Balloon pulmonary angioplasty

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Balloon pulmonary angioplasty
Pulmonary artery catheter english.JPG
Other namesBPA
Specialty Cardiovascular medicine

Balloon pulmonary angioplasty (BPA) is an emerging minimally invasive procedure to treat chronic thromboembolic pulmonary hypertension (CTEPH) in people who are not suitable for pulmonary thromboendarterectomy (PTE) or still have residual pulmonary hypertension and areas of narrowing in the pulmonary arterial tree following previous PTE. [1] [2]

Contents

The procedure uses balloons to open pulmonary arteries that have been narrowed or blocked by webs, bands and fibrous tissue [2] and therefore restores blood flow to the lungs, reduces shortness of breath, and improves exercise tolerance. More data on its safety and effectiveness are still required. [3] [4]

Medical uses

BPA may be considered in people with symptomatic CTEPH who are not suitable for surgery. [3] [5] PTE is an established treatment for CTEPH but is only performed at a few specialist centres, requires surgical competence and intermittent total circulatory arrest under deep hypothermia. [6] [7] However, co-existing illnesses and inaccessible clots may contraindicate performing the operation. [6] [7] Up to 40% of those diagnosed with CTEPH are considered ineligible for surgery. [6] [7] Selection criteria may vary between centres. [1]

Technique

Computed tomograph of pulmonary vessels. Pulmonary emboli can be classified according to level along the arterial tree. Computed tomograph of pulmonary vessels.jpg
Computed tomograph of pulmonary vessels. Pulmonary emboli can be classified according to level along the arterial tree.

BPA is performed by specialists in a catheterization laboratory. Each procedure takes between two and four hours and most people undergo up to six treatments with the first two sessions being performed a fortnight apart and subsequent treatments being individually tailored upon follow-up assessment. [8]

A local anesthetic and moderate sedation are used but a general anaesthetic is not required, hence the person remains awake throughout the procedure. After inserting the catheter into the vein of the neck (right internal jugular vein) or groin (right femoral vein), a hollow tube is introduced through the catheter and passed to the affected blocked lung arteries. [8] [7]

X-rays and pressures in the narrowed arteries are assessed by the specialist team before a thin wire with a deflated balloon is guided through the blood vessels to the site of blockage, where the balloon is then inflated. [8] This mainly disrupts the organised thrombus and to a lesser degree presses it against the walls of the arteries. [9] This increases the size of the lumen of the arteries, thus opening them and allowing the blood flow to be restored. [9] The balloon is then deflated and removed. [8] A number of arteries can be treated during each BPA procedure. [8]

Recovery and follow-up

One overnight stay in hospital is usually required. This is followed by a check up appointment within three months. [8] The overall survival has been shown to be comparable with PTE and better than with medication only. [9]

Complications

The pulmonary arteries have thinner walls than the blood vessels of the heart and therefore injury by rupture or dissection caused by over-dilatation of the balloon or piercing pulmonary arteries by the tip of the guide wire, resulting in haemorrhage, are risks. [9] Injury to the lung including reperfusion oedema is also a possibility and these injuries are less likely with more experienced specialists. [9]

History

BPA was originally developed and established for treating children with congenital pulmonary stenosis. Subsequently, it was first tried for the treatment of CTEPH in 1988. Initial results of performing BPA in inoperable CTEPH were reported in 2001, but had a high mortality. [10] Since 2012, reports of the effect of BPA has mainly come from the National Hospital Organization Okayama Medical Center in Japan [9] where the procedure was refined and where smaller balloons were used. In addition, the number of balloon inflations per session were carefully limited to one or two lung vessel segments with targeting only one lung lobe during each session. Intravascular imaging was also introduced. [3]

Research

More data on its safety and effectiveness are still required. [11] Long-term results on disease recurrence, the requirement for stenting and long-term survival also need to be evaluated. [6] In addition, studies to clarify BPA's comparability with the drug riociguat are needed. [5]

See also

Related Research Articles

Cardiology Branch of medicine dealing with the heart

Cardiology is a branch of medicine that deals with the disorders of the heart as well as some parts of the circulatory system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease and electrophysiology. Physicians who specialize in this field of medicine are called cardiologists, a specialty of internal medicine. Pediatric cardiologists are pediatricians who specialize in cardiology. Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons, a specialty of general surgery.

Angioplasty

Angioplasty, is also known as balloon angioplasty and percutaneous transluminal angioplasty (PTA), is a minimally invasive endovascular procedure used to widen narrowed or obstructed arteries or veins, typically to treat arterial atherosclerosis. A deflated balloon attached to a catheter is passed over a guide-wire into the narrowed vessel and then inflated to a fixed size. The balloon forces expansion of the blood vessel and the surrounding muscular wall, allowing an improved blood flow. A stent may be inserted at the time of ballooning to ensure the vessel remains open, and the balloon is then deflated and withdrawn. Angioplasty has come to include all manner of vascular interventions that are typically performed percutaneously.

