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Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension

Irene Lang, Bernhard C. Meyer, Takeshi Ogo, Hiromi Matsubara, Marcin Kurzyna, Hossein-Ardeschir Ghofrani, Eckhard Mayer, Philippe Brenot
European Respiratory Review 2017 26: 160119; DOI: 10.1183/16000617.0119-2016
Irene Lang
1Dept of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
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  • For correspondence: irene.lang@meduniwien.ac.at
Bernhard C. Meyer
2Dept of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
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Takeshi Ogo
3Division of Pulmonary Circulation, Dept of Advanced Medicine for Pulmonary Hypertension, National Cerebral and Cardiovascular Center, Suita, Japan
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Hiromi Matsubara
4Dept of Clinical Science, National Hospital Organization, Okayama Medical Centre, Okayama, Japan
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Marcin Kurzyna
5Dept of Pulmonary Circulation and Thromboembolic Diseases, Medical Centre of Postgraduate Education, European Health Centre Otwock, Otwock, Poland
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Hossein-Ardeschir Ghofrani
6Universities of Giessen and Marburg Lung Center, Giessen, Germany, Member of the German Center for Lung Research (DZL)
7Dept of Medicine, Imperial College London, London, UK
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Eckhard Mayer
8Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
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Philippe Brenot
9Hôpital Marie Lannelongue, Le Plessis-Robinson, France
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  • FIGURE 1
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    FIGURE 1

    a) Pulmonary angiography, showing a stenosis in the subsegment of the 10th segmental artery (anterior view); b) the catheter is introduced into a web stenosis; c) the wire is introduced between the fibrotic material and the balloon is inflated, leading to rupture of the web. d) Angiography after balloon pulmonary angioplasty shows an improvement of blood flow with better perfusion of the parenchyma and quick venous return. In contrast to pulmonary endarterectomy, the fibrous material is not removed from the arteries, but is crushed against the vessel wall.

  • FIGURE 2
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    FIGURE 2

    Pulmonary arterial imaging before and after percutaneous balloon pulmonary angioplasty (BPA). a) Pre-procedure pulmonary angiogram demonstrating an intra-arterial fibrous “web” lesion; b) the corresponding intravascular ultrasound image showing the intravascular filling defect; c) the BPA balloon in place; d) pulmonary angiogram after the BPA procedure, showing the patent arterial lumen.

  • FIGURE 3
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    FIGURE 3

    a–d) Selective angiograms and e–h) digital-subtraction angiograms of the right and left pulmonary arteries in a 76-year-old female with chronic thromboembolic pulmonary hypertension manifestation at the level of segmental and subsegmental branching. e–h) Image acquisition in the digital-subtraction angiography technique in frontal or lateral (90° left anterior oblique) projection using intra-arterial contrast injection (iomeprol 300 mg iodine·mL−1, flow rate 12 mL·s−1, volume per injection 35 mL, frame rate 7.5·s-1).

  • FIGURE 4
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    FIGURE 4

    a) Conventional pulmonary angiogram, with b) and c) corresponding optical coherence tomography images from a patient with chronic thromboembolic pulmonary hypertension, showing the nature of vascular obstructions at two locations. #: location for b); ¶: location for c). Scale bars=1 mm.

Tables

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  • Supplementary Materials
  • TABLE 1

    Published results with balloon pulmonary angioplasty (BPA) in the management of patients with chronic thromboembolic pulmonary hypertension (CTEPH)

