Table 1.

UC San Diego approach to balloon pulmonary angioplasty

Overall treatment plan

•4-6 separate BPA sessions

•Baseline pulmonary angiogram

•Baseline and intermittent perfusion scanning

•Baseline and intermittent 6-min walk test, BNP, functional assessment

•Treatment concluded with one BPA procedure in each lung

Individual BPA procedure steps

1. Identify target lung region with largest defect on most recent perfusion scan

2. Ultrasound-guided right (or left) femoral vein access, 9-French sheath placement

3. Right heart catheterization and hemodynamic measurement within target lung

4. 6-French 90-cm sheath advanced over wire into target lung pulmonary artery

5. Anticoagulation using IV unfractionated heparin (goal ACT 200-250 ​s)

6. 6-French 110-cm Judkins Right, Multipurpose, Hockeystick or Extended Back-Up guide catheter advanced over stiff, angled Glidewire into target lung region

7. Segmental pulmonary angiography is performed with deep breath holds and injection of 1:1 diluted contrast at 7.5-15 frames/s without digital subtraction

8. Atraumatic, workhorse 0.014-inch guidewire, supported by 2.0-mm rapid exchange balloon catheter used to cross target lesions; avoid polymer jacketed guidewires

9. For complete occlusions, antegrade wire escalation with a microcatheter and increasing guidewire tip stiffness; avoid polymer jacketed guidewires

10. Pd/Pa measurements during free breathing or deep breath hold using microcatheter-based pressure measurements for easy and repeated use during BPA

11. Serial balloon inflation using 2.0-4.0 mm semi- and non-compliant balloons with serial dilations of undersized balloons to avoid vessel perforation/rupture and injury

12. Selective use of sculpting or scoring balloons for fibrotic recalcitrant lesions

13. Procedure conclusion when 3-5 diseased segments are treated during an initial session, 400 ml IV contrast is administered, and/or 2Gy exposure reached

14. Overnight admission to a monitored bed/IMU

BPA, balloon pulmonary angioplasty.

Reproduced with permission from Elsevier.¹