Interventional radiology

Interventional radiology (IR) is a medical subspecialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs both diagnostic and therapeutic procedures through very small incisions or body orifices. Diagnostic IR procedures are those intended to help make a diagnosis or guide further medical treatment, and include image-guided biopsy of a tumor or injection of an imaging contrast agent into a hollow structure, such as a blood vessel or a duct. By contrast, therapeutic IR procedures provide direct treatment—they include catheter-based medicine delivery, medical device placement, and angioplasty of narrowed structures.

Pulmonary artery Artery in the pulmonary circulation that carries deoxygenated blood from the heart to the lungs

A pulmonary artery is an artery in the pulmonary circulation that carries deoxygenated blood from the right side of the heart to the lungs. The largest pulmonary artery is the main pulmonary artery or pulmonary trunk from the heart, and the smallest ones are the arterioles, which lead to the capillaries that surround the pulmonary alveoli.

dextro-Transposition of the great arteries Medical condition

dextro-Transposition of the great arteries, is a potentially life-threatening birth defect in the large arteries of the heart. The primary arteries are transposed.

Pulmonary hypertension Medical condition

Pulmonary hypertension is a condition of increased blood pressure in the arteries of the lungs. Symptoms include shortness of breath, fainting, tiredness, chest pain, swelling of the legs, and a fast heartbeat. The condition may make it difficult to exercise. Onset is typically gradual.

Interventional cardiology

Interventional cardiology is a branch of cardiology that deals specifically with the catheter based treatment of structural heart diseases. Andreas Gruentzig is considered the father of interventional cardiology after the development of angioplasty by interventional radiologist Charles Dotter.

Cardiac catheterization

Cardiac catheterization is the insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes.

Renal artery stenosis Medical condition

Renal artery stenosis (RAS) is the narrowing of one or both of the renal arteries, most often caused by atherosclerosis or fibromuscular dysplasia. This narrowing of the renal artery can impede blood flow to the target kidney, resulting in renovascular hypertension – a secondary type of high blood pressure. Possible complications of renal artery stenosis are chronic kidney disease and coronary artery disease.

Percutaneous coronary intervention Medical techniques used to manage coronary occlusion

Percutaneous coronary intervention (PCI) is a non-surgical procedure used to treat narrowing of the coronary arteries of the heart found in coronary artery disease. The process involves combining coronary angioplasty with stenting, which is the insertion of a permanent wire-meshed tube that is either drug eluting (DES) or composed of bare metal (BMS). The stent delivery balloon from the angioplasty catheter is inflated with media to force contact between the struts of the stent and the vessel wall, thus widening the blood vessel diameter. After accessing the blood stream through the femoral or radial artery, the procedure uses coronary catheterization to visualise the blood vessels on X-ray imaging. After this, an interventional cardiologist can perform a coronary angioplasty, using a balloon catheter in which a deflated balloon is advanced into the obstructed artery and inflated to relieve the narrowing; certain devices such as stents can be deployed to keep the blood vessel open. Various other procedures can also be performed.

Pulmonary thromboendarterectomy

In thoracic surgery, a pulmonary thromboendarterectomy (PTE), also referred to as pulmonary endarterectomy (PEA) is an operation that removes organized clotted blood (thrombus) from the pulmonary arteries, which supply blood to the lungs.

Computed tomography angiography

Computed tomography angiography is a computed tomography technique used for angiography — the visualization of arteries and veins — throughout the human body. Using contrast injected into the blood vessels, images are created to look for blockages, aneurysms, dissections, and stenosis. CTA can be used to visualize the vessels of the heart, the aorta and other large blood vessels, the lungs, the kidneys, the head and neck, and the arms and legs.

CT pulmonary angiogram

A CT pulmonary angiogram (CTPA) is a medical diagnostic test that employs computed tomography (CT) angiography to obtain an image of the pulmonary arteries. Its main use is to diagnose pulmonary embolism (PE). It is a preferred choice of imaging in the diagnosis of PE due to its minimally invasive nature for the patient, whose only requirement for the scan is an intravenous line.

Atrial septostomy Surgical procedure on the heart

Atrial septostomy is a surgical procedure in which a small hole is created between the upper two chambers of the heart, the atria. This procedure is primarily used to palliate dextro-Transposition of the great arteries or d-TGA, a life-threatening cyanotic congenital heart defect seen in infants. It is performed prior to an arterial switch operation. Atrial septostomy has also seen limited use as a surgical treatment for pulmonary hypertension. The first atrial septostomy was developed by Vivien Thomas in a canine model and performed in humans by Alfred Blalock. The Rashkind balloon procedure, a common atrial septostomy technique, was developed in 1966 by American cardiologist William Rashkind at the Children's Hospital of Philadelphia.

The following outline is provided as an overview of and topical guide to cardiology, the branch of medicine dealing with disorders of the human heart. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease and electrophysiology. Physicians who specialize in cardiology are called cardiologists.

Congenital stenosis of vena cava Medical condition

Congenital stenosis of vena cava is a congenital anomaly in which the superior vena cava or inferior vena cava has an aberrant interruption or coarctation.