    First author, year [ref.]Patients (location)ProceduresCTEPH medical therapy pre-BPAMean age yearsReduction in mPAP mmHgFC improvement6MWD improvementComplicationsAcute mortality (<30 days after BPA)Long-term outcomes
    Feinstein, 2001 [15]18 (USA)47 catheterisations
    107 dilations
    Mean 2.6 procedures per patient
    NR52±1243.0±12.1 to 33.7±10.2 (p=0.007)NYHA FC 3.3 to 1.8 (p<0.001)209 to 497 yards (p<0.0001)11/18 RPO
    3/18 MV
    1 (5.6%)
    RPO + RHF, day 7
    16/18 (89%)
    alive at 34.2 months
    Mizoguchi, 2012 [43]68 (Japan)255 sessions;
    2–8 sessions
    per patient;
    1–14 vessels dilated
    per session
    68/68 epoprostenol
    1–5 ng·kg−1·min−1
    for ∼5 days
    pre-BPA
    62.2±11.945.4±9.6 to
    24±6.4 (p<0.01)
    WHO FC
    3.0 to 2.0 (p<0.01)
    296 to 368 m (p<0.01)76/255 sessions RPO
    4/68 patients MV
    1 RHF, day 2866/68 (97%) alive at 2.2±1.4 years
    Kataoka, 2012 [16]29 (Japan)51 procedures (mean 1.8 per patient)
    Mean 3 vessels dilated per session
    Mean 6.5 vessels per patient
    14/29 bosentan
    2/29 ambrisentan
    24/29 PDE-5i
    15/29 beraprost
    62.3±11.545.3±9.8 to 31.8±10 (p<0.01)At 6 months
    NYHA FC (p<0.01)#
    NR27/51 procedures RPO
    1/29 patients MV
    1 wire perforation of PANR
    Sugimura, 2012 [17]12 with distal webs
    39 controls (Japan)
    Mean 5 procedures
    14 lesions
    1–3 months pre-BPA:
    7/12 epoprostenol
    5/12 beraprost
    11/12 sildenafil
    5/12 bosentan
    58Mean±sem 47.8±11.6 to 24.8±4.9 (p<0.01)WHO FC
    II/III/IV 33/42/25% at baseline; 100% FC II at follow-up
    Mean±sem 350±105 m to 441±76 m (p<0.05)6/12 haemoptysis0All alive at mean 12 months
    Andreassen, 2013 [18]20 (Norway)73 catheterisations
    Mean 3.7 procedures and 18.6 BPAs per patient
    2/20 sildenafil, stopped before BPA60±1045±11 to 33±10 (p<0.001)NYHA FC 3.0±0.5 to 2.0±0.5 (p<0.001)NR7/20 RPO1 RVF, day 1
    1 acute PE, day 9
    17/20 (85%) patients alive at median 51 months
    Fukui, 2014 [19]20 (Japan)Mean 3.2±0.9 procedures per patient5/20 ERA
    13/20 PCA
    4/20 PDE-5i
    6/20
    combination therapy
    67±9.039.4±7.6 to 27.3±8.5 (p<0.001)WHO FC 2.8 to 2.0 (p<0.001)361±104 m to 463±76 m (p<0.001)No major events0NR (1-year retrospective study)
    Shimura, 2015 [20]110, including 9 post-PEA (Japan)423
    44 BPA sessions in 9 post-PEA patients
    NR55.1 (post-PEA patients)43 to 26 (p<0.05)NYHA FC
    I/II/III/IV 0/3/5/1 to 7/2/0/0 (p<0.05)
    NR1 RPO09/9 alive at median 1.97 years after BPA
    Inami, 2014 [21]103 (Japan)350 procedures; 145 with PEPSI + PWGBosentan, ambrisentan, sildenafil, tadalafil or beraprost65In patients with PEPSI + PWG, from 38 to ≈24¶NRIn patients with PEPSI + PWG, from ≈360 to ≈420 m¶0 with PEPSI + PWG0 with PEPSI + PWG0 at median 6.4 months with BPA + PEPSI + PWG
    Inami, 2014 [22]68 (Japan)213 sessionsFor BPA and PEA patients combined (n=107)
    prostanoids 60%
    PDE-5i 66%
    ERAs 55%
    6242.9 to 25.0NYHA FC improved (p<0.05)349±130 m to 424±111 m (p<0.0001)RPO 7.0%
    Haemosputum 2.3%
    Haemoptysis 3.3%
    Dissection 2.3%
    Perforation 0.9%
    1.47%Mortality 1.5% at 14.3±10.4 months
    Yanagisawa, 2014 [23]<65 years: 39
    ≥65 years: 31 (Japan)
    <65 years: mean 4 sessions
    ≥65 years: mean 3 sessions (p=0.054)
    Bosentan, ambrisentan, sildenafil, tadalafil or beraprost<65 years: 54
    ≥65 years: 70
    <65 years: 42 to 26.0
    ≥65 years: 41 to 23.5 (p=0.11)
    Improved in both groups (p<0.05)
    More in age ≥65 years (p<0.0001)
    <65 years: 380 to 441 m
    ≥65 years: 310 to 409 m (p=0.553)
    1 wire perforationAt 1 year
    <65 years: 0%
    ≥65 years: 3.2%
    Kurzyna, 2015 [9]20 (Poland)37 procedures
    105 vessels
    82% of patients, mainly sildenafilNR58±6 to 41±9WHO FC III/IV 95% at baseline;
    35% at follow-up
    Improved exercise tolerance2 RPO10% (RPO)NR
    Velázquez Martín, 2015 [24]7 (Spain)22 (mean 3 procedures per patient; each procedure mean 2.4 segments, 1.2 lobes)ERA + sildenafil + epoprostenol in most patients6156±17 to 36±10 (p<0.06)NYHA FC 3.8±0.2 to 2.3±0.2 (p<0.001)NR2 RPO1 CVA day 7NR
    Roik, 2016 [25]9 (Poland)27 sessions in 9 patients
