The following are key points to remember from this viewpoint article about balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH):

• After CTEPH diagnosis is established, all patients should be evaluated by a comprehensive team of CTEPH experts including pulmonary endarterectomy–experienced surgeons.
• In recent years, therapeutic options for CTEPH patients have expanded with the development of catheter-based interventional therapy, namely BPA.
• European Society of Cardiology and European Respiratory Society guidelines recognize BPA as a therapeutic strategy (Class IIb recommendation) in CTEPH patients with technically inoperable disease or with unfavorable risk-to-benefit ratio for surgery.
• BPA treatment goals are relief of pulmonary hypertension and treatment is considered complete when patients are symptom-free off pulmonary hypertension–specific drugs or no longer have obstructive lesions on pulmonary angiography. BPA for symptom relief in patients without pulmonary hypertension is unproven.

Best practice recommendations:

• BPA should be performed using: 1) Lung perfusion scintigraphy-guidance: right lung > left lung; inferior lobe > superior or middle lobes. 2) Lesion morphology-guidance: “webs and bands” and “abrupt narrowing” > “chronic total occlusion” and “pouch defects.”
• BPA should be staged over multiple sessions limiting contrast and radiation dose exposure (<300 cc and <1 Gy) per session.
• Endpoints for each target lesion are: 1) Pulmonary flow grade 3. 2) Ratio of distal: proximal pressures across the target lesion (detected by pressure wire) >0.8. 3) Mean pulmonary arterial pressure distal to treated lesion does not exceed 35 mm Hg to avoid reperfusion pulmonary edema.

Keywords: Angiography, Angioplasty, Angioplasty, Balloon, Cardiac Surgical Procedures, Cardiology Interventions, Endarterectomy, Heart Failure, Hypertension, Pulmonary, Perfusion Imaging, Pulmonary Edema, Radiation Dosage, Vascular Diseases

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