A Review of Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Hypertension

Monday, March 31, 2025

5:05 PM – 5:10 PM CT

Location: Music City Center, 202 BC

Abstract Presenter(s)

Yanqing Zhao, MD (he/him/his)

Research fellow
Division of Vascular & Interventional Radiology, Department of Radiology; University of Michigan Health, United States

Author/Co-author(s)

MT

Michael P. Thomas, MD

Assistant Professor of Internal Medicine and Associate Fellowship Director
Division of Cardiovascular Medicine, Department of Internal Medicine, UMICH, United States
ED

Elias Dayoub, MD

Clinical Assistant Professor of Internal Medicine, Medical School
Division of Cardiovascular Medicine; Department of Internal Medicine; University of Michigan Health, United States
WS

William Sherk, MD

Clinical Assistant Professor, Interventional Radiology
University of Michigan Hospital, United States
Minhaj S. Khaja, MD, FSIR, MBA (he/him/his)

Professor of Radiology & Cardiac Surgery
University of Michigan, United States

Learning Objectives:

Recognize the role of balloon pulmonary angioplasty (BPA) as a therapeutic option for managing inoperable chronic thromboembolic pulmonary hypertension (CTEPH), including its procedural details, techniques, efficacy, and complications.

Background: CTEPH arises from unresolved pulmonary embolism (PE), leading to fibrous tissue formation in 3-5% of PE patients. While pulmonary endarterectomy (PEA) is the gold standard, many patients are inoperable. BPA offers a promising alternative, especially for those with residual or recurrent pulmonary hypertension after PEA.

Clinical Findings/Procedure Details:

1. Imaging modalities:

Planar V/Q lung imaging is the first-line tool for identifying perfusion defects but lacks detailed lesion characterization. Pulmonary angiography serves as the reference standard for vascular anatomy, limited to 2D projections. CT pulmonary angiography and dual-energy CT offer high sensitivity for visualizing distal vessels and guiding BPA, while SPECT and cone-beam CT have specific limitations.

2. BPA Goals:

The primary goal is to restore blood flow to distal arteries, evidenced by reduced mean pulmonary artery pressure and pulmonary vascular resistance. A secondary goal is to enhance respiratory function, pulmonary perfusion, and oxygenation.

3. Procedure details:

Typically involves 4-6 sessions spaced one week apart to minimize reperfusion pulmonary edema, focusing on one lobe and addressing 2–6 lesions in 2–3 segmental branches. Utilizes 2.0–4.0 mm semi-compliant balloons inflated to targeted pressures for effective lesion dilation.

4. Target lesion selection:

Selection based on location, morphology, and perfusion imaging findings, prioritizing types A and B lesions{1} due to their higher success rates and lower complications. Achieving a pulmonary flow grade of 3 for optimal regional blood flow.

5. Complications and management:

Vascular complications during BPA, such as guidewire perforation, can lead to hemoptysis minutes after injury. Management strategies depend on the injury mechanism and the patient's tolerance to hypoxemia.

Conclusion and/or Teaching Points: BPA achieves hemodynamic improvements comparable to PEA, with a favorable safety profile and long-term benefits. Its effectiveness is enhanced by careful lesion selection and smaller balloons during staged sessions. Ongoing research aims to further define BPA's role in CTEPH management, while standardization of techniques will broaden its applicability as a key treatment for inoperable CTEPH patients.