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Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension.

Kurzyna M, Darocha S, Koteja A, Pietura R, Torbicki A - Postepy Kardiol Interwencyjnej (2015)

View Article: PubMed Central - PubMed

Affiliation: Department of Pulmonary Circulation and Thromboembolic Diseases, Medical Centre of Postgraduate Education, European Health Centre Otwock, Otwock, Poland.

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Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but potentially life-threatening disease of the pulmonary circulation... The most accepted scenario is that of aborted recanalisation of pulmonary arteries after a thromboembolic episode... Usually, individual cardiac surgeons are responsible for PEA in their centres, as the learning curve for this intervention has been well documented... With growing experience of clinicians, radiologists, surgeons, and anaesthesiologists, an increasing proportion of patients with CTEPH may benefit from PEA despite distal, less accessible intravascular residua and/or advanced age and comorbidities... Until now, the experience of our team includes 37 BPA procedures, which consisted of angioplasty of 105 vessels in 20 patients with CTEPH... All patients who underwent BPA because of distal lesion localisation survived... In technical terms, BPA does not significantly differ from balloon angioplasty performed in other vessels (Figure 2)... It is not recommended that BPA procedures be performed by cardiologists or interventional radiologists who have experience in other vascular regions but no experience in interventions within the pulmonary circulation... During one procedure, no more than two segmental arteries or their subsegmental equivalents should be dilated due to the risk of reperfusion oedema... Reperfusion oedema results from redistribution of blood flow to areas supplied by dilated vessels, in which vascular resistance has abruptly decreased... However, selection of patients for the procedure will not be a binary choice between a risky but potentially curative surgery and moderately or poorly effective pharmacotherapy alone... Balloon angioplasty, currently recommended in patients who do not qualify for PEA, will become an increasingly common treatment option in the future... The order of the procedures performed would remain an open question... From our preliminary experience, it may be concluded that BPA in vessels with the removed media is more difficult to perform and is associated with a higher risk of complications... In conclusion, BPA procedures and modern pharmacotherapy with drugs used in PAH so far will play an increasingly significant role in the treatment of patients with CTEPH.

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Balloon pulmonary angioplasty in a 67-year-old patient with persistent form of CTEPH. Left panel (A) presents the angiogram of occluded segmental pulmonary artery of left lower lobe. The BPA results in reperfusion of the vessel – right panel (B)
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Figure 0002: Balloon pulmonary angioplasty in a 67-year-old patient with persistent form of CTEPH. Left panel (A) presents the angiogram of occluded segmental pulmonary artery of left lower lobe. The BPA results in reperfusion of the vessel – right panel (B)

Mentions: In technical terms, BPA does not significantly differ from balloon angioplasty performed in other vessels (Figure 2). Nevertheless, the complicated anatomy of the pulmonary tree, the necessity to advance the instruments through enlarged right heart chambers, and the fact that pulmonary vessels can be easily damaged with the guide wire or balloon catheter requires specific experience. It is not recommended that BPA procedures be performed by cardiologists or interventional radiologists who have experience in other vascular regions but no experience in interventions within the pulmonary circulation. During one procedure, no more than two segmental arteries or their subsegmental equivalents should be dilated due to the risk of reperfusion oedema. Reperfusion oedema results from redistribution of blood flow to areas supplied by dilated vessels, in which vascular resistance has abruptly decreased. This may cause blood cells to migrate into the alveoli, excluding them from gas exchange. One way to prevent reperfusion oedema is to undersize the balloon catheter being used, on the basis of angiography, or by means of intravascular ultrasound (IVUS) or optical coherence tomography (OCT). Also, pressure distal to a residual lesion and a gradient across the lesion can be measured by means of an fractional flow reserve (FFR) probe [22]. As there is no tendency towards restenosis, it is unnecessary to use stents. The results achieved in the group of patients who have completed a series of BPA procedures are very encouraging. A reduction in mean PAP from baseline 58 ±6 mm Hg to 41 ±9 mm Hg and in PVR from 11.7 ±4.3 Wood units to 6.6 ±2.2 Wood units was achieved in our series. The haemodynamic improvement corresponds with an improvement in exercise tolerance. Prior to BPA procedures, 95% of patients were in NYHA class III and IV, and the rate of patients in class III and IV decreased to 35% after treatment. A significant issue limiting growth in the number of such procedures performed in Poland is that BPA is not reimbursed by the National Health Fund.


Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension.

