Balloon pulmonary angioplasty can pose risks for CTEPH patients
Complications seen with older age, poorer response to first embolism surgery
Older age and high blood pressure in the pulmonary arteries raise the risk of complications with balloon pulmonary angioplasty (BPA), a second-line treatment for chronic thromboembolic pulmonary hypertension (CTEPH), a study suggested.
If high blood pressure persists after surgery to remove the pulmonary arterial blood clots that cause CTEPH, bleeding into the lungs can accompany BPA, findings showed. Surgery to remove pulmonary embolisms is the first treatment approach given patients.
The study, ”Predictors of procedural complications in balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension,” was published in the Journal of Cardiology.
Balloon pulmonary angioplasty given to 81 CTEPH patients in Japan
CTEPH is caused by the formation of blood clots within the pulmonary arteries, the blood vessels that supply the lungs. This obstructs blood flow and leads to localized increases in blood pressure, reducing the flow of oxygen to the rest of the body.
A surgery to remove these embolisms, called pulmonary endarterectomy (PEA), is the first-line CTEPH treatment.
BPA is recommended for patients unable to undergo this surgery or those with persistent high blood pressure after it. The procedure involves widening blocked pulmonary arteries by inflating small balloons, typically over several sessions.
Still, BPA is known to carry complications, such as bleeding caused by the wire that guides the balloons or by overinflated balloons.
Researchers at Tokyo Medical University Hospital, in Japan, investigated risk factors for such complications with BPA.
Clinical data were collected from 81 CTEPH patients who underwent BPA over 321 sessions, an average of four sessions per patient. Their mean age was 62.3, and most, 58 patients, were women. A majority of these people — 44 or 54.3 % — underwent BPA for inoperable CTEPH, with the other 37 (54.3 %) treated for persistent high blood pressure that followed PEA, meaning residual pulmonary hypertension (PH).
Procedural complications occurred in 79 BPA sessions (24.6 %). The majority involved pulmonary hemorrhage, or bleeding into the lungs, reported in 75 sessions. The bleeding site was blocked with a balloon catheter. Low blood oxygen or desaturation, and coughing were observed in four sessions.
Severe pulmonary hemorrhage was reported in 29 sessions, which was treated with embolization, a procedure to block a specific blood vessel to stop the bleeding. All of these patients improved, and none required mechanical breathing support or blood oxygenation.
Complications seen in patients age 75 or older, those with a high mean PAP
A likelihood of complications associated with BPA was two times higher in older patients, those age 75 or older, and three times greater in patients with elevated mean pulmonary artery pressure (mPAP), defined as 30 mmHg or higher.
Independent predictors of severe pulmonary hemorrhage requiring embolization included being 75 or older, raising the risk 5.4 times; a mean pulmonary artery pressure of 30 mmHg or more, with risk 6.9 times higher; and persistent high blood pressure after PEA, with its three times higher risk.
“Most patients undergoing BPA have an mPAP ≥ 30 mmHg,” so doctors considering a BPA “should always be cautious to prevent procedural complications and be prepared to implement appropriate measures in case of complication,” the researchers wrote.
While residual PH increased the risk of severe pulmonary hemorrhage with embolization, it was “not an independent predictor of overall complications,” they noted.
“Older patients and patients with high PAP are at an increased risk of procedural complications in BPA,” the scientists concluded. “Furthermore, BPA for residual PH after PEA increases the risk of severe pulmonary hemorrhage requiring embolization.”
They noted that BPA given for persistent PH after embolism surgery “is an effective treatment strategy,” but added it “should be performed in high-volume PEA and BPA centers because of the high risk of critical pulmonary hemorrhage.”
Among the study’s limitations were its relatively small number of patients all treated at a single center, so that “the broader clinical relevance of the findings should be interpreted cautiously,” they noted. Also, use of riociguat (approved as Adempas with generics available) increased during follow-up and may have affected the results.