Periprocedural Complications With Balloon Pulmonary Angioplasty: Analysis of Global Studies

Non-contrast dual-energy CT iodine quantification for lung injury characterization after balloon pulmonary angioplasty

ObjectivesThis study aimed to identify differences in iodine concentrations in new-onset pulmonary injuries and normal lung parenchyma after balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH) using non-contrast dual-energy CT (NC-DECT) between patients with pulmonary hemorrhage and reperfusion pulmonary edema.

METHODS

Patients undergoing NC-DECT after BPA between January 2019 and April 2023 due to hemoptysis or clinical worsening were retrospectively evaluated for inclusion. Patients were divided based on the presence or absence of BPA-related hemoptysis. Intralesional iodine concentrations were measured in new-onset lung injuries, adjacent normal parenchyma, same lobe, and contralateral lung. CT morphological features, including lesion shape, imaging pattern, absolute density, and ROI size, were recorded. Statistical comparisons were performed using Mann-Whitney U, Friedman, and Wilcoxon signed-rank tests.

RESULTS

Thirteen patients with 32 new-onset post-BPA lung injuries were included. Median iodine concentration in lung injuries was significantly higher in patients with hemoptysis than those without (3.4 mg/mL versus 0.6 mg/mL; p < 0.001). In the hemoptysis group, iodine concentration in lung injuries was significantly higher compared with the different locations of normal lung parenchyma (p < 0.001). In the non-hemoptysis group, no significant differences in iodine concentration were observed between lung injuries and normal parenchyma (p = 0.167; p = 0.351; p = 0.246). Absolute density (p = 0.767), lesion shape (p = 0.610), imaging appearance (p = 0.530), ROI area (p = 0.452), and halo sign (p = 0.810) showed no significant correlation with hemoptysis.

CONCLUSION

NC-DECT identifies iodine concentration differences in lung injuries between patients with and without hemoptysis after BPA. Elevated iodine concentrations may serve as an imaging marker for post-procedural pulmonary hemorrhage.

CRITICAL RELEVANCE STATEMENT

This exploratory study demonstrates the potential of NC-DECT in distinguishing between pulmonary hemorrhage and reperfusion pulmonary edema in lung injuries after BPA in patients with CTEPH. The ability to quantify iodine concentrations in lung lesions offers a novel imaging biomarker for pulmonary hemorrhage, which could play a pivotal role in improving clinical decision-making and management strategies for patients undergoing BPA.

Recent Advances in Chronic Thromboembolic Pulmonary Hypertension: Expanding the Disease Concept and Treatment Options

Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive form of pulmonary hypertension characterized by unresolved thromboembolic occlusion of pulmonary arteries, leading to increased pulmonary arterial pressure and right heart failure. This review examines recent advances in the pathophysiology, diagnosis, and management of CTEPH, focusing on expanding disease concepts and evolving therapeutic approaches. The incidence of CTEPH has been revised upward with improved diagnostic techniques revealing a higher prevalence than previously recognized. Advances in surgical and interventional therapies, particularly pulmonary endarterectomy and balloon pulmonary angioplasty, have significantly improved outcomes. Emerging medical therapies, including pulmonary vasodilators like riociguat, have offered new hope for inoperable cases. The understanding of CTEPH has broadened, leading to better diagnostic strategies and more comprehensive treatment options that significantly enhance patient outcomes. Multidisciplinary team approaches are crucial in managing the disease effectively.

Feasibility of revascularization after gelatin sponge embolization for hemoptysis during balloon pulmonary angioplasty

BACKGROUND

Vessel injury is a common complication during balloon pulmonary angioplasty (BPA). For persistent hemoptysis, gelatin sponge embolization (GSE) is considered, but its impact on subsequent perfusion in embolized vessels remains unknown. This study explores the feasibility of revascularization in vessels post-GSE.

METHODS

We included 64 vessels from 50 patients with chronic thromboembolic pulmonary hypertension who experienced hemoptysis during BPA in 2012-2023. Twenty-four vessels were treated conservatively (conservative group), while 40 were treated with GSE for persistent hemoptysis or desaturation despite conservative treatment (GSE group). We assessed hemoptysis-related parameters, perfusion of injured vessels pre- and post-treatment, and hemodynamic parameters through multiple BPA sessions.