Kurzyna M, Darocha S, Koteja A, Pietura R, Torbicki A - Postepy Kardiol Interwencyjnej (2015)

Balloon pulmonary angioplasty in a 67-year-old patient with persistent form of CTEPH. Left panel (A) presents the angiogram of occluded segmental pulmonary artery of left lower lobe. The BPA results in reperfusion of the vessel – right panel (B)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4372623&req=5

Figure 0002: Balloon pulmonary angioplasty in a 67-year-old patient with persistent form of CTEPH. Left panel (A) presents the angiogram of occluded segmental pulmonary artery of left lower lobe. The BPA results in reperfusion of the vessel – right panel (B)
Mentions: In technical terms, BPA does not significantly differ from balloon angioplasty performed in other vessels (Figure 2). Nevertheless, the complicated anatomy of the pulmonary tree, the necessity to advance the instruments through enlarged right heart chambers, and the fact that pulmonary vessels can be easily damaged with the guide wire or balloon catheter requires specific experience. It is not recommended that BPA procedures be performed by cardiologists or interventional radiologists who have experience in other vascular regions but no experience in interventions within the pulmonary circulation. During one procedure, no more than two segmental arteries or their subsegmental equivalents should be dilated due to the risk of reperfusion oedema. Reperfusion oedema results from redistribution of blood flow to areas supplied by dilated vessels, in which vascular resistance has abruptly decreased. This may cause blood cells to migrate into the alveoli, excluding them from gas exchange. One way to prevent reperfusion oedema is to undersize the balloon catheter being used, on the basis of angiography, or by means of intravascular ultrasound (IVUS) or optical coherence tomography (OCT). Also, pressure distal to a residual lesion and a gradient across the lesion can be measured by means of an fractional flow reserve (FFR) probe [22]. As there is no tendency towards restenosis, it is unnecessary to use stents. The results achieved in the group of patients who have completed a series of BPA procedures are very encouraging. A reduction in mean PAP from baseline 58 ±6 mm Hg to 41 ±9 mm Hg and in PVR from 11.7 ±4.3 Wood units to 6.6 ±2.2 Wood units was achieved in our series. The haemodynamic improvement corresponds with an improvement in exercise tolerance. Prior to BPA procedures, 95% of patients were in NYHA class III and IV, and the rate of patients in class III and IV decreased to 35% after treatment. A significant issue limiting growth in the number of such procedures performed in Poland is that BPA is not reimbursed by the National Health Fund.

View Article: PubMed Central - PubMed

Affiliation: Department of Pulmonary Circulation and Thromboembolic Diseases, Medical Centre of Postgraduate Education, European Health Centre Otwock, Otwock, Poland.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but potentially life-threatening disease of the pulmonary circulation... The most accepted scenario is that of aborted recanalisation of pulmonary arteries after a thromboembolic episode... Usually, individual cardiac surgeons are responsible for PEA in their centres, as the learning curve for this intervention has been well documented... With growing experience of clinicians, radiologists, surgeons, and anaesthesiologists, an increasing proportion of patients with CTEPH may benefit from PEA despite distal, less accessible intravascular residua and/or advanced age and comorbidities... Until now, the experience of our team includes 37 BPA procedures, which consisted of angioplasty of 105 vessels in 20 patients with CTEPH... All patients who underwent BPA because of distal lesion localisation survived... In technical terms, BPA does not significantly differ from balloon angioplasty performed in other vessels (Figure 2)... It is not recommended that BPA procedures be performed by cardiologists or interventional radiologists who have experience in other vascular regions but no experience in interventions within the pulmonary circulation... During one procedure, no more than two segmental arteries or their subsegmental equivalents should be dilated due to the risk of reperfusion oedema... Reperfusion oedema results from redistribution of blood flow to areas supplied by dilated vessels, in which vascular resistance has abruptly decreased... However, selection of patients for the procedure will not be a binary choice between a risky but potentially curative surgery and moderately or poorly effective pharmacotherapy alone... Balloon angioplasty, currently recommended in patients who do not qualify for PEA, will become an increasingly common treatment option in the future... The order of the procedures performed would remain an open question... From our preliminary experience, it may be concluded that BPA in vessels with the removed media is more difficult to perform and is associated with a higher risk of complications... In conclusion, BPA procedures and modern pharmacotherapy with drugs used in PAH so far will play an increasingly significant role in the treatment of patients with CTEPH.

No MeSH data available.