Balloon pulmonary angioplasty (BPA) is increasingly used to treat patients with chronic thromboembolic pulmonary hypertension (CTEPH). Although pulmonary thromboendarterectomy remains the treatment of choice for patients with CTEPH, BPA is an effective treatment option for nonoperative patients and those with residual pulmonary hypertension (PH) after pulmonary thromboendarterectomy.1
Early experience with BPA was associated with significant procedure-related morbidity and mortality,2 thus limiting its role as a therapeutic option; however, subsequent refinement of the technique led to a substantial reduction in the procedural complication rate, paving the way to wider adoption.3,4 A recently published report from the International BPA registry showed a relatively low complication rate among experienced centers across the world.5 Nevertheless, there remains a clear learning curve to BPA,6,7 with more complications occurring during the early phase of operator experience and in lower volume centers.8
In this issue of JSCAI, Katz et al9 published an excellent review discussing an approach to the management of complications during BPA. This comprehensive piece examines both the ways in which an operator can anticipate potential complications as well as technical approaches to their management.
Importantly, anticipation of BPA complications starts long before the day of the actual procedure. Patients with CTEPH are often medically complex and may have competing comorbidities that can affect patient outcomes, especially in the case of a complication. For example, patients with significant concomitant parenchymal lung disease may experience worsening hypoxia if angioplasty is performed in an area of the lung with poor ventilation. Alternatively, patients with nonthrombotic causes of PH would not benefit from BPA and instead face unnecessary procedural risk. Appropriate patient selection, therefore, is a critical first step to minimizing procedural complications.
Procedural risk reduction also depends on identifying clear and individualized therapeutic goals. Although some patients need BPA to lower pulmonary vascular resistance and re-establish appropriate right ventricular-to-pulmonary artery coupling, others have relatively normal right ventricular function and are undergoing BPA to reduce symptoms and improve quality of life. In the latter group, the therapeutic goals may be reached by treating the lowest risk lesions (ie, webs/stenoses) first and potentially avoiding recanalization attempts of the highest-risk lesions (ie, chronic total occlusions) altogether.
For reasons outlined above, BPA should not be viewed as a standalone procedure in any given institution. Instead, it is an important component of a comprehensive multidisciplinary PH team, which includes medical PH specialists, cardiothoracic surgeons, and interventionalists. A full and comprehensive team evaluation of any patient with suspected CTEPH is essential to ensuring appropriate patient selection, optimized procedural strategy, and medical stabilization in the event of a complication.
Declaration of competing interest
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Acknowledgments
Funding sources
This work was not supported by funding agencies in the public, commercial, or not-for-profit sectors.
References
- 1.Aggarwal V., Giri J., Visovatti S.H., et al. Status and future directions for balloon pulmonary angioplasty in chronic thromboembolic pulmonary disease with and without pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2024;149(15):e1090–e1107. doi: 10.1161/CIR.0000000000001261. [DOI] [PubMed] [Google Scholar]
- 2.Feinstein J.A., Goldhaber S.Z., Lock J.E., Ferndandes S.M., Landzberg M.J. Balloon pulmonary angioplasty for treatment of chronic thromboembolic pulmonary hypertension. Circulation. 2001;103(1):10–13. doi: 10.1161/01.cir.103.1.10. [DOI] [PubMed] [Google Scholar]
- 3.Mizoguchi H., Ogawa A., Munemasa M., Mikouchi H., Ito H., Matsubara H. Refined balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension. Circ Cardiovasc Interv. 2012;5(6):748–755. doi: 10.1161/CIRCINTERVENTIONS.112.971077. [DOI] [PubMed] [Google Scholar]
- 4.Bashir R., Noory A., Oliveros E., et al. Refined balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension: initial results of U.S. Regional Program. JACC Adv. 2023;2(3) doi: 10.1016/j.jacadv.2023.100291. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Lang I.M., Brenot P., Bouvaist H., et al. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: results of an international multicenter prospective registry. J Am Coll Cardiol. 2025;85(23):2270–2284. doi: 10.1016/j.jacc.2025.04.021. [DOI] [PubMed] [Google Scholar]
- 6.Kurzyna M., Darocha S., Pietura R., et al. Changing the strategy of balloon pulmonary angioplasty resulted in a reduced complication rate in patients with chronic thromboembolic pulmonary hypertension. A single-centre European experience. Kardiol Pol. 2017;75(7):645–654. doi: 10.5603/KP.a2017.0091. [DOI] [PubMed] [Google Scholar]
- 7.Jain N., Sheikh M.A., Bajaj D., et al. Periprocedural complications with balloon pulmonary angioplasty: analysis of global studies. JACC Cardiovasc Interv. 2023;16(8):976–983. doi: 10.1016/j.jcin.2023.01.361. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Ogo T., Shinke T., Inami T., et al. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: a nationwide prospective multicenter registry in Japan (J-BPA) Circ Cardiovasc Interv. 2025 doi: 10.1161/CIRCINTERVENTIONS.125.016172. [DOI] [PubMed] [Google Scholar]
- 9.Katz J.B., Chen K., Cuttica M.J., et al. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: identifying and managing complications for the operator. J Soc Cardiovasc Angiogr Interv. 2026;5(1) doi: 10.1016/j.jscai.2025.104049. [DOI] [PMC free article] [PubMed] [Google Scholar]