top of page

Balloon Pulmonary Angioplasty (BPA)

Image by Robina Weermeijer

Balloon Pulmonary Angioplasty (BPA) is an interventional radiology procedure employed in the management of chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is a severe and potentially life-threatening condition characterized by the presence of organized thromboembolic material within the pulmonary arteries, leading to increased pulmonary vascular resistance and subsequent pulmonary hypertension.

​

The BPA procedure is a minimally invasive technique that aims to alleviate the pulmonary hypertension associated with CTEPH by improving blood flow through the affected pulmonary arteries. It involves a series of meticulous steps and specialized equipment under the guidance of fluoroscopy and angiography.


Prior to the procedure, the patient undergoes thorough evaluation, including imaging studies such as computed tomography pulmonary angiography (CTPA) and in some cases, right heart catheterization to assess the severity of CTEPH.

​

Balloon angioplasty and inflation exerts radial pressure on the thromboembolic material, compressing it against the arterial wall. This process disrupts and fractures the organized clots, thereby widening the lumen of the pulmonary artery.

​

Depending on the extent of CTEPH and the response to the initial BPA, multiple sessions of angioplasty may be required to treat various segments of the pulmonary arteries. Hemodynamic measurements are repeated to assess the improvement in pulmonary artery pressures and right heart function.


Potential complications of BPA include vessel injury, bleeding, arrhythmias, and reperfusion pulmonary edema. Close monitoring and prompt intervention are essential to manage any adverse events.

​​

A&I Protocol

Femoral approach:

 

  • Seldinger technique is used to gain access into the right femoral vein.

  • A 5F catheter and 0.014" guidewire are advanced up the inferior vena cava (IVC) and up towards right side of the heart (right atrium and right ventricle) and into the pulmonary arteries.

  • For this example, starting with the left pulmonary artery.

  • Introduce a long 6F (55 cm) sheath, 6F guide catheter (e.g. JR4, 100 cm) and use a 5F angled pigtail catheter and to perform digital subtraction angiography (DSA) in each pulmonary artery segment where suspected pulmonary emboli are present.

  • A long 7F or 8F sheath (e.g. 77 cm length) can also be used for anchoring support if needed.

  • The DSA run will show any sign of narrowing or occlusion along the pulmonary artery branch, especially with the use of high DSA frame rates (15 - 30 fps).

  • The 5 F angled pigtail catheter is removed.

  • One 0.014" guidewire is used for anchoring and support, and a second 0.014" guidewire is used for accessing each individual pulmonary artery branch with a thromboembolism.

  • A DSA run is performed to check the diameter of the pulmonary artery and demonstrate the narrowing or occlusion, and then the radiographer can perform diameter measurements on the pulmonary artery.

  • Pulmonary artery pressure measurements are recorded pre-BPA for each segment.

  • Starting with a smaller diameter (than measured), an 0.014" monorail angioplasty balloon is dilated to open up the narrowed or occluded pulmonary artery segment.

  • Multiple inflations and deflations of the balloon may be necessary to achieve optimal results.

  • A diameter matching the measured pulmonary artery can be dilated next at the discretion of the interventional radiologist.

  • Pulmonary artery pressure measurements are recorded post-BPA of each segment.

  • A DSA run at a high frame rate is used to check the outcome post-BPA.

  • The 0.014" guidewire is then used to access the next stenotic pulmonary artery.

  • If a different segment of the pulmonary artery branch is needed to be accessed, for example, the left upper lobe or changing to the right upper, middle, or lower lobe, then the guide catheter and sheaths are repositioned to allow access with the guidewire and any angioplasty balloon required for possible treatment. Pulmonary artery pressure measurements are also recorded.

  • Once the pulmonary arteries with thromboembolisms have been investigated and treated, the devices are removed, and manual pressure is applied on the right groin for hemostasis.

  • After the procedure, patients are closely monitored in a specialized care unit. Long-term follow-up is crucial to assess the durability of the treatment and the need for further interventions.

Pulmonary angiogram showing pre- and post-balloon angioplasty

References

  1. Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension - PubMed [Internet]. [cited 2023 Sep 20]. Available from: https://pubmed.ncbi.nlm.nih.gov/28356406/

  2. Patel N, Giri J, Rosenfield K, Aggarwal V. Best Practices in the Technical Performance of Balloon Pulmonary Angioplasty. Am J Cardiol. 2023 Feb 1;188:87–8.

  3. Steinberg ZL, Lombardi WL, Lee J, Mulligan MS, Leary PJ. Balloon Pulmonary Angioplasty in Chronic Totally Occluded Pulmonary Arteries: Applying Lessons Learned From the Treatment of Coronary Artery Chronic Total Occlusions. J Invasive Cardiol. 2021 Aug;33(8):E632–9.

  4. Formigari R, Santoro G, Guccione P, Giamberti A, Pasquini L, Grigioni M, et al. Treatment of pulmonary artery stenosis after arterial switch operation: stent implantation vs. balloon angioplasty. Catheter Cardiovasc Interv. 2000 Jun;50(2):207–11.

  5. Kim CW, Aronow WS, Dutta T, Spevack DM, Frishman WH. Treatment of Peripheral Pulmonary Artery Stenosis. Cardiol Rev. 2021 Jun 1;29(3):115–9.



     

bottom of page