (version 2.4.4.10379, Medapp SA, Kraków, Poland). (B) First-person view of the hologram of the pulmonary artery branches displayed throughout the BPA procedure; (Images courtesy of Grzegorz Bałda). (C) The operator using an AR headset (HoloLens 2, Microsoft) during one of the procedures.

Figure 3

Selective pulmonary angiograms: (A) before BPA; (B) during 4.0 mm balloon inflation (arrow); and (C) after BPA.

Figure 4

(A) IVUS image of the web lesion in a segmental branch of pulmonary artery and (B) IVUS image of the same lesion with color flow imaging showing recanalized flow channels in the central part of the vessel.

Figure 5

Representative CT image of lung injury. (A) Second day after BPA procedure; (B) 3 months after BPA procedure; and (C) 10 months after BPA procedure.