Percutaneous transluminal pulmonary angioplasty for the treatment of chronic thromboembolic pulmonary hypertension: Challenges and future directions.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a common type of pulmonary hypertension, resulting from fibrotic transformation of pulmonary artery clots causing chronic obstruction of major pulmonary arteries and associated vascular remodeling in more distal vessels. The mainstay of CTEPH treatment is pulmonary endarterectomy (PEA), which has the potential to be curative but is possible in less than two thirds of cases. In inoperable patients and those with residual or recurrent CTEPH, medical therapy has been shown to be beneficial, albeit not curative. Balloon pulmonary angioplasty (BPA) is a percutaneous technique for the relief of chronic thromboembolic lesions, first reported over two decades ago. More recent case series have demonstrated that, as the technique is refined, results are improving. The potential indications for BPA are now expanding beyond inoperable CTEPH patients, with Shimura et al. demonstrating the aggressive nature of residual or recurrent CTEPH, treated successfully by BPA years after PEA. Major challenges lie ahead of BPA before it can take its place alongside PEA and medication in the treatment of CTEPH.