RESULTS

Hemoptysis resolved immediately after the procedure in 67% of patients, including 70% of those in the GSE group, and all cases resolved by the next day. Of 37 embolized vessels, 41% showed spontaneous perfusion improvement in subsequent sessions. BPA was reperformed in 22 embolized vessels, with 86% showing further improvement, resulting in 70% of all embolized vessels finally showing improvement in perfusion. In both groups, clinical and hemodynamic parameters significantly improved after BPA.

CONCLUSIONS

Perfusion of embolized vessels improved after GSE, suggesting that GSE is safe for the treatment of severe persistent hemoptysis after conservative treatment.

Chronic thromboembolic pulmonary disease

Chronic thromboembolic pulmonary hypertension is a complication of pulmonary embolism and a treatable cause of pulmonary hypertension. The pathology is a unique combination of mechanical obstruction due to failure of clot resolution, and a variable degree of microvascular disease, that both contribute to pulmonary vascular resistance. Accordingly, multiple treatments have been developed to target the disease components. However, accurate diagnosis is often delayed. Evaluation includes high-quality imaging modalities, necessary for disease confirmation and for appropriate treatment planning. All patients with chronic thromboembolic pulmonary disease, and especially those with pulmonary hypertension, should be referred to expert centres for multidisciplinary team decision on treatment. The first decision remains assessment of operability, and the best improvement in symptoms and survival is achieved by the mechanical therapies, pulmonary endarterectomy and balloon pulmonary angioplasty. With the advances in multimodal therapies, excellent outcomes can be achieved with 3-year survival of >90%.

One Neglected Complication in the BPA Process? Severe Vagal Response During the Angioplasty Procedure-A Case Report

Balloon pulmonary angioplasty (BPA) is now a widely accepted treatment for inoperable chronic thromboembolic pulmonary hypertension (CTEPH), but it still faces the problem of high complications. Herein, we report a rare case of severe vagal response during the BPA of a total occlusion lesion in a patient with CTEPH. The patient experienced acute chest pain and dyspnea, accompanied by a significant decrease in heart rate and blood pressure. After administering atropine, the patient's symptoms rapidly subsided. This case highlights the potential for vascular and pleural injury with chest pain, which can lead to severe vagal response during the BPA procedures. To minimize this risk, avoiding guide wire-induced injury to the pleura situated distal to the target vessel is crucial.

Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Disease: Success Rate and Complications among Different Patient Populations

INTRODUCTION

Balloon pulmonary angioplasty (BPA) is an effective intervention for patients with chronic thromboembolic pulmonary disease (CTEPD). We aimed to identify the patient group with a low success rate or high complication rate of BPA, which is still unclear.

METHODS

Both CTEPD patients with or without pulmonary hypertension (CTEPH and NoPH-CTEPD) were included. CTEPH patients were divided into groups with or without pulmonary endarterectomy (PEA-CTEPH and NoPEA-CTEPH). The efficacy and safety of BPA were compared among the groups.

RESULTS

There were 450, 66, and 41 sessions in the NoPEA-CTEPH, PEA-CTEPH, and NoPH-CTEPD groups, respectively. The success rate (≥1 degree improvement in flow grade) in the PEA-CTEPH group was 94.5%, significantly lower than that in the NoPEA-CTEPH (97.1%) and NoPH-CTEPD (98.4%) groups (p = 0.014). The percentage of complete flow recovery in treated vessels was also lower in PEA-CTEPH group. BPA-related complication rate in NoPEA-CTEPH, PEA-CTEPH, and NoPH-CTEPD patients was 6.1%, 6.0%, and 0.0%, respectively (p = 0.309). One BPA-related death occurred (solely in NoPEA-CTEPH). Mean pulmonary artery pressure ≥41.5 mm Hg was a predictor of BPA-related complications. NoPEA-CTEPH patients had more improvement in 6-min walk distance (6MWD, 87 ± 93 m NoPEA-CTEPH vs. 40 ± 43 m PEA-CTEPH vs. 18 ± 20 m NoPH-CTEPD, p = 0.012).

CONCLUSIONS

BPA was safe and effective for all CTEPD groups with less improvement for the PEA-CTEPH and NoPH-CTEPD groups. The success rate of BPA was lower in the PEA-CTEPH group and the complication rate was lower in the NoPH-CTEPD group. Pre-BPA treatment to lower pulmonary artery pressure should not be overlooked in CTEPD patients.

