Catheter-directed therapies in chronic thromboembolic pulmonary hypertension

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Introduction: Catheter-directed therapies (CDT) for acute pulmonary embolism (PE), including catheter-directed thrombolytics and suction thrombectomy are becoming increasingly popular. While potentially beneficial in acute PE, CDT is ineffective for chronic thromboembolic disease. Here, we present our experience in patients with later confirmed chronic thromboembolic pulmonary hypertension (CTEPH) who initially received CDT prior to referral. Methods: Retrospective review of all pulmonary thromboendarterectomy (PTE) surgeries performed at the University of California San Diego from January 1, 2020 to December 31, 2021. Results: 354 PTE surgeries were performed. 52 patients received CDT prior to referral (15%) (18 in 2020, 34 in 2021). Prior to CDT attempt, duration of dyspnea ranged from 3 days to 10 years and mean right ventricular systolic pressure by echocardiography was 74 ± 23 mmHg. Five patients reported full recovery of symptoms after CDT, 26 patients had none and 21 patients had some improvement but not to baseline. Imaging prior to CDT was available for review in 30 patients; 24 had radiographic evidence of CTEPH and one was suspicious for sarcoma. Complications associated with CDT occurred in six patients, and included pulmonary hemorrhage, groin hematoma, hemoptysis, respiratory failure requiring mechanical ventilation and ECMO. Conclusion: Radiologic signs of CTEPH were frequently overlooked (83%) at the time of CDT attempt. Most had minimal to no improvement in symptoms with CDT, and 11% experienced complications. It is important to look for clinical and radiologic signs of CTEPH when considering CDT in acute PE to minimize unnecessary risk and instead, refer for appropriate CTEPH evaluation.

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