Region’s first balloon pulmonary angioplasty program puts more air in the lungs of CTEPH patients

For patients with chronic thromboembolic pulmonary hypertension (CTEPH), BPA can open up lung arteries that surgery can’t reach.
Oct. 9, 2023
Connie and husband Jim Starr at Memorial Park in Woodland Park, Colo. Connie, who had previously undergone surgery to remove blood clots in major lung arteries, in March became the first UCHealth patient treated with balloon pulmonary angioplasty, an emerging procedure for CTEPH patients. Photo courtesy of Connie Starr.
Connie and her husband, Jim Starr, at Memorial Park in Woodland Park, Colorado. Connie, who had previously undergone surgery to remove blood clots in major lung arteries, in March became the first UCHealth patient treated with balloon pulmonary angioplasty, an emerging procedure for chronic thromboembolic pulmonary hypertension patients. Photo courtesy of Connie Starr.

Lungs have filled countless balloons. Balloons are now returning the favor. They’re doing so through a procedure called balloon pulmonary angioplasty (BPA). It’s a minimally invasive technique through which an interventional cardiologist strings a balloon catheter deep into a lung to open up arteries narrowed by chronic thromboembolic pulmonary hypertension, or CTEPH.

UCHealth’s Comprehensive Lung and Breathing Program performed its first BPA procedure in March, making Connie Starr, 78, of Woodland Park, the first patient of the first BPA program in the region. Starr, who works for a cleaning business, has a family history of blood clots. But she suspects that shoulder-replacement surgery in 2017 triggered hers.

CTEPH happens when blood clots from surgery, trauma, or other causes travel back to the right side of the heart, get pumped to the lungs with blood headed for oxygenation, and get stuck there as pulmonary embolisms. Usually, anticoagulation medications and the body’s own clot-clearing abilities dissolve the clots. But about 4% of the time, the clots gradually get covered like scars by endothelial cells that line arteries. The narrowing or blocking of blood flow stresses the right side of the heart over time.

Shortness of breath, difficulty exercising, fainting, and, with time, heart failure can result.

First, pulmonary thrombendarterectomy, or PTE

Starr’s CTEPH case was serious. Blood thinners weren’t solving the problem. She was referred to Dr. Todd Bull, a University of Colorado School of Medicine pulmonologist and the director of the Comprehensive Lung and Breathing Program at UCHealth University of Colorado Hospital (UCH) on the Anschutz Medical Campus.

A photo of Dr. Todd Bull, the doctor who performed a pulmonary thromboendarterectomy, or PTE, on the patient.
Dr. Todd Bull

Scans showed multiple chronic clots, in both the left and right pulmonary arteries – major arteries in the left and right lung. Bull recommended a major surgery, called a pulmonary thromboendarterectomy, or PTE, to remove them. During the open procedure, the body is chilled to 68 degrees – about 30 degrees below a normal core temperature. That’s so the patient’s brain and vital organs aren’t damaged when the heart is intentionally stopped for multiple 20-minute sessions during which surgeons remove clots.

In November 2018, UCH became the first hospital in the region to perform a PTE. Five years and 57 successful surgeries later, UCH remains the only institution in the region offering them, with cardiothoracic surgeons Dr. Jordan Hoffman and Dr. Michael Cain performing the operations.

Starr underwent her PTE in January 2022, with cardiothoracic surgeons presiding.

“It definitely helped,” Starr said.

Next, balloon pulmonary angioplasty, or BPA

But her symptoms returned, and it became clear that there was more to her CTEPH than those two big clots. Pulmonary embolisms had formed in smaller blood vessels deeper in her lungs. Bull suggested a different approach to opening them up: balloon pulmonary angioplasty. BPA happens not in an operating room but in a catheterization laboratory. The patient remains awake. An interventional cardiologist inserts a balloon catheter into the femoral vein near the groin and then guides it through the right side of the heart and into a lobe of the lung. During a roughly three-hour session, the balloon opens three to five bottlenecks. The patient may do three to five separate BPA sessions in total, Bull says.

“The goal is to improve pressures, symptoms, oxygenation, and exercise tolerance,” he said. Bull still recommends PTE surgery for patients such as Starr with major clots in surgically accessible lung arteries.

But BPA helping patients who might not withstand PTE surgery as well as patients whose clots are out of reach of PTE surgeons. (One study estimated that more than a third of CTEPH patients fall into these categories.) Then there are patients like Starr, for whom surgery is the first step, but who then may need BPA to reach hard-to-reach residual disease.

A photo of Dr. Kevin Rogers, the doctor who performed a balloon pulmonary angioplasty on the patient.
Dr. Kevin Rogers

Since March, Starr has undergone four BPA procedures. During each session, University of Colorado School of Medicine and UCHealth interventional cardiologist Dr. Kevin Rogers has focused on opening arteries in specific, limited areas in the lung, usually staying on one lung segment or lobe during a procedure.

Rogers, whose work typically involves arteries in the heart, kidneys, legs, and elsewhere, described BPA as more “technically challenging” than many other catheter-based procedures. Reasons for that include more extreme differences in lung-artery anatomy from patient to patient, a lack of BPA-specific medical devices (he typically uses tools designed for heart procedures), and the need for multiple BPA procedures to achieve desired outcomes. But, he says, it’s worth it.

“The improvement to patients’ functional status as far as how they feel and perform in everyday life is gratifying,” Rogers said.

Starr is a case in point.

“Each time, I feel better and breathe easier,” Starr said. “I have much more energy than I had before.”

Advance the science of BPA

She and Bull are contemplating a fifth BPA procedure. Starr is still on supplemental oxygen – at 8,600 feet elevation, the air in Woodland Park has about 28% less oxygen than at sea level and 13% less than in Denver.

But Bull hopes that BPA and maintenance medications can help wean her from her cannulas. Bull and colleagues are working to refine the procedure and contribute to the still-limited medical literature on BPA outcomes.

Radiologist Dr. Robert Quaife is collaborating with Bull’s team to develop 3D models of lung vasculature that pulmonologists interventional cardiologists can use to prepare for the procedure. Pulmonologist Dr. Andrea Yu is studying the clots removed during PTE surgery to better grasp how they form and what their composition is, the aim being to provide a basis for new treatments.

Starr says she’s doing her part to stay as healthy as she can. She spends an hour at the gym each day, splitting that time between an exercise bike and resistance work. Plus she’s back working and running garage sales on weekends, she says.

“People at church say my color is good and ask, ‘Where do you get all your energy?’” Starr said. “And I’m 78 – I’m not youngster anymore.”

About the author

Todd Neff has written hundreds of stories for University of Colorado Hospital and UCHealth. He covered science and the environment for the Daily Camera in Boulder, Colorado, and has taught narrative nonfiction at the University of Colorado, where he was a Ted Scripps Fellowship recipient in Environmental Journalism. He is author of “A Beard Cut Short,” a biography of a remarkable professor; “The Laser That’s Changing the World,” a history of lidar; and “From Jars to the Stars,” a history of Ball Aerospace.