Endovascular management of Chronic thromboembolic pulmonary Disease and

Post thrombotic syndrome

Riyaz Bashir MD, FACC Director Vascular and Endovascular medicine

Professor of medicine Temple University Hospital

786

Disclosures

• Thrombolex Inc. • Equity Interest

Why Balloon Pulmonary Angioplasty?

Operable 64%

In-operable 36%

CTEPH Patients

57% - Treated with Pulmonary Thromboendarterectomy

(Circulation . 2011; 124:1973-1981.)

Post PTE - CTEPH

• Many patients post PTE continue to have significant symptoms and PAH

Eur Heart J. Published online September 23, 2017. doi:10.1093/eurheartj/ehx530

Outcomes of BPA – Japanese Experience

Eur Heart J. Published online September 23, 2017. doi:10.1093/eurheartj/ehx530

Outcomes of BPA – Japanese Experience

Challenges of BPA

Coronary Arteries Pulmonary Arteries

Eur Heart J. Published online September 23, 2017. doi:10.1093/eurheartj/ehx530 Eur Heart J | Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.

Challenges of BPA Reperfusion Pulmonary Edema

47 Yr. Old Male Self Employed Painter S/P Splenectomy Perfusion Scan Non-Selective pulmonary Angiogram

Selective angiograms – Distal Level III CTEPH

Technical Procedure of BPA

• Right Femoral vein access

• 7Fr Long sheath (70cm)

• 6Fr Guiding Catheter (Multipurpose, JR 4)

• Cross the lesion with a Radi wire

• BPA over a RADI Wire

Pressure wire across the lesion

Proximal to the lesion Distal to the lesion Within the lesion

Pressure wire guided BPA

PRE BPA POST BPA

Post Balloon Pulmonary Angioplasty

Non Selective Pulmonary Angiogram

Pre BPA Post BPA

Perfusion Scan

Pre BPA Post BPA

Echocardiographic Changes

Pre BPA 6 min walk distance – 360 m

PVR – 6.8 WU

Post BPA 6 min walk distance – 449 m

PVR - 4.0

Web/Band Lesion

PRE BPA POST BPA

Total Occlusions

Lobar Artery Occlusion

TEMPLE CTEPH TEAM

Paul Forfia Anjali Vaidya Arslan Mirza Yousi Toyoda Chandra Dass Riyaz Bashir

Temple’s Early Experience with Balloon Pulmonary Angioplasty

Temple BPA Experience

32 patients

63 sessions

194 Vessels

191 Surgical Thromboendarterectomies

0

5

10

15

20

25

30

35

40

45

50

FY2013

FY2014

FY2015

FY2016

FY2017

FY2018

FY2019

1

10 13

34 37

46 48

3

13 15

30

PTE

0

2

4

6

8

10

12

14

Pre-BPA 1 monthPost-BPA

3 MonthPost-BPA

6 MonthPost-BPAN

um

be

r o

f C

TEP

H P

atie

nts

(N

=13

)

New York Heart Association (NYHA) Functional Class Before and After BPA Based on Six Minute Walk Test

NYHA IV (<300 m)

NYHA III (300-376 m)

NYHA II (377-450 m)

NYHA I ( >450 m)

6 MWD increased from 342 ± 113 m to 429 ±151 m

2019 – At CTEPH Centers of Excellence

1. PTE is the first line of therapy for CTEPH – Potentially curative.

2. BPA is a reasonable option in patients who have in-operable disease or are very poor surgical risk

Kashmir

Chronic DVT Post Thrombotic Syndrome

Post Thrombotic Syndrome May Thurner Syndrome

PRE stent Post Stent

Eliahou R et al. Radiographics 2012;32:E33-E49

Stents Across the Common Femoral Veins

External Iliac Stenosis

Pre stent Post stent

IVC Stenting

Post hysterectomy venogram

showing decompression of IVC

and IVC filter (arrow).

IVC venogram: filling defect in the IVC and compression of filter from external compression

CT angiogram of chest and abdomen demonstrating large leiomyoma with compression of the IVC and IVC filter (blue arrow).

Uterine Fibroids

CONCLUSION

• Venous CTO stenting of the iliofemoral and caval vessels leads to significant improvement in functional capacity

• Ongoing CTRACT Trial – level 1 Evidence

C-TRACT Trial Referral - Mobile App

• Open Apple App Store or Google Play Store

• Using the search feature, type “C-TRACT.” - Android users must use caps and hyphen

• Locate the “C-TRACT Referral Tool” App.

• Click “GET” or “Install” from search screen

• You are ready to refer patients to C-TRACT!

C-TRACT App Icon

Temple University

Venous Thromboembolism Program

Riyaz.bashir@temple.edu

215-316-0232

CAD STEMI Stroke (LVO) Large Vessel VTE

CV cause of M & M #1 #2 #3

Pathogenesis Thrombus/stenosis Thrombus/stenosis Thrombus/stenosis

Standard of Care Endovascular Endovascular ? Endovascular

Challenges 1. Resistance to interventional therapies

2. Systems/processes 3. Technology

1. Resistance to interventional therapies

2. Systems/Processes

3. Technology

1. Resistance to interventional therapies

2. Systems and processes

3. Technology - Volume of thrombus

2019

VTE – Challenge Burden of Thrombus

Courtesy of W. Jaber, Brent Keeling and Omar Lattouf

Acute ST elevation Myocardial infarction

Acute Stroke Acute Pulmonary Embolism

Lesion Types

Pouch

Web/bands

Abrupt narrowing

Total occlusions

Intimal irregularities

Haruhisa Ishiguro et al. JIMG 2016;9:324-325

Limitations of Angiography

Intravascular Ultrasound

Iliac Vein Compression

A

V

Iliac Vein

V

BPA – Total Occlusion

Pre BPA Immediate Post BPA One month Post BPA

Safety of BPA

• Zero procedure related mortality

• Two patients had mild hemoptysis one required brief intubation

• One patient mild radiographic reperfusion edema

Case

• 53 yr. female • Severe left leg swelling and venous claudication • Severe post thrombotic syndrome

• Venous Duplex: • Chronic DVT left common femoral and iliac veins

• PMHX: • Heterozygous Factor 5 Leiden mutation • 1989 – after starting oral contraceptives • Developed left iliofemoral DVT complicated by phlegmasia cerulea Dolens treated with

systemic thrombolysis. • One recurrence on anticoagulation

Venogram

Stenting • Need to extend into IVC

• Need to cover CFV stenosis

• Avoid stenting across the Profunda vein

Complete resolution of swelling and Claudication

BPA survival

Treatment of CTEPH

Mahmud, et al J A CC VO L. 7 1, N O . 21, 2018 MA Y 29, 201 8 : 24 6 8 – 86

PTE

BPA

Pulmonary Artery Balloon Angioplasty

PRE POST

Stenting Superior Vena Cava