    Mean 3 per patient
    6/11 sildenafil76Median (IQR) 40 (32−54) to 34.5 (29−42)
    (p=0.01)
    NYHA FC
    I/II/III/IV 0/0/6/3 to 0/7/2/0 (p=0.018)
    Median (IQR) 304 (135−450) to 304 (205−530)
    (p=0.03)
    2 RPO
    1 haemoptysis
    0NR
    Aoki, 2016 [26]25 (Japan)113 procedures
    Mean 4.7 per patient
    ERA 4%
    PDE-5i 71%
    Oral prostanoid 21%
    Epoprostenol 8%
    Riociguat 12%
    Median (IQR)
    70 (60–74)
    Median (IQR)
    37 (28–45) to 23 (19–27) (p<0.01)
    WHO FC
    I/II/III/IV 0/50/46/4% at baseline; 24/76/0/0% at follow-up (p=0.04)
    Median (IQR) 390
    (286–484) m to 490 (411–617) m (p<0.01)
    No severe complications0NR
    Kawakami, 2016 [27]97 (Japan)500 procedures
    Mean 5.2 per patient
    (1936 lesions)
    ERA 47.4%
    PDE-5i 36.1%
    Oral prostanoid 50.5%
    i.v. prostanoid 9.3%
    61.7±12.345.1±10.8 to 23.3±6.4 (p<0.01)WHO FC
    I/II/III/IV 0/0/70/27% at baseline; 13/76/4/0% at follow-up
    276.3±123.2 m to 359.3±91.9 m (p<0.01)Haemoptysis (19.6%)
    Pulmonary injury (26.0%)
    4%NR
    Kimura, 2016 [28]66 (Japan)Mean 6.8 sessions per patient; mean 13.1 vessels per patientERA 41%
    PDE-5i 55%
    Prostanoid 29%
    Riociguat 11%
    63.2±13.239.2±10.5 to 20.9±5.4 (p<0.001)NRNRHaemosputum (6.1%)
    RPO requiring NPPV (1.1%)
    0NR
    Koike, 2016 [29]8 (Japan)16 procedures
    Mean 2 per patient
    NR70.8±8.630.4±11.0 to 25.6±8.2 (p=0.04)NR332.3±59.6 m to 352.1±
    64.1 m (p<0.0001)
    NR0NR
    Ogo, 2016 [30]80 (Japan)385 sessions
    Mean 4.8 per patient (1155 lesions)
    ERA 23%
    PDE-5i 25%
    Oral prostanoid 42%
    i.v. prostanoid 6%
    Riociguat 6%
    Median (IQR)
    68 (58–76)
    42±11 to 25±6 (p<0.01)WHO FC
    3.0±0.4 to 1.8±0.4 (p<0.01)
    372±124 m to 470±99 m (p<0.01)Wire perforation (7.5%)
    RPO (4.7%)
    Haemoptysis (4.7%)
    0NR
    Tsugu, 2016 [31]26 (Japan)Mean 6 sessions per patientERA 46%
    PDE-5i 72%
    Prostanoid 40%
    63±1638.3±8.4 to 18.0±4.2 (p<0.01)WHO FC
    2.9±0.6 to 1.2±0.4 (p<0.01)
    326.8±83.7 m to 400.3±77.4 m (p<0.01)NRNRNR
    Yamasaki, 2016 [32]29 (Japan)Mean 2.7 sessions per patientERA 45%
    PDE-5i 50%
    Oral prostanoid 40%
    Riociguat 40%
    61.9±10.642.6±11.0 to 30.0±6.6 (p<0.0001)NR391±75 m to 437±68 m (p<0.0001)NR0NR
    • Data are presented as n or mean±sd, unless otherwise stated. mPAP: mean pulmonary arterial pressure; FC: functional class; 6MWD: 6-min walking distance; NR: not reported; NYHA: New York Heart Association; RPO: reperfusion pulmonary oedema; MV: mechanical ventilation; RHF: right heart failure; PDE-5i: phosphodiesterase type-5 inhibitor; PA: pulmonary artery; WHO: World Health Organization; PE: pulmonary embolism; ERA: endothelin receptor antagonist; PCA: prostacyclin analogue; PEA: pulmonary endarterectomy; PEPSI: Pulmonary Edema Predictive Scoring Index; PWG: pressure-wire guidance; CVA: cerebrovascular accident; IQR: interquartile range; NPPV: non-invasive positive pressure ventilation. #: values not reported; ¶: estimated from graphs.

Supplementary Materials

  • Figures
  • Tables
  • Supplementary Material

    H-A. Ghofrani ERR-0119-2016_Ghofrani

    I. Lang ERR-0119-2016_Lang

    H. Matsubara ERR-0119-2016_Matsubara

    E. Mayer ERR-0119-2016_Mayer

    B.C. Meyer ERR-0119-2016_Meyer

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Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension
Irene Lang, Bernhard C. Meyer, Takeshi Ogo, Hiromi Matsubara, Marcin Kurzyna, Hossein-Ardeschir Ghofrani, Eckhard Mayer, Philippe Brenot
European Respiratory Review Mar 2017, 26 (143) 160119; DOI: 10.1183/16000617.0119-2016

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Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension
Irene Lang, Bernhard C. Meyer, Takeshi Ogo, Hiromi Matsubara, Marcin Kurzyna, Hossein-Ardeschir Ghofrani, Eckhard Mayer, Philippe Brenot
European Respiratory Review Mar 2017, 26 (143) 160119; DOI: 10.1183/16000617.0119-2016
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  • Article
    • Abstract
    • Abstract
    • Introduction
    • History, evolution and evidence for BPA
    • Current BPA practice
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