Top Things to Know: Top Things to Know

Published: March 07, 2024

  1. Chronic thromboembolic pulmonary disease with pulmonary hypertension is the most feared long-term complication of acute pulmonary embolism. The incidence of chronic thromboembolic pulmonary disease with pulmonary hypertension is approximately 2-3% of all acute pulmonary embolism patients.
  2. Pulmonary endarterectomy is the treatment of choice for technically operable patients who are good surgical candidates. Balloon pulmonary angioplasty is a treatment option (class I recommendation) for patients who are not suitable candidates for pulmonary endarterectomy or patients with residual obstruction after pulmonary endarterectomy. Medical therapy with riociguat is advised prior to performing balloon pulmonary angioplasty for surgically inoperable chronic thromboembolic pulmonary disease with pulmonary hypertension.
  3. Balloon pulmonary angioplasty can be considered for the following set of patients: a) patients who cannot tolerate or afford riociguat pre-treatment; b) patients who decline pulmonary endarterectomy due to personal choice; c) patients with residual chronic thromboembolic pulmonary disease with pulmonary hypertension after pulmonary endarterectomy; d) patients with chronic thromboembolic disease without pulmonary hypertension at rest; e) patients with mild symptoms and mild chronic thromboembolic pulmonary disease with pulmonary hypertension. Shared decision making and risk-benefit assessment is important when assessing the candidacy of the above group of patients for balloon pulmonary angioplasty.
  4. Balloon pulmonary angioplasty programs should be established within experienced chronic thromboembolic pulmonary disease with pulmonary hypertension centers which also offer pulmonary endarterectomy.
    • Patient selection should involve a multidisciplinary team with experts in the diagnosis and medical management of pulmonary vascular disease, radiologic expertise in cross-sectional cardiothoracic imaging and nuclear medicine, pulmonary endarterectomy surgical expertise, interventional expertise in nonselective invasive pulmonary angiography and balloon pulmonary angioplasty and nursing expertise in pulmonary vasodilator therapies.
  5. The anatomic disease level (lesion classification) is the first factor to consider when deciding between pulmonary endarterectomy and balloon pulmonary angioplasty treatment modalities. Anatomic disease levels 1-3 are surgically accessible and best treated with pulmonary endarterectomy, while isolated level 4 disease is best treated with balloon pulmonary angioplasty.
    • Other factors to consider when deciding between pulmonary endarterectomy and balloon pulmonary angioplasty:
      • obstructive disease burden
      • correlation with patient symptoms and cardio-pulmonary hemodynamic abnormalities
      • the absence of other patient-related contraindications to surgery.
  6. Ventilation-perfusion scans, computed tomography pulmonary angiography and nonselective invasive pulmonary angiography have complementary roles in anatomic disease level and operability assessment.
    • Suggested best practices for non-selective invasive pulmonary angiography with digital subtraction angiography include.
      • obtaining two orthogonal projection angiograms for each lung during deep inspiration breath holds
      • utilizing a systemic perfusion zone methodology for non-selective invasive pulmonary angiography interpretation.
  7. Balloon pulmonary angioplasty procedure related complications include a) hemoptysis (with/without vascular injury), b) vascular injury c) lung injury. Vascular complications are higher with subtotal and total occlusion lesions (higher risk lesions) compared with ring and web-like lesions (standard risk lesions). Balloon pulmonary angioplasty should be avoided in the diffusely tortuous vessels distal to subsegmental branches.
  8. Balloon pulmonary angioplasty is usually completed over several (4-8) procedural sessions to achieve the goal of dilation/complete revascularization of all treatable lesions. Only one lung should be treated in each procedural session, and the limits for each procedure session is guided by contrast volume, total radiation time or total procedural time. Post-procedure follow-up assessments include:
    • right heart catheterization and/or ventilation-perfusion imaging or non-selective invasive pulmonary angiogram at 3-6 months post procedure.
  9. Future areas of research for balloon pulmonary angioplasty include the development of balloon pulmonary angioplasty-specific endovascular interventional equipment, standardized post-procedure protocols and endpoints for balloon pulmonary angioplasty procedures, consensus anatomic definitions for subsegmental branch anatomy and a singular imaging modality for the diagnosis of acute and chronic thromboembolic disease.
  10. Balloon pulmonary angioplasty has become safer and more efficacious for the treatment of chronic thromboembolic pulmonary disease with pulmonary hypertension due to refinement of procedural technique, patient, and lesion selection. Procedural availability remains one of the significant limitations for this interventional procedure.


Aggarwal V, Giri J, Visovatti SH, Mahmud E, Matsubara H, Madani M, Rogers F, Gopalan D, Rosenfield K, McLaughlin VV; on behalf of the American Heart Association Council on Clinical Cardiology; Council on Peripheral Vascular Disease; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; and Council on Cardiovascular and Stroke Nursing. Status and future directions for balloon pulmonary angioplasty in chronicthromboembolic pulmonary disease with and without pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. Published online March 7, 2024. doi: 10.1161/CIR.0000000000001197