Angioscopic findings during balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension
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IMAGES IN CARDIOVASCULAR INTERVENTION
Angioscopic findings during balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension Toshiki Takano1 · Kazuyuki Ozaki1 · Makoto Hoyano1 · Takao Yanagawa1 · Takeshi Kashimura1 · Tohru Minamino1 Received: 12 June 2019 / Accepted: 9 December 2019 © Japanese Association of Cardiovascular Intervention and Therapeutics 2019
Keywords Chronic thromboembolic pulmonary hypertension · Angioscopy · Optical coherence tomography · Balloon pulmonary angioplasty 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. CTEPH is defined as precapillary pulmonary hypertension in the presence of chronic/organized flow-limiting thrombi/emboli in the elastic PA [1]. Various thrombus formations were observed by angioscopy, and the most frequently observed type was the “mesh” thrombus [2]. Generally, fresh thrombus is rarely observed in angiographic lesions. Although it is possible to identify fresh thrombus even with angiography, in the present case, angioscopy could observe fresh thrombus which could not be determined by angiography. Angiographic findings do not match the specific morphologic type of organized thrombus [3]. Angioscopy is useful for BPA by identifying the type of thrombus.
* Toshiki Takano [email protected] 1
Department of Cardiovascular Biology and Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1‑757 Asahimachidori, Chuo‑ku, Niigata 951‑8510, Japan
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Fig. 1 a Angiography of the left pulmonary artery (PA) demonstrating the “web” lesion in A9 (arrow). b Optical coherence tomography (OCT) image revealing “mesh” appearance the thrombus in A9
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