Effect of off-label targeted drugs on long-term survival in chronic thromboembolic pulmonary hypertension: Insights from a national multicentre prospective registry

BACKGROUND AND OBJECTIVE

Off-label pulmonary arterial hypertension (PAH)-targeted drugs are commonly prescribed for non-operated chronic thromboembolic pulmonary hypertension (CTEPH), but their effect on the long-term prognosis of CTEPH remains unknown. This study investigated the effect of off-label PAH-targeted drugs on the long-term survival of CTEPH patients.

METHODS

CTEPH patients were enrolled from a prospective multicentre national registry. Except for licensed riociguat and treprostinil, other PAH-targeted drugs were off-label. In the original and propensity score-matched (PSM) samples, five-year survival was compared in two groups: (a) patients not receiving off-label PAH-targeted drugs (control) versus (b) patients receiving off-label PAH-targeted drugs (treatment). The latter group was investigated for the effect of started off-label PAH-targeted drugs at baselines (initial) or during follow-up (subsequent).

RESULTS

Of 347 enrolled patients, 212 were treated with off-label PAH-targeted drugs initially (n = 173) or subsequently (n = 39), and 135 were untreated. The 1-, 2-, 3- and 5-year survival of the treatment group was significantly higher than that of the control group (97.1% vs. 89.4%, 92.3% vs. 82.1%, 83.2% vs. 75.1% and 71.1% vs. 55.3%, respectively, log-rank test, p = 0.005). Initial treatment was correlated with better 5-year survival after excluding patients with subsequent treatment to reduce the immortal-time bias (hazard ratio: 0.611; 95% CI: 0.397-0.940; p = 0.025). In PSM samples, patients given initial treatment showed significantly better 5-year survival than untreated patients (68.9% vs. 49.3%, log-rank test, p = 0.008).

CONCLUSION

Off-label targeted drugs contributed to improved long-term survival in CTEPH patients receiving pharmacotherapies.

Status and Future Directions for Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Disease With and Without Pulmonary Hypertension: A Scientific Statement From the American Heart Association

Balloon pulmonary angioplasty continues to gain traction as a treatment option for patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. Recent European Society of Cardiology guidelines on pulmonary hypertension now give balloon pulmonary angioplasty a Class 1 recommendation for inoperable and residual chronic thromboembolic pulmonary hypertension. Not surprisingly, chronic thromboembolic pulmonary hypertension centers are rapidly initiating balloon pulmonary angioplasty programs. However, we need a comprehensive, expert consensus document outlining critical concepts, including identifying necessary personnel and expertise, criteria for patient selection, and a standardized approach to preprocedural planning and establishing criteria for evaluating procedural efficacy and safety. Given this lack of standards, the balloon pulmonary angioplasty skill set is learned through peer-to-peer contact and training. This document is a state-of-the-art, comprehensive statement from key thought leaders to address this gap in the current clinical practice of balloon pulmonary angioplasty. We summarize the current status of the procedure and provide a consensus opinion on the role of balloon pulmonary angioplasty in the overall care of patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. We also identify knowledge gaps, provide guidance for new centers interested in initiating balloon pulmonary angioplasty programs, and highlight future directions and research needs for this emerging therapy.

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

Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by persistent organized thromboembolic obstruction of the pulmonary arteries from incompletely resolved pulmonary embolism. The treatment of choice is pulmonary thromboendarterectomy (PTE) surgery and all patients should be evaluated for operability candidacy. Despite advancements in PTE technique allowing more segmental-subsegmental surgeries, up to a third of patients with CTEPH may still be considered inoperable. Over the past decade, there have been increasing treatment options for these inoperable CTEPH patients. Balloon pulmonary angioplasty (BPA) is a percutaneous-based interventional treatment option for select CTEPH cases. Early BPA experiences were plagued by high complication rates, but further refinements in technique and equipment pioneered by Japan led to the worldwide spread and adoption of BPA. Multiple centers have shown that patients experience significant improvements in hemodynamics, quality of life, exercise capacity, and survival with BPA treatment. There remain many questions on best practices, but BPA has evolved into a pivotal cornerstone of CTEPH treatment.

Management of Complications of Balloon Pulmonary Angioplasty

Since the publication of the first case series reporting the outcomes of patients with chronic thromboembolic pulmonary hypertension who underwent treatment with balloon pulmonary angioplasty more than 30 years ago, significant improvements to the procedural technique have made balloon pulmonary angioplasty (BPA) a safe and effective therapy that we know today. Nevertheless, BPA carries a small risk of complications, which require rapid recognition and immediate management. The most commonly seen complications associated with BPA include pulmonary vascular injury and reperfusion pulmonary edema.