Embolectomy is the emergency surgical removal of emboli which are blocking blood circulation. It usually involves removal of thrombi, and is then referred to as thrombectomy. Embolectomy is an emergency procedure often as the last resort because permanent occlusion of a significant blood flow to an organ leads to necrosis. Other involved therapeutic options are anticoagulation and thrombolysis.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a long-term disease caused by a blockage in the blood vessels that deliver blood from the heart to the lungs. These blockages cause increased resistance to flow in the pulmonary arterial tree which in turn leads to rise in pressure in these arteries. The blockages either result from organised blood clots that usually originate from the deep veins of the lower limbs of the body (thromboembolism) and lodge in the pulmonary arterial tree after passing through the right side of the heart. The blockages may also result from scar tissue that forms at the site where the clot has damaged the endothelial lining of the pulmonary arteries, causing permanent fibrous obstruction. Most patients have a combination of microvascular and macrovascular obstruction. Some patients may present with normal or near-normal pulmonary pressures at rest despite symptomatic disease. These patients are labelled as having chronic thromboembolic disease (CTED).

Stuart W. Jamieson

Stuart William Jamieson is a British cardiothoracic surgeon, specialising in pulmonary thromboendarterectomy (PTE), a surgical procedure performed to remove organized clotted blood (thrombus) from pulmonary arteries in people with chronic thromboembolic pulmonary hypertension (CTEPH).

National Hospital Organization Okayama Medical Center

The National Hospital Organization Okayama Medical Center is a medical centre in Okayama, Japan. It is where innovations have taken place in Pulmonary Arterial Hypertension.

References

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  2. 1 2 Brenot, Philippe; Mayer, Eckhard; Ghofrani, Hossein-Ardeschir; Kurzyna, Marcin; Matsubara, Hiromi; Ogo, Takeshi; Meyer, Bernhard C.; Lang, Irene (31 March 2017). "Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension". European Respiratory Review . 26 (143): 160119. doi: 10.1183/16000617.0119-2016 . ISSN   1600-0617. PMID   28356406.
  3. 1 2 3 Sirenko, Yuriy; Coghlan, Gerry; Kaymaz, Cihangir; Mahdhaoui, Abdallah; Dijk, Van; J, Arie P.; Srbinovska-Kostovska, Elizabeta; Schwerzmann, Markus; Wikström, Gerhard (2016-01-01). "2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertensionThe Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT)". European Heart Journal. 37 (1): 67–119. doi: 10.1093/eurheartj/ehv317 . ISSN   0195-668X. PMID   26320113.
  4. Saggar, R.; Kao, S. D.; Khan, S. N.; Moriarty, J. M. (23 July 2018). "Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension". CardioVascular and Interventional Radiology. 41 (12): 1826–1839. doi:10.1007/s00270-018-2012-2. ISSN   1432-086X. PMC   4372623 . PMID   30039506.(subscription required)
  5. 1 2 "Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension". www.nice.org.uk. 27 April 2016. Retrieved 26 December 2018.
  6. 1 2 3 4 Ogawa, Aiko; Matsubara, Hiromi (17 February 2015). "Balloon Pulmonary Angioplasty: A Treatment Option for Inoperable Patients with Chronic Thromboembolic Pulmonary Hypertension". Frontiers in Cardiovascular Medicine. 2: 4. doi: 10.3389/fcvm.2015.00004 . ISSN   2297-055X. PMC   4671397 . PMID   26664876.
  7. 1 2 3 4 Specialised Commissioning Team (April 2018). "Clinical Commissioning Policy: Balloon pulmonary angioplasty for chronic Document Name thromboembolic pulmonary hypertension (all ages)" (PDF). NHS England. Retrieved 26 December 2018.
  8. 1 2 3 4 5 6 "Balloon Pulmonary Angioplasty | UC San Diego Health". UC Health - UC San Diego. Retrieved 24 December 2018.
  9. 1 2 3 4 5 6 Matsubara, Hiromi; Ogawa, Aiko (2017). "15. Balloon pulmonary hypertension". In Fukumoto, Yoshihiro (ed.). Diagnosis and Treatment of Pulmonary Hypertension: From Bench to Bedside. Springer. p. 193. ISBN   9789812878397.
  10. Matsubara, Hiromi.; Ogawa, Aiko (2016). "49. Balloon Pulmonary Angioplasty". In Peacock, Andrew J.; Naeije, Robert; Rubin, Lewis J. (eds.). Pulmonary Circulation: Diseases and Their Treatment, Fourth Edition. CRC Press. p. 530. ISBN   978-1-4987-1991-9.
  11. Wiedenroth, Christoph B.; Olsson, Karen M.; Guth, Stefan; Breithecker, Andreas; Haas, Moritz; Kamp, Jan-Christopher; Fuge, Jan; Hinrichs, Jan B.; Roller, Fritz (28 December 2017). "Balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic disease". Pulmonary Circulation. 8 (1): 2045893217753122. doi:10.1177/2045893217753122. ISSN   2045-8932. PMC   5798689 . PMID   29283044.