Dr Vikas Aggarwal on Balloon Pulmonary Angioplasty for CTEPH

Hi, my name is Dr Vikas Aggarwal. I'm an international cardiologist at the University of Michigan Hospital in Ann Arbor. My area of expertise happens to be in pulmonary vascular interventions and I'm currently leading the balloon pulmonary angioplasty program for CTEPH patients. I work hands in hand with our multidisciplinary CTEPH team, led by Dr. Valerie McLaughlin, Dr. Scott Visovatti and our cardiac surgeon, Dr. Jonathan Haft.

The University of Michigan Hospital happens to be the lead academic medical center in the state of Michigan. Recently, balloon pulmonary angioplasty was introduced as a new treatment option for patients with chronic thromboembolic pulmonary hypertension who are no longer surgical candidates.

CTEPH stands for chronic thromboembolic pulmonary hypertension. It's a disease that involves blood clots in the arteries supplying both our lungs. These blood clots are leftover clots from prior pulmonary embolisms and are now apparent and organized within the wall of these arteries, which leads to narrowing of the branches of the pulmonary arteries in our lung, leading to increased pressure inside the lungs, which in turn leads to extra stress and effects the right side of our heart.

The treatment of choice for patients with this pathology happens to be cardiac surgery, in which a surgeon dissects down into these branches of the pulmonary artery and takes this clot out. However, more than 50% of all patients with this pathology are not able to get the surgery, due to multiple clinical and anatomical reasons.

Recently, pulmonary angioplasty, which is a minimally invasive procedure in which we pass a wire across these narrowed arteries and use small balloons to open those arteries and to relieve those narrowings, has shown a lot of promise. That's where my experience lies in and that's where we want to make a difference in the care of these patients.

Balloon pulmonary angioplasty was, in fact, first reported from the United States in 2001 by Feinstein, et al, from Boston, Massachusetts. However, that experience showed a significantly high rate of complications and bleeding from this procedure.

However, since then, the Japanese have taken the forefront in this field and have now consistently shown over the past decade that this procedure, if done right, can be performed safely and effectively in such cases. Since the Japanese experience has been more widely known and widely published, experience and interest has been increasing in the United States over the past five years.

I was first introduced to this procedure in 2014 when I was working in Philadelphia at Temple University Hospital, and then over the course of the next four years, I was fortunate to gain more experience and expertise and refine my technique.

Subsequently, I also interacted and now became very good friends with my colleagues at Kyushu University in Fukuoka, Japan and was able to go visit them and learn the Japanese way of doing pulmonary angioplasty hand in hand this past summer. More recently, I'm very excited and fortunate to join the University of Michigan's pulmonary hypertension and CTEPH Center of Excellence and I am able to bring this newer technology to our patients at the University of Michigan.

Currently, the standard of care for patients with CTEPH happens to be cardiac surgery or pulmonary endarterectomy. Balloon pulmonary angioplasty is a relatively new procedure and the Japanese have shown that in most patients with CTEPH, balloon pulmonary angioplasty is often as effective as cardiac surgery, albeit it requires on an average, four to five treatment sessions per patient.

However, in the absence of randomized, well designed clinical trial data, pulmonary endarterectomy continues to be the standard of care in the United States, and balloon pulmonary angioplasty currently is only limited to patients who cannot undergo pulmonary endarterectomy due to clinical or patient anatomical factors.

Our first patient in the state of Michigan that received balloon pulmonary angioplasty at our expert center has had one session and they are scheduled to undergo two or three more sessions over the next few weeks. This patient had severe pulmonary hypertension, despite being on pulmonary hypertension medications, and was noted to have chronic thromboembolic disease on pulmonary imaging. However, her disease was so distal in the subsegmental branches, which were not accessible to cardiac surgery. She was evaluated by our expert surgeon as well as our pulmonary hypertension team and was thought to be a better candidate for pulmonary angioplasty and not pulmonary endarterectomy.

She underwent her first session of the balloon pulmonary angioplasty at our center last month and she's already feeling a lot better compared to how she was feeling prior to the procedure. We plan on performing a few more sessions on her with the goal of normalizing her pulmonary pressures and hopefully getting her off the pulmonary hypertension medications.

When we saw the patient after her first treatment, she was very excited and pleased to see her symptoms get better. She told us that she was able to do more, [was] less short of breath, and that was heartening and exciting to hear.

Our goal is to spread the word about our multidisciplinary expert CTEPH center now here in the state of Michigan, and we hope to take care of patients from all over the Midwest, not just the state of Michigan, as well as nationally, and from Canada, too.

If you have unexplained shortness of breath and limitation in your activity level, you should be seen by either a cardiologist or a pulmonologist, and the workup for this pathology starts with an echocardiogram. If the echocardiogram shows evidence of right heart strain and/or pulmonary hypertension, you should definitely receive a ventilation profusion scan or a V/Q scan to look for chronic thromboembolic pulmonary hypertension as the underlying pathology behind the diagnosis of pulmonary hypertension.

If you happen to have evidence of ventilation profusion mismatch or chronic thromboembolic pulmonary hypertension, you should be referred to an expert center like ours as soon as possible for further evolution and the workup of this disease, which includes right heart catheterization as well as a pulmonary angiogram and a CT angiogram to better define the hemodynamics as well as the anatomy and the obstructive component from this pathology.

The only piece of advice I would give everybody is chronic thromboembolic pulmonary hypertension is common and is often misdiagnosed or is diagnosed very late in the disease pathology, so please, everyone think about chronic thromboembolic pulmonary hypertension in your patients with unexplained dyspnea or dyspnea out of proportion to their medical condition, and please screen your patients for this disease with a V/Q scan.

If you have any questions, we can help you take care of these patients. Please feel free to reach out.

My name is Dr. Vikas Aggarwal and I'm aware that I'm rare.

Vikas Aggarwal, MD, is a board-certified interventional cardiologist and endovascular interventional specialist. He directs the interventional vascular medicine program in the division of cardiology at the University of Michigan Hospital in Ann Arbor. Dr Aggarwal specializes in percutaneous therapies for deep vein and pulmonary thromboembolic disease, including catheter based thrombus removal and balloon pulmonary angioplasty.

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