Skip to main content

Advertisement

SpringerLink
Log in

Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension

  • Review
  • Published:
CardioVascular and Interventional Radiology Aims and scope Submit manuscript

Abstract

Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially lethal outcome of pulmonary embolism. Balloon pulmonary angioplasty (BPA) is aimed at improving pulmonary perfusion and pulmonary hemodynamics and has gained a lot of interest recently in patients either unsuitable for or refractory to surgical pulmonary endarterectomy. This article outlines the clinical features and diagnostic criteria, imaging evaluation, current medical and surgical treatment options for CTEPH. BPA is discussed in detail, focusing on the rationale, patient selection, technical details, post-procedural care and outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

Abbreviations

mPAP:

Mean pulmonary artery pressure

WHO:

World Health Organization

RVP:

Right ventricular pressure

mRAP:

Mean right atrial pressure

CI:

Cardiac index

PVR:

Pulmonary vascular resistance

TPR:

Total pulmonary resistance

6MWD:

Six-minute walking distance

BNP:

B-type natriuretic peptide

NT-proBNP:

N-terminal pro b-type natriuretic peptide

PAI:

Pulmonary artery injury

RPE:

Reperfusion edema

RHF:

Right heart failure

PE:

Pulmonary embolism

NPPV:

Noninvasive positive pressure ventilation

vaECMO:

Venoarterial extracorporeal membrane oxygenation

POD:

Postoperative day

References

  1. Freed DH, et al. Survival after pulmonary thromboendarterectomy: effect of residual pulmonary hypertension. J Thorac Cardiovasc Surg. 2011;141(2):383–7.

    Article  Google Scholar 

  2. Galie N, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension: the task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J. 2009;30(20):2493–537.

    Article  Google Scholar 

  3. Machuca T, de Perrot M. When to refer a patient with chronic thromboembolic pulmonary hypertension for pulmonary endarterectomy. Can J Cardiol. 2015;31(4):509–14.

    Article  Google Scholar 

  4. Lang IM, Madani M. Update on chronic thromboembolic pulmonary hypertension. Circulation. 2014;130(6):508–18.

    Article  Google Scholar 

  5. Gall H, et al. An epidemiological analysis of the burden of chronic thromboembolic pulmonary hypertension in the USA, Europe and Japan. Eur Respir Rev. 2017. https://doi.org/10.1183/16000617.0121-2016.

    Article  PubMed  Google Scholar 

  6. Pengo V, et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med. 2004;350(22):2257–64.

    Article  CAS  Google Scholar 

  7. Pepke-Zaba J, et al. Chronic thromboembolic pulmonary hypertension (CTEPH): results from an international prospective registry. Circulation. 2011;124(18):1973–81.

    Article  Google Scholar 

  8. Held M, et al. Chronic thromboembolic pulmonary hypertension: time delay from onset of symtoms to diagnosis and clinical condition at diagnosis. Dtsch Med Wochenschr. 2014;139(33):1647–52.

    Article  CAS  Google Scholar 

  9. Bonderman D, et al. Risk factors for chronic thromboembolic pulmonary hypertension. Eur Respir J. 2009;33(2):325–31.

    Article  CAS  Google Scholar 

  10. Galie N, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Kardiol Pol. 2015;73(12):1127–206.

    Article  Google Scholar 

  11. Riedel M, et al. Longterm follow-up of patients with pulmonary thromboembolism. Late prognosis and evolution of hemodynamic and respiratory data. Chest. 1982;81(2):151–8.

    Article  CAS  Google Scholar 

  12. Lewczuk J, et al. Prognostic factors in medically treated patients with chronic pulmonary embolism. Chest. 2001;119(3):818–23.

    Article  CAS  Google Scholar 

  13. Mehta S, et al. Diagnostic evaluation and management of chronic thromboembolic pulmonary hypertension: a clinical practice guideline. Can Respir J. 2010;17(6):301–34.

    Article  Google Scholar 

  14. Konstantinides SV. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35(45):3145–6.

    Article  Google Scholar 

  15. Tunariu N, et al. Ventilation-perfusion scintigraphy is more sensitive than multidetector CTPA in detecting chronic thromboembolic pulmonary disease as a treatable cause of pulmonary hypertension. J Nucl Med. 2007;48(5):680–4.

