Angioscopic findings during balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension

Excerpt

A 71-year-old woman diagnosed with chronic thromboembolic pulmonary hypertension (CTEPH) complained of exertional dyspnea. Her mean pulmonary artery pressure (PAP) was 37 mmHg. Pulmonary endarterectomy was suggested impossible because of distal-type CTEPH. After administration of anticoagulant therapy and riociguat 4.5 mg, her mean PAP improved to 29 mmHg. However, her symptom did not improve satisfactorily. Six sessions of balloon pulmonary angioplasty (BPA) were performed for all pulmonary artery (PA) segments. To obtain the angioscopic images, a 6-Fr guiding catheter was advanced to the distal segment of PA under the guidance of a 0.014-in. guidewire supported with an 8-Fr guiding catheter. After an angioscopic fiber (Forwardlooking^®, OVALIS, Osaka, Japan) was advanced to the lesion, low molecular weight dextran was infused from 6-Fr guiding catheter to remove the blood. Optical coherence tomography and angioscopy revealed “mesh” thrombus (Fig. 1b, c) in angiographic “web” lesion of the left PA A9 (Fig. 1a). After dilation with 3.0-mm semi-compliant balloon, thrombus formation was disrupted with enlargement of the lumen (Fig. 1e, f). In angiographic lesion of left PA A3, angioscopy revealed red fresh thrombus (Fig. 1i). After dilation with 3.0-mm semi-compliant balloon, the thrombus moved to the distal of PA (Fig. 1h). Finally, her mean PAP was 18 mmHg with BPA, and her symptom was improved well.

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