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Angiographic classification of total occlusion and its implication on balloon pulmonary angioplasty
1Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Insights
Balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH) total occlusions is challenging. Classifying total occlusions by morphology guides tailored strategies, improving BPA success and reducing complications.
Area of Science:
- Cardiology
- Interventional Cardiology
- Pulmonary Hypertension
Background:
- Balloon pulmonary angioplasty (BPA) is a treatment for chronic thromboembolic pulmonary hypertension (CTEPH).
- Total occlusions present a significant challenge in BPA for CTEPH, often associated with low success and high complication rates.
- Limited literature exists on the performance of BPA specifically for total occlusions.
Purpose of the Study:
- To classify total occlusions in CTEPH based on morphology.
- To develop a tailored treatment strategy for each distinct type of total occlusion.
- To evaluate the impact of occlusion morphology on BPA success and complication rates.
Main Methods:
- Retrospective analysis of 204 CTEPH patients who underwent BPA between May 2018 and May 2022.
- Categorization of 38 total occluded lesions into three morphological groups: pointed-head, round-head, and orifice occlusions.
- Correlation of lesion morphology with procedural success and complication rates.
Main Results:
- Three distinct morphologies of total occlusion were identified: pointed-head, round-head, and orifice.
- Success rates varied significantly by morphology: pointed-head (95.45%), round-head (46.15%), and orifice (33.33%).
- Orifice occlusions exhibited the highest complication rate (50%) and were significantly associated with lower BPA success compared to pointed-head occlusions.
Conclusions:
- Occlusion morphology is a critical determinant of BPA success and complication rates in CTEPH.
- A morphology-guided, tailored treatment strategy can optimize clinical outcomes for patients with total occlusions.
- This classification and strategy provide a valuable guide for interventional cardiologists managing CTEPH.
Aims:
Despite refinements in balloon pulmonary angioplasty (BPA), total occlusion remains a challenge in chronic thromboembolic pulmonary hypertension (CTEPH). Owing to their low success and high complication rates, most interventional cardiologists are reluctant to address total occlusion, and there is a paucity of literature on BPA performance in total occlusion. We aimed to classify total occlusion according to morphology and present an illustrative approach for devising a tailored treatment strategy for each distinct type of total occlusion.
Methods And Results:
All patients diagnosed with CTEPH who underwent BPA between May 2018 and May 2022 at Fuwai Hospital in Beijing, China, were included retrospectively. A total of 204 patients with CTEPH who underwent BPA were included in this study. Among these, 38 occluded lesions were addressed in 33 patients. Based on the morphology, we categorized the lesions into three groups: pointed-head, round-head, and orifice occlusions. Pointed-head occlusion could be successfully addressed using soft-tip wire, round-head occlusion warranted hard-tip wire and stronger backup, and orifice occlusion warranted the strongest backup force. The success rates for each group were as follows: pointed-head (95.45%), round-head (46.15%), and orifice occlusion (33.33%), with orifice occlusion having the highest complication rate (50%). The classification of occlusion was associated with BPA success (round-head occlusion vs. pointed-head occlusion, OR 24.500, 95% CI 2.498-240.318, P = 0.006; orifice occlusion vs. pointed-head occlusion, OR 42.000, 95% CI 3.034-581.434, P = 0.005).
Conclusions:
Occlusion morphology has a significant impact on BPA success and complication rates. A treatment strategy tailored to each specific occlusive lesion, as outlined in the present study, has the potential to serve as a valuable guide for clinical practitioners.
