Technically Inoperable CTEPH: What to Do When Medical Therapy Has Not Met Haemodynamic Targets
This protocol applies to patients with chronic thromboembolic pulmonary hypertension who are technically inoperable — fibrotic obstructions lie within pulmonary artery segments not surgically accessible.
When medical therapy for inoperable CTEPH — including riociguat (first-line), or alternatives such as macitentan, subcutaneous treprostinil, or off-label oral combination therapy — has failed to achieve the treatment targets: specifically, a good functional class (WHO-FC I–II) and/or normalisation of haemodynamics at rest confirmed at right heart catheterisation, escalation to the next step is warranted.
An interventional, staged procedure targeting distal pulmonary artery obstructions is considered for patients whose anatomy is amenable to this technique. The complete protocol — covering patient selection, staging strategy, and session-level detail — is available in the structured regimen.
Full procedural protocol available below.
The target is achieving a good functional class (WHO-FC I–II) and/or normalisation or near-normalisation of haemodynamics at rest, confirmed at right heart catheterisation 3–6 months post-procedure, alongside improvement in quality of life.
References
DOI: 10.1093/eurheartj/ehac237
Riociguat is recommended for symptomatic patients with inoperable CTEPH or persistent/recurrent PH after PEA.
BPA is recommended in patients who are technically inoperable or have residual PH after PEA and distal obstructions amenable to BPA.
A staged interventional procedure with a limited number of dilated PA segments per session is preferred.
Most experts accept achieving a good functional class (WHO-FC I-II) and/or normalization or near normalization of haemodynamics at rest, obtained at RHC 3-6 months post-procedure (PEA or last BPA), and improvement in quality of life.
View source ↗