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Background: Balloon pulmonary angioplasty (BPA) has become an alternative treatment for inoperable patients with chronic thromboembolic pulmonary hypertension. Lung injury (LI) is a major complication of BPA and may attenuate the benefits of BPA. Therefore, we conducted a retrospective study to evaluate the association between patient and procedural characteristics and LI in patients with chronic thromboembolic pulmonary hypertension. Methods and Results: We reviewed 76 patients with chronic thromboembolic pulmonary hypertension who underwent BPA and multidetector computed tomography scanning pre- and post-BPA procedures. We performed BPA on 1247 vessels during 297 BPA procedures and reviewed 594 multidetector computed tomography scans. By comparing pre- and post-BPA multidetector computed tomography images, we diagnosed LI as follows: newly appeared ground-glass opacity, consolidation, and pleural effusion. LI was detected using multidetector computed tomography scans during 138 procedures (47%), and mechanical ventilation was required during 40 procedures (13%). Angiographic findings of extravasation with or without simultaneous clinical symptoms (BPA-related vascular injury) occurred during 50 procedures (17%). In mixed-effect logistic regression models, the BPA-related vascular injury was an independent predictor of LI after BPA, odds ratio, 20.1 (6.43–63.1). High mean pulmonary artery pressure before BPA procedure and BPA-related vascular injury were independent predictors of mechanical ventilation after BPA, odds ratio, 1.13 (1.03–1.24) and 10.8 (3.77–30.9), respectively. Conclusions: Vascular injury during BPA could be a triggering factor of LI after BPA, and its severity could be exacerbated by a high pulmonary artery pressure.

A 41-year-old man was referred to our hospital for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH). On admission, he was in World Health Organization functional class III. Right heart catheterization demonstrated that pulmonary arterial pressure (systolic/diastolic/mean) was 140/42/71 mm Hg, cardiac index was 1.6 L/min/m2 and pulmonary vascular resistance was 1663 dyn ·s·cm–5. The patient had severe pulmonary hypertension and was considered inoperable because of peripheral organized thrombi and coexisting seminoma; therefore, balloon pulmonary angioplasty (BPA) was performed. After BPA, pulmonary angiography showed improvement of pulmonary arterial flow (Figure 1A). Pulmonary arterial pressure was 108/42/67 mm Hg and cardiac index was 2.5 L/min/m2 when he returned to the cardiac care unit after BPA. His condition temporarily improved; however, 2 hours later, it deteriorated because of reperfusion pulmonary injury and gastrointestinal bleeding. He required mechanical ventilation and percutaneous cardiopulmonary support. To improve hemodynamics, another session of BPA was tried 9 days later (Figures 2A and 3A) and pulmonary arterial pressure seemed to improve to 83/48/58 mm Hg. However, he died from right heart failure on day 26 after BPA despite intensive care. Figure 1. Representative images of pulmonary angiography and histology of pulmonary arteries of the upper lobe of the right lung. A , Angiographic images before (a) and after (b) BPA. A web lesion of the right pulmonary artery (arrow) was treated by BPA. Angiography after BPA showed a dilated vessel and increased flow in the distal arteries. Arrows indicate the areas where specimen for B was obtained. B , Histology of a pulmonary artery treated by BPA (arrow in A ). This lesion was treated by BPA at the initial session and second session (26 and 17 days before death). (a) Hematoxylin–eosin stain, low magnification. A large …

Background— Although balloon pulmonary angioplasty (BPA) for inoperable patients with chronic thromboembolic pulmonary hypertension was first reported over a decade ago, its clinical application has been restricted because of limited efficacy and complications. We have refined the procedure of BPA to maximize its clinical efficacy. Methods and Results— Sixty-eight consecutive patients with inoperable chronic thromboembolic pulmonary hypertension underwent BPA. We evaluated pulmonary artery diameters and determined the appropriate balloon size by using intravascular ultrasound. We performed BPA in a staged fashion over multiple, separate procedures to maximize efficacy and reduce the risk of reperfusion pulmonary injury. A total of 4 (2–8) sessions were performed in each patient, and the number of vessels dilated per session was 3 (1–14). The World Health Organization functional class improved from 3 to 2 ( P P Conclusions— Our refined BPA procedure improves clinical status and hemodynamics of inoperable patients with chronic thromboembolic pulmonary hypertension, with a low mortality. A refined BPA procedure could be considered as a therapeutic approach for patients with inoperable chronic thromboembolic pulmonary hypertension.

Background— Balloon pulmonary angioplasty (BPA) is an alternative therapy for patients with chronic thromboembolic pulmonary hypertension who are ineligible for standard therapy, pulmonary endarterectomy. Although there are several classifications of vascular lesions, these classifications are based on the features of the specimen removed during pulmonary endarterectomy. Because organized thrombi are not removed during balloon pulmonary angioplasty, we attempted to establish a new classification of vascular lesions based on pulmonary angiographic images. We evaluated the success and complication rate of BPA in accordance with the location and morphology of thromboembolic lesions. Methods and Results— We reviewed 500 consecutive procedures (1936 lesions) of BPA in 97 patients with chronic thromboembolic pulmonary hypertension and investigated the outcomes of BPA based on the lesion distribution and the angiographic characteristics of the thromboembolic lesions, as follows: type A, ring-like stenosis lesion; type B, web lesion; type C, subtotal lesion; type D, total occlusion lesion, and type E, tortuous lesion. The success rate was higher, and the complication rate was lower in ring-like stenosis and web lesions. The total occlusion lesions had the lowest success rate. Tortuous lesions were associated with a high complication rate and should be treated only by operators with extensive experience with BPA. Conclusions— We modified the previous angiographic classification and established a new classification for each vascular lesion. We clarified that the outcome and complication rate of the BPA are highly dependent on the lesion characteristics.