Balloon Pulmonary Angioplasty for Recurrent Lesions Six Years Following Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension

Pulmonary endarterectomy (PEA) is the standard treatment for chronic thromboembolic pulmonary hypertension (CTEPH). However, repeating surgery in recurrent cases is generally deemed high-risk. Balloon pulmonary angioplasty (BPA), an alternative treatment for organized thrombotic lesions of the peripheral pulmonary artery, has also shown a good prognosis in cases of inoperable CTEPH. Here, we report the case of a 65-year-old woman who presented with dyspnea. She had been admitted to our hospital in 2015 and diagnosed with University of San Diego (USD)-California classification CTEPH of level II. PEA had been performed, which resolved her respiratory discomfort, and her WHO functional class had improved from IV to I. Post-surgery pulmonary angiography had shown several residual lesions; nonetheless, pulmonary hypertension had not been noted, and the patient had not experienced dyspnea thereafter. We had decided to continue medical therapy; however, the patient stopped taking anticoagulation and pulmonary vasodilators due to the absence of symptoms. In 2021, dyspnea recurred, and she was hospitalized for examination. Chest radiography showed no cardiomegaly, and heart failure and tricuspid regurgitation were absent on echocardiography. The six-minute walk test distance was 565 m, and the lowest oxygen saturation during the test was 92%. Right heart catheterization demonstrated a mean pulmonary arterial pressure (PAP) of 15 mmHg without pulmonary hypertension; however, pulmonary angiography showed new organized thrombotic lesions in the left segments of the lower lobe. Based on the advancement of the lesions, we speculated that they were the cause of the symptoms even without concurrent pulmonary hypertension. Therefore, we performed two additional BPA procedures. Subsequently, the mean PAP decreased further to 13 mmHg. The patient's symptoms improved, the six-minute walk test distance increased to 656 m, and the WHO functional class returned to I. In conclusion, BPA for recurrent lesions after surgery for CTEPH can improve the patient’s symptoms and exercise tolerance.