Ihab Haddadin, MD, an Interventional Radiologist and Physician at Cleveland Clinic talks about CTEPH and the new BPA procedure.
Interview conducted by Ivanhoe Broadcast News in September 2018.
Can you start out by describing what is the BPA procedure?
Dr. Haddadin: BPA procedure stands for balloon pulmonary angioplasty and it’s a minimally-invasive procedure that is now beginning to gain more acceptance in the United States. It’s a procedure through tiny incisions that come in from either the neck or from the groin. The incisions are probably around three millimeters. We’re able to go in there with catheters, wires and balloons, and with x-ray and ultrasound guidance, able to get in and find the webs that are associated with chronic pulmonary hypertension from chronic PE’s and basically open them up to optimize the blood flow.
So, are you actually removing the clots or just opening the vessel?
Dr. Haddadin: We’re actually just opening the vessel. The technology is not quite there for physically removing the clots the way a surgeon does There’s probably a role in patients who cannot undergo surgery for just pushing some of the clots aside to help improve the blood flow in the lung.
What makes CTEPH such a difficult condition to treat?
Dr. Haddadin: CTEPH is a relatively uncommon disease. Some of the symptoms that the patients suffer with are fairly non-specific. Nobody is going to show up to their doctor’s office with signs and symptoms of CTEPH. They’re going to have shortness of breath, tiredness, fatigue and a lot of these are not very specific. Fortunately, sometimes there’s a delay in the diagnosis for these patients. The care of these patients really requires a very highly specialized multidisciplinary team. It’s not just one physician, but a group of physicians that take care of these patients. There’s that initial step of delay of identifying the patients and the referral. Second, the disease, for a very rare disease, has a very biological presentation. No two patients are exactly identical. Some patients will have significant disease with limited burden and vice versa. That’s one of the challenges where I think a multidisciplinary team is able to come in to really help better define the strategy that you’re going to develop to treat that patient.
With this BPA, what kind of results have you been seeing with patients?
Dr. Haddadin: We’re still early in our experience. Again, this is a fairly new technique. In the procedures that we’ve done so far, the things that we’re looking at are how the patient feels. That’s obviously the most important thing. All the other numbers are just metrics that we use to follow the patients. Patients have come to us with significant limitations. They’re oxygen-dependent with really very limited ability to carry on mundane routine life activities. Just going shopping, doing the laundry, or going up a flight of stairs. With a few sessions, they’ll actually be able to see some improvement in their day to day function. Plus, we follow some clinical metrics such as the pulmonary artery pressures and how well their heart is functioning after the procedure. Again, we’re early in our experience but there’s evidence to suggest that we’re actually able to see not just the clinical benefit but some clinically measured metric that we can follow.
Can you describe what you’re actually doing in there and why you have to perform the procedure multiple times?
Dr. Haddadin: Sure. The first procedure that we typically do is a mapping procedure. That is purely a diagnostic procedure to get an idea of what the patient’s human dynamics are. The extent of the disease… is it proximal, is it distal, is it disease that could be surgically accessible or not? Once we define the patient’s anatomy, then we discuss this at our conference to decide what’s really the best approach. If we’re going to go down the angioplasty route, then we bring the patient back. We typically do this over the course of multiple steps. The biggest improvements that have been achieved in this procedure is to try to optimize the safety profile. Some of the initial experiences were unfortunately hampered by complications such as pulmonary edema and hemorrhage and through some refinement of techniques, we were able to improve that. The biggest refinement is don’t do everything all at once. You have to resist the urge to try to treat everything all at once. That way, if there is an issue or problem, it only occurs in a small sub-segment of the lung that’s much easier to manage for both the clinician and the patient.
People may have heard of coronary angioplasty. What makes this so much more difficult?
Dr. Haddadin: The anatomy is much more challenging. Coronary circulation, I don’t want to say is simple, but it’s a little more straight forward. The pulmonary circulation is far, far more complex. All of the body’s blood ends up in the pulmonary circulation whereas only a fraction of the body’s blood will end up in the coronary circulation. So, it’s just from sheer volume, the anatomy is much more complex. It’s a three-dimentional structure that goes in all sorts of different directions. The procedure does become very technically demanding and challenging.
How long does it typically take for patient to notice a difference?
Dr. Haddadin: It varies from patient to patient but we typically say if you’re going to get anything it’s usually perhaps maybe by the second treatment. But, sometimes we’ve had patients who have actually noticed a difference with the first angioplasty session. It usually takes at least three to four days perhaps as much as a week for the patient to start noticing a difference. And, that difference becomes additive with the multiple procedures that we do.
What are the risks of the procedures?
Dr. Haddadin: The biggest risks that we worry about are reperfusion, pulmonary edema and pulmonary hemorrhage. The thought is you have a vessel that’s occluded that wasn’t getting blood and before that occlusion there’s a very elevated blood pressure. Now, you open that up and that elevated blood pressure rushes right in and the body doesn’t always handle that very well. So, one of the ways that can manifest is pulmonary edema and pulmonary hemorrhage. We try to minimize that risk by undersizing. We don’t open things right away. We open it to a small size and let the body basically do its thing over the next couple of weeks. We try to treat smaller fragments at a time. So far, we’ve been very happy with our results.
What is it like for you to be able to treat patients who previously may not have an option?
Dr. Haddadin: The joys of being in the medical profession is that you’re able to meet patients before an intervention and then see what happens to them after the intervention and see how much of a difference it makes in their life. In this particular instance where you’re at the forefront of that treatment, you know. We’re actually able to offer that patient that option whereas ten, twenty years ago, we weren’t able to do that.
What’s it been like following Peggy?
Dr. Haddadin: It’s been very rewarding with every single procedure. When we first started out I asked Peggy, what do you want to do? What is it that you want to do that you can’t do? And, her biggest thing was that she was a prisoner to her house. She couldn’t really go anywhere. She was oxygen-dependent and had to almost live in a wheelchair. She was afraid to go anywhere without anybody with her because of fear of the limitations that she had. She no longer has that. Is she cured? No. But she’s come quite a long way and I think we’ve made a significant improvement in her quality of life.
Is there anything else that you want to add?
Dr. Haddadin: I think we’re excited about this and if folks have any questions they can always reach out to our CTEPH program here at the Cleveland Clinic and I would be happy to answer any questions that they might have.
When did the U.S. start doing this procedure?
Dr. Haddadin: I don’t know off the top of my head. I’d have to look that up. I think that the group that’s been at the biggest front here and has the biggest experience is UC San Diego. