Balloon Angioplasty: A Reasonable Plan B for Chronic Thromboembolic Hypertension

Thromboembolic pulmonary hypertension is caused by pulmonary artery stenosis caused by organized thrombi.

The only treatment potentially healing for this disease is surgical thrombectomy. However, patients with lesions in very peripheral branches or high surgical risk patients with comorbidities might benefit from a plan B, such as balloon pulmonary angioplasty. The percentage of patients with chronic thromboembolic pulmonary hypertension that cannot access surgery varies between 12 and 60.9%, according to the series.

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This multicenter registry included 308 patients (62 men and 246 women, mean age 61) receiving 1408 procedures in 7 hospitals in Japan.

Hemodynamics improved in 249 patients after 1154 procedures, basically because of mean pressure or symptomatic improvement. This improvement was maintained in 196 patients undergoing follow up right heart catheterization.

Mean pulmonary arterial pressure decreased form 43.2±11.0 to 24.3±6.4 mmHg after final balloon pulmonary angioplasty and was maintained at 22.5±5.4 mmHg at follow up, with reduction of concomitant use of pulmonary hypertension-targeted therapy and oxygen supplementation.

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There were complications in 511 procedures (36.3%) including pulmonary injury (17.8%), hemoptysis (14%) and pulmonary artery perforation (2.9%). Twelve patients (3.9%) died during follow up, including 8 that passed away within 30 days after procedure.

Global survival at one year was 96.8% and at two years, 94.5%.

Conclusion

This multicenter registry suggests a significant hemodynamic improvement after balloon pulmonary angioplasty. Complications were frequent but global survival was comparable to pulmonary thrombectomy, which makes angioplasty an reasonable alternative to treat chronic thromboembolic hypertension.

Editorial Comment

More than 80% of patients included in this registry were considered high risk inoperable patients.  

Drugs specifically prescribed for primary pulmonary hypertension have been shown ineffective for chronic thromboembolic pulmonary hypertension (with the exception of riociguat), which is why we need an effective treatment for these patients. Physicians compassionately prescribe these drugs when patients are deemed inoperable.

The most frequent complication was lung reperfusion injury, which this study saw in 20% of cases (though some others report up to 60%). Injury occurs in the pulmonary segment corresponding to the dilated artery and disappears roughly by day four. 

Original title: Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension. Results of a Multicenter Registry.

Reference: Aiko Ogawa et al. Circ Cardiovasc Qual Outcomes. 2017;10:e004029.

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