Indications for Balloon Pulmonary Angioplasty in CTEPH
Balloon pulmonary angioplasty (BPA) should be considered for CTEPH patients who are technically inoperable or carry an unfavorable risk-benefit ratio for pulmonary endarterectomy (PEA), as determined by a multidisciplinary CTEPH team that includes at least one experienced PEA surgeon. 1
Primary Indication Framework
The decision to proceed with BPA follows a hierarchical treatment algorithm where PEA remains the first-line, potentially curative treatment for all CTEPH patients 2, 3. BPA serves as an alternative intervention when surgery is not feasible 1.
Specific Patient Populations for BPA:
Technically inoperable patients - Those with distal segmental or subsegmental disease beyond surgical reach, where thrombi are not surgically accessible in the main, lobar, or proximal segmental pulmonary arteries 1, 2
High surgical risk patients - Those with an unfavorable risk-benefit ratio for PEA despite technically operable disease, which may include severe comorbidities or extremely elevated pulmonary vascular resistance (>1200 dyn·s·cm⁻⁵) 1, 3
Persistent/recurrent pulmonary hypertension post-PEA - Patients with residual symptomatic pulmonary hypertension after surgical endarterectomy 1, 4
Critical Decision-Making Process
All operability assessments must be performed by a multidisciplinary CTEPH team at an experienced center 1, 2. This is a Class I, Level C recommendation from the European Society of Cardiology/European Respiratory Society 1. The team must include at least one experienced PEA surgeon to ensure accurate determination of surgical candidacy 1.
Key Evaluation Points:
The distinction between "technically operable" versus "technically non-operable" disease is based on the anatomic location and accessibility of thromboembolic material 1, 2
There is no absolute upper limit of pulmonary vascular resistance or right ventricular dysfunction that excludes BPA consideration in experienced centers 2, 5
Advanced age alone does not contraindicate BPA 2
Evidence Strength and Guideline Support
The 2015 ESC/ERS guidelines assign BPA a Class IIb, Level C recommendation for patients deemed technically non-operable or with unfavorable surgical risk-benefit ratio 1. While this represents a lower level of evidence compared to PEA (Class I, Level C), more recent data shows BPA has gained stronger support, with the 2022 European guidelines upgrading BPA to a Class 1 recommendation for inoperable and residual CTEPH 4.
Supporting Outcomes Data:
BPA demonstrates significant improvements in WHO functional class, with most patients achieving Class I/II status post-procedure 6
Hemodynamic improvements include mean pulmonary artery pressure reduction of 18% and pulmonary vascular resistance reduction of 32% 6
Six-minute walk distance improves by approximately 54 meters 6
Quality of life shows substantial improvement with 37% increase in overall health status assessment 6
Twelve-month survival reaches 94.6% in contemporary series 6
Safety Considerations and Contraindications
BPA should only be performed in experienced, high-volume CTEPH centers with appropriate expertise 1, 2. The procedure requires specialized training, with operators needing at least 50 supervised procedures before independent practice 7.
Complication Rates in Modern Practice:
Reperfusion pulmonary edema has been reduced to approximately 2% in experienced centers using refined techniques (smaller balloons, limited segments per session) 1
Overall non-fatal complication rate is approximately 11.9%, predominantly hemoptysis (10% of sessions) 6
Fatal complications occur in approximately 1.6% of patients 6
Absolute Requirements Before BPA:
Lifelong anticoagulation must be established in all CTEPH patients, regardless of treatment modality 1, 2
Comprehensive right heart catheterization confirming precapillary pulmonary hypertension (mean PAP ≥25 mmHg, PCWP ≤15 mmHg, PVR >2 Wood units) 3
Ventilation/perfusion scanning and pulmonary angiography to characterize disease distribution 3, 8
Common Pitfalls to Avoid
Never proceed with BPA without formal evaluation by a multidisciplinary team including an experienced PEA surgeon - patients initially deemed "inoperable" at non-expert centers may actually be surgical candidates 1, 2
Do not use BPA as first-line therapy - PEA remains superior with potential for cure and should always be considered first 2, 3
Avoid performing BPA at inexperienced centers - complication rates are significantly higher without proper expertise and equipment 1, 7
Do not overlook the need for continued medical therapy - BPA patients may still require riociguat or other pulmonary hypertension medications for optimal outcomes 1