Balloon angioplasty could be effective CTEPH treatment option
Gains in blood flow dynamics, exercise capacity noted in comparison study
Pulmonary endarterectomy (PEA) and balloon pulmonary angioplasty (BPA) — two treatment approaches for chronic thromboembolic pulmonary hypertension (CTEPH) — significantly improved blood flow dynamics and functional capacity in patients given either procedure, a study from Norway reported.
PEA was more effective at reducing pressure and resistance in the lungs’ blood vessels, but the two approaches were similar in terms of exercise capacity.
“While long term data after BPA is lacking, BPA treated CTEPH patients can expect physical gains in line with PEA,” the study’s researchers wrote, noting that for patients in whom PEA fails or isn’t an option, BPA is a reasonable alternative.
The study, “Pulmonary endarterectomy and balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension: comparison of changes in hemodynamics and functional capacity,” was published in the journal Pulmonary Circulation.
Pulmonary endarterectomy is mainstay treatment, but not always possible
People with CTEPH have clots that obstruct the lung’s blood vessels (pulmonary arteries), leading to high blood pressure and restricted blood flow that make the heart work harder to pump blood.
PEA, a surgical procedure to remove problematic blood clots from these vessels, is a mainstay CTEPH treatment.
But while PEA can be curative, it isn’t an option for all patients. More than one-third of those being considered for PEA are ineligible for the surgery, and PH can continue or recur in up to 50% of patient after the surgery, the researchers noted.
For inoperable patients or those with persistent disease after PEA, BPA is emerging as an alternative treatment. It involves inflating one or more small balloons in blocked vessels, helping them to widen by pressing the clots against the artery walls, usually over the course of several sessions.
According to current guidelines, “BPA is not a replacement for PEA, but rather an evolving treatment alternative for patients who are not eligible for PEA,” the researchers wrote.
To compare the two techniques, researchers conducted an observational study of CTEPH patients treated with either approach, or both approaches, between 2011 and 2021 at their Oslo clinic. Patient characteristics were comparable among groups.
A total of 42 people underwent a PEA and 31 were treated with BPA as a first-line treatment. Nine others given PEA subsequently underwent BPA due to residual or recurrent disease. For those given BPA, the mean number of sessions was 5.1, with five to eight weeks separating each session.
Reasons for PEA ineligibility included the distribution of clots throughout the body, significant coexisting conditions or comorbidities, and a previous PEA. Two patients also refused to undergo the surgery.
The success of either treatment approach was evaluated in two ways. First, a procedure called right heart catheterization was used to look at cardiovascular and blood flow changes, or hemodynamics, both before the procedure and again at about five months after PEA or three months after BPA.
Exercise tests also were given to evaluate oxygen consumption and respiration while patients were using a stationary bicycle.
Significant gains seen in pulmonary artery pressure, vascular resistance
Both procedures led to significant reductions in pulmonary artery pressure and pulmonary vascular resistance, a measure of how resistant the pulmonary arteries are to blood flow. Consistently, cardiac output — how much blood the heart can pump out — significantly increased with both procedures.
Still, these reductions in pressure and resistance were significantly more pronounced among patients receiving PEA compared with BPA.
Exercise testing showed gains in functional capacity with both procedures, with no significant differences between them.
Improvements also were seen under the New York Heart Association classification of heart failure stages, with patients generally moving to a stage reflecting less severe heart disease and better exercise capacity.
After the procedure, 59% of PEA-treated patients and 43% of those given BPA as a first treatment remained intolerant to exercise, meaning their oxygen consumption during exercise was below 80% of that expected.
Among the nine people who received both procedures, improvements were similar to those seen in the BPA-only group, although not all reached statistical significance.
“Larger cohorts are needed to further clarify the level of improvement attainable in patients with residual or recurrent PH after PEA,” the researchers wrote, noting this group was too small for more definitive findings.
Complications after BPA included vessel rupture (5.4% of procedures), coughing up blood (7%, excluding rupture cases), lung injury (3.1% of procedures), and access site complications (1.2%). Most symptoms resolved shortly after the procedure.
Hospital stays were significantly longer for PEA patients, a median of 19 days, than those given BPA (a median of 10 days).
Two people in the PEA group and one person in the BPA group died within a month of surgery, and one patient in each group died more than 30 days after surgery.
Overall, “BPA is an effective therapeutic option with acceptable safety in patients with CTEPH,” the researchers wrote.
“While long-term follow-up results are needed, our results suggest that BPA is a good treatment alternative in selected patients with CTEPH,” they added.