    Article  Google Scholar 

  16. Gutte H, et al. Comparison of V/Q SPECT and planar V/Q lung scintigraphy in diagnosing acute pulmonary embolism. Nucl Med Commun. 2010;31(1):82–6.

    Article  Google Scholar 

  17. Quirce R, et al. Contribution of V/Q SPECT to planar scintigraphy in the diagnosis of pulmonary embolism. Rev Esp Med Nucl Imagen Mol. 2014;33(3):153–8.

    CAS  PubMed  Google Scholar 

  18. Auger WR, et al. Chronic major-vessel thromboembolic pulmonary artery obstruction: appearance at angiography. Radiology. 1992;182(2):393–8.

    Article  CAS  Google Scholar 

  19. Galie N, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: the joint task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J. 2016;37(1):67–119.

    Article  Google Scholar 

  20. Jenkins D, et al. State-of-the-art chronic thromboembolic pulmonary hypertension diagnosis and management. Eur Respir Rev. 2012;21(123):32–9.

    Article  CAS  Google Scholar 

  21. Schwickert H, et al. Detection of chronic recurrent pulmonary emboli using spiral-CT. Rofo. 1993;158(4):308–13.

    Article  CAS  Google Scholar 

  22. Shimizu H, et al. Dilatation of bronchial arteries correlates with extent of central disease in patients with chronic thromboembolic pulmonary hypertension. Circ J. 2008;72(7):1136–41.

    Article  Google Scholar 

  23. Ley S, et al. Bronchopulmonary shunts in patients with chronic thromboembolic pulmonary hypertension: evaluation with helical CT and MR imaging. AJR Am J Roentgenol. 2002;179(5):1209–15.

    Article  Google Scholar 

  24. Heinrich M, et al. CT scan findings in chronic thromboembolic pulmonary hypertension: predictors of hemodynamic improvement after pulmonary thromboendarterectomy. Chest. 2005;127(5):1606–13.

    Article  Google Scholar 

  25. Ridker PM, et al. Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism. N Engl J Med. 2003;348(15):1425–34.

    Article  CAS  Google Scholar 

  26. Ghofrani HA, et al. Riociguat: mode of action and clinical development in pulmonary hypertension. Chest. 2017;151(2):468–80.

    Article  Google Scholar 

  27. Jais X, et al. Bosentan for treatment of inoperable chronic thromboembolic pulmonary hypertension: BENEFiT (Bosentan Effects in iNopErable Forms of chronIc Thromboembolic pulmonary hypertension), a randomized, placebo-controlled trial. J Am Coll Cardiol. 2008;52(25):2127–34.

    Article  CAS  Google Scholar 

  28. Becattini C, et al. Bosentan for chronic thromboembolic pulmonary hypertension: findings from a systematic review and meta-analysis. Thromb Res. 2010;126(1):e51–6.

    Article  CAS  Google Scholar 

  29. Suntharalingam J, et al. Long-term use of sildenafil in inoperable chronic thromboembolic pulmonary hypertension. Chest. 2008;134(2):229–36.

    Article  CAS  Google Scholar 

  30. Cabrol S, et al. Intravenous epoprostenol in inoperable chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant. 2007;26(4):357–62.

    Article  Google Scholar 

  31. Olschewski H, et al. Inhaled iloprost for severe pulmonary hypertension. N Engl J Med. 2002;347(5):322–9.

    Article  CAS  Google Scholar 

  32. Skoro-Sajer N, et al. Treprostinil for severe inoperable chronic thromboembolic pulmonary hypertension. J Thromb Haemost. 2007;5(3):483–9.

    Article  CAS  Google Scholar 

  33. Fedullo P, et al. Chronic thromboembolic pulmonary hypertension. Am J Respir Crit Care Med. 2011;183(12):1605–13.

    Article  Google Scholar 

  34. Simonneau G, Torbicki A, Dorfmüller P, Kim N. The pathophysiology of chronic thromboembolic pulmonary hypertension. Eur Respir Rev. 2017. https://doi.org/10.1183/16000617.0112-2016.

    Article  PubMed  Google Scholar 

  35. Sharma S, Lang IM. Current understanding of the pathophysiology of chronic thromboembolic pulmonary hypertension. Thromb Res. 2017;164:136–44.

    Article  Google Scholar 

  36. Olman MA, et al. Pulmonary vascular steal in chronic thromboembolic pulmonary hypertension. Chest. 1990;98(6):1430–4.

