Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension: Identifying and Managing Complications for the Operator

Balloon pulmonary angioplasty (BPA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension who cannot receive pulmonary thromboendarterectomy or who have residual pulmonary hypertension after pulmonary thromboendarterectomy. As BPA volume and expertise have increased, significant strides in refining this technique have improved success and minimized complications; yet, minimal literature exists on appropriate complication management. This review summarizes how interventionalists can prevent, recognize, and manage BPA complications effectively. Operators must first focus on appropriate patient and vessel selection. Lower lung zones coupled with ring-like stenoses and web lesions are more favorable. Increased patient age, tortuous or subtotal lesions, and elevated pulmonary vascular resistance (>6 Wood units) portend a higher risk for complications. Vascular perforation can be treated with balloon tamponade, embolization (gelfoam and/or coils), and covered stents. Massive hemoptysis is managed with intubation and single lung ventilation if needed. As shock is predominantly hemorrhagic and/or cardiogenic, first-line therapies include vasopressors, inodilators, pulmonary vasodilators, and volume resuscitation, whereas mechanical support devices are second-line. Although reperfusion lung injury (RLI) is uncommon, it is generally well tolerated and managed with positive pressure ventilation, high-flow oxygen therapy, and diuresis. Acute kidney injury can be reduced by dilution of contrast dye, use of extension catheters, and procedural planning. Utilization of standard, angle-minimizing techniques, avoidance of high-dose cinefluoroscopy, and digital subtraction angiography minimizes radiation dose. In conclusion, most complications can be avoided or managed effectively without major morbidity or mortality by optimal preparation, patient selection, and commitment to a comprehensive BPA program.