Pulmonary Endarterectomy After Balloon Pulmonary Angioplasty: A Single‐Center USA Experience

ABSTRACT

Pulmonary endarterectomy (PEA) is the treatment of choice for operable chronic thromboembolic pulmonary hypertension (CTEPH), while balloon pulmonary angioplasty (BPA) is reserved for inoperable disease. However, operability is subjective and there are patients who may undergo BPA prior to PEA. It is not clear if prior BPA affects PEA outcomes. We present a series of patients from a single, high‐volume, referral center who underwent PEA after prior BPA. CTEPH patients who underwent BPA prior to undergoing PEA at the University of California, San Diego between January 2013 and July 2025 were included. Post‐PEA outcomes were compared to all PEA patients who did not have prior BPA from the year 2022. Twenty‐one patients were identified. Average number of BPA sessions prior to PEA was 3.4 ± 2.1. The most common reason for initial BPA was distal disease deemed inoperable (43%). Average total circulatory arrest time was 61.5 ± 21.8 min, compared to 47.9 ± 19.3 min ( p  = 0.003) in the control PEA cases ( n  = 188). Post‐operatively, the PEA after BPA cohort had longer ventilator days ( p  < 0.001), ICU days ( p  = 0.022) and post‐operative length of stay (LOS) ( p  < 0.001); there were also higher rates of post‐operative bleeding ( p  < 0.001) requiring transfusions ( p  = 0.033) and return to the operating room ( p  = 0.008). There was one death related to prior BPA complications despite adequate endarterectomy with improved hemodynamics. There was similar hemodynamic improvement post‐operatively in both cohorts. Although prior BPA made PEA more challenging and increased select post‐operative complications, it is not a contraindication for successful PEA.