Lung Injury After Balloon Pulmonary Angioplasty for CTEPH: Histopathologic Findings and Management Implications

Balloon pulmonary angioplasty (BPA) has emerged as a guideline-recommended therapy for surgically inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Lung injury occurs in approximately 6% of BPA sessions and is the leading cause of procedure-related mortality. While lung injury post-BPA has recently been associated with vascular injury and hemorrhage, pathologic evidence is lacking regarding whether injury is uniformly hemorrhagic or whether a permeability-mediated pattern, such as seen in reperfusion edema, predominates in some cases. We present a case of severe BPA-associated lung injury resulting in mortality, report the first histopathologic characterization of the parenchymal injury pattern in this setting, and describe how these findings informed successful rescue veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in a second case.