    Article  CAS  Google Scholar 

  37. Levinson RM, Shure D, Moser KM. Reperfusion pulmonary edema after pulmonary artery thromboendarterectomy. Am Rev Respir Dis. 1986;134(6):1241–5.

    CAS  PubMed  Google Scholar 

  38. Hou X, et al. Venoarterial extracorporeal membrane oxygenation support for two patients after pulmonary thromboendarterectomy. Can J Anaesth. 2012;59(6):622–3.

    Article  Google Scholar 

  39. Mydin M, et al. Extracorporeal membrane oxygenation as a bridge to pulmonary endarterectomy. Ann Thorac Surg. 2011;92(5):e101–3.

    Article  Google Scholar 

  40. Bonderman D, et al. Predictors of outcome in chronic thromboembolic pulmonary hypertension. Circulation. 2007;115(16):2153–8.

    Article  Google Scholar 

  41. Corsico AG, et al. Long-term outcome after pulmonary endarterectomy. Am J Respir Crit Care Med. 2008;178(4):419–24.

    Article  Google Scholar 

  42. Mayer E, et al. Surgical management and outcome of patients with chronic thromboembolic pulmonary hypertension: results from an international prospective registry. J Thorac Cardiovasc Surg. 2011;141(3):702–10.

    Article  Google Scholar 

  43. Berman M, et al. Pulmonary endarterectomy: outcomes in patients aged > 70. Eur J Cardiothorac Surg. 2012;41(6):e154–60.

    Article  Google Scholar 

  44. Saouti N, et al. Long-term outcome after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: a single institution experience. Eur J Cardiothorac Surg. 2009;35(6):947–52 discussion 952.

    Article  Google Scholar 

  45. Delcroix M, et al. Long-term outcome of patients with chronic thromboembolic pulmonary hypertension: results from an international prospective registry. Circulation. 2016;133(9):859–71.

    Article  CAS  Google Scholar 

  46. Feinstein JA, et al. Balloon pulmonary angioplasty for treatment of chronic thromboembolic pulmonary hypertension. Circulation. 2001;103(1):10–3.

    Article  CAS  Google Scholar 

  47. Ishiguro H, et al. Percutaneous transluminal pulmonary angioplasty for central-type chronic thromboembolic pulmonary hypertension. JACC Cardiovasc Interv. 2013;6(11):1212–3.

    Article  Google Scholar 

  48. Tsuji A, et al. Rescue balloon pulmonary angioplasty in a rapidly deteriorating chronic thromboembolic pulmonary hypertension patient with liver failure and refractory infection. Pulm Circ. 2014;4(1):142–7.

    Article  Google Scholar 

  49. Ghofrani HA, et al. Riociguat for the treatment of pulmonary arterial hypertension. N Engl J Med. 2013;369(4):330–40.

    Article  CAS  Google Scholar 

  50. Condliffe R, et al. Improved outcomes in medically and surgically treated chronic thromboembolic pulmonary hypertension. Am J Respir Crit Care Med. 2008;177(10):1122–7.

    Article  Google Scholar 

  51. Shimura N, et al. Additional percutaneous transluminal pulmonary angioplasty for residual or recurrent pulmonary hypertension after pulmonary endarterectomy. Int J Cardiol. 2015;183:138–42.

    Article  Google Scholar 

  52. Mahmud E, et al. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. Interv Cardiol Clin. 2018;7(1):103–17.

    PubMed  Google Scholar 

  53. Yanagisawa R, et al. Safety and efficacy of percutaneous transluminal pulmonary angioplasty in elderly patients. Int J Cardiol. 2014;175(2):285–9.

    Article  Google Scholar 

  54. Tatebe S, et al. Multiple beneficial effects of balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension. Circ J. 2016;80(4):980–8.

    Article  CAS  Google Scholar 

  55. Nakamura T, et al. Successful balloon pulmonary angioplasty with gadolinium contrast media for a patient with chronic thromboembolic pulmonary hypertension and iodine allergy. Respir Med Case Rep. 2016;17:75–82.

