Balloon pulmonary angioplasty for proximal chronic thromboembolic pulmonary hypertension in patients ineligible for pulmonary endarterectomy

Abstract

Balloon pulmonary angioplasty (BPA) to treat chronic thromboembolic pulmonary hypertension (CTEPH) is generally reserved for distal obstruction precluding pulmonary endarterectomy (PEA) but can be used in patients with proximal disease who are at high surgical risk or refuse surgery. This single-center retrospective study compared BPA efficacy in patients with proximal versus distal CTEPH. Of the 478 patients, 36 had proximal disease, follow-up was 11.6 months and mean number of BPA 6. After BPA, PVR, and mean pulmonary artery pressure decreased significantly in the proximal and distal groups (from 6.5 to 4.0 WU and 39 to 31 mmHg and from 7.6 to 3.8 WU and 44 to 31 mmHg, respectively, p < 0.001 for all comparisons). NYHA class also improved significantly in both groups, from 3 to 2, whereas the 6-min walk distance, cardiac output, and serum NT pro-BNP showed significant improvements only in the distal group. Thus, when PEA for CTEPH is technically feasible but not performed due to severe comorbidities or patient refusal, BPA can produce significant hemodynamic improvements, albeit less marked than in patients with distal disease. Better patient selection to BPA might improve outcomes in patients with proximal disease who are ineligible for PEA.

Keywords: morbidity; pulmonary endarterectomy.

Figure 1

Patient flowchart.

Figure 2

Location and distribution of the lesions of patients presenting a proximal CTEPH treated by BPA, according to the Kawakami and Matsubara classification. LLL, left lower lobe LUL, left upper lobe; ML, middle lobe; RLL, right lower lobe; RUL, right upper lobe.

Figure 3

Pulmonary angiography examples in two patients. (a) Proximal lesions at the segmental level in a patient with severe comorbidities. (b) Proximal lesions at the lobar level (occlusion of the right lower lobar pulmonary artery) in a patient who refused surgery.