    PubMed  PubMed Central  Google Scholar 

  56. Funaki B. Carbon dioxide angiography. Semin Intervent Radiol. 2008;25(1):65–70.

    Article  Google Scholar 

  57. Cho KJ. carbon dioxide angiography: scientific principles and practice. Vasc Specialist Int. 2015;31(3):67–80.

    Article  Google Scholar 

  58. Roik M, et al. Refined balloon pulmonary angioplasty driven by combined assessment of intra-arterial anatomy and physiology–Multimodal approach to treated lesions in patients with non-operable distal chronic thromboembolic pulmonary hypertension–Technique, safety and efficacy of 50 consecutive angioplasties. Int J Cardiol. 2016;203:228–35.

    Article  Google Scholar 

  59. Tatebe S, et al. Optical coherence tomography as a novel diagnostic tool for distal type chronic thromboembolic pulmonary hypertension. Circ J. 2010;74(8):1742–4.

    Article  Google Scholar 

  60. Roik M, et al. Optical coherence tomography imaging of inoperable chronic thromboembolic pulmonary hypertension treated with refined balloon pulmonary angioplasty. Pol Arch Med Wewn. 2014;124:742–3.

    PubMed  Google Scholar 

  61. Hinrichs JB, et al. Comparison of c-arm computed tomography and digital subtraction angiography in patients with chronic thromboembolic pulmonary hypertension. Cardiovasc Intervent Radiol. 2016;39(1):53–63.

    Article  Google Scholar 

  62. Hinrichs JB, et al. C-arm computed tomography adds diagnostic information in patients with chronic thromboembolic pulmonary hypertension and a positive V/Q SPECT. Rofo. 2017;189(1):49–56.

    PubMed  Google Scholar 

  63. Hinrichs JB, et al. Balloon pulmonary angioplasty: applicability of c-arm CT for procedure guidance. Eur Radiol. 2016;26(11):4064–71.

    Article  Google Scholar 

  64. Kawakami T, et al. Retrograde approach in balloon pulmonary angioplasty: useful novel strategy for chronic total occlusion lesions in pulmonary arteries. JACC Cardiovasc Interv. 2016;9(2):e19–20.

    Article  Google Scholar 

  65. Kawakami T, et al. Novel angiographic classification of each vascular lesion in chronic thromboembolic pulmonary hypertension based on selective angiogram and results of balloon pulmonary angioplasty. Circ Cardiovasc Interv. 2016. https://doi.org/10.1161/CIRCINTERVENTIONS.115.003318.

    Article  PubMed  Google Scholar 

  66. Aoki T, et al. Comprehensive evaluation of the effectiveness and safety of balloon pulmonary angioplasty for inoperable chronic thrombo-embolic pulmonary hypertension: long-term effects and procedure-related complications. Eur Heart J. 2017;38(42):3152–9.

    Article  Google Scholar 

  67. Olsson KM, et al. Balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension: the initial German experience. Eur Respir J. 2017. https://doi.org/10.1183/13993003.02409-2016.

    Article  PubMed  Google Scholar 

  68. Sueoka J, et al. Therapeutic efficacy after percutaneous transluminal pulmonary angioplasty in CTEPH with and without clotting disorder according to anti-cardiolipin antibody. Int J Cardiol. 2015;201:271–3.

    Article  Google Scholar 

  69. Fukui S, et al. Right ventricular reverse remodelling after balloon pulmonary angioplasty. Eur Respir J. 2014;43(5):1394–402.

    Article  Google Scholar 

  70. Tsugu T, et al. Significance of echocardiographic assessment for right ventricular function after balloon pulmonary angioplasty in patients with chronic thromboembolic induced pulmonary hypertension. Am J Cardiol. 2015;115(2):256–61.

    Article  Google Scholar 

  71. Kataoka M, et al. Percutaneous transluminal pulmonary angioplasty for the treatment of chronic thromboembolic pulmonary hypertension. Circ Cardiovasc Interv. 2012;5(6):756–62.

    Article  Google Scholar 

  72. Broch K, et al. Echocardiographic evidence of right ventricular functional improvement after balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant. 2016;35(1):80–6.

    Article  Google Scholar 

  73. Sugimura K, et al. Percutaneous transluminal pulmonary angioplasty markedly improves pulmonary hemodynamics and long-term prognosis in patients with chronic thromboembolic pulmonary hypertension. Circ J. 2012;76(2):485–8.

    Article  Google Scholar 

  74. Koike H, et al. Quantification of lung perfusion blood volume (lung PBV) by dual-energy CT in patients with chronic thromboembolic pulmonary hypertension (CTEPH) before and after balloon pulmonary angioplasty (BPA): preliminary results. Eur J Radiol. 2016;85(9):1607–12.

    Article  Google Scholar 

  75. Kimura M, et al. Balloon pulmonary angioplasty using contrast agents improves impaired renal function in patients with chronic thromboembolic pulmonary hypertension. Int J Cardiol. 2015;188:41–2.

    Article  Google Scholar 

  76. Moriyama K, et al. Noninvasive positive pressure ventilation against reperfusion pulmonary edema following percutaneous transluminal pulmonary angioplasty. Case Rep Anesthesiol. 2011;2011:204538.

    PubMed  Google Scholar 

  77. Taniguchi Y, et al. Balloon pulmonary angioplasty: an additional treatment option to improve the prognosis of patients with chronic thromboembolic pulmonary hypertension. EuroIntervention. 2014;10(4):518–25.

    Article  Google Scholar 

  78. Inami T, et al. A new era of therapeutic strategies for chronic thromboembolic pulmonary hypertension by two different interventional therapies; pulmonary endarterectomy and percutaneous transluminal pulmonary angioplasty. PLoS ONE. 2014;9(4):e94587.

    Article  Google Scholar 

  79. Inami T, et al. Pressure-wire-guided percutaneous transluminal pulmonary angioplasty: a breakthrough in catheter-interventional therapy for chronic thromboembolic pulmonary hypertension. JACC Cardiovasc Interv. 2014;7(11):1297–306.

    Article  Google Scholar 

  80. Andreassen AK, et al. Balloon pulmonary angioplasty in patients with inoperable chronic thromboembolic pulmonary hypertension. Heart. 2013;99(19):1415–20.

    Article  Google Scholar 

  81. Inami T, et al. Incidence, avoidance, and management of pulmonary artery injuries in percutaneous transluminal pulmonary angioplasty. Int J Cardiol. 2015;201:35–7.

    Article  Google Scholar 

  82. Hosokawa K, et al. Delayed-onset lung injury after balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension-a case report. Eur Heart J Cardiovasc Imaging. 2017;18(12):1426.

    Article  Google Scholar 

  83. Mizoguchi H, et al. Refined balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension. Circ Cardiovasc Interv. 2012;5(6):748–55.

    Article  Google Scholar 

  84. Velázquez Martín M, Albarrán González-Trevilla A, Alonso Charterina S, García Tejada J, Cortina Romero JM, Escribano Subías P. Balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension. Preliminary experience in Spain in a series of 7 patients. Rev Esp Cardiol (Engl Ed). 2015;68(6):535–7. https://doi.org/10.1016/j.rec.2015.02.004.

    Article  Google Scholar 

  85. Inami T, Kataoka M, Shimura N, Ishiguro H, Yanagisawa R, Taguchi H, et al. Pulmonary edema predictive scoring index (PEPSI), a new index to predict risk of reperfusion pulmonary edema and improvement of hemodynamics in percutaneous transluminal pulmonary angioplasty. JACC Cardiovasc Interv. 2013;6(7):725–36. https://doi.org/10.1016/j.jcin.2013.03.009.

    Article  PubMed  Google Scholar 

  86. Ogo T, Fukuda T, Tsuji A, Fukui S, Ueda J, Sanda Y, et al. Efficacy and safety of balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension guided by cone-beam computed tomography and electrocardiogram-gated area detector computed tomography. Eur J Radiol. 2017;89:270–6. https://doi.org/10.1016/j.ejrad.2016.12.013.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Interventional Radiology, Department of Radiology, Ronald Reagan UCLA Medical Center, 10945 Le Conte Avenue Suite 3371, Los Angeles, CA, 90095, USA

    J. M. Moriarty, S. N. Khan & S. D. Kao

  2. Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, 90095, CA, USA

    R. Saggar

Authors
  1. J. M. Moriarty
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. S. N. Khan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. S. D. Kao
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. R. Saggar
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to J. M. Moriarty.

Ethics declarations

Conflict of interest

All the authors declared that they have no conflict of interest.

Ethical Approval

This review article does not contain any studies with human participants or animals performed by any of the authors.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Moriarty, J.M., Khan, S.N., Kao, S.D. et al. Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension. Cardiovasc Intervent Radiol 41, 1826–1839 (2018). https://doi.org/10.1007/s00270-018-2012-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00270-018-2012-2

Keywords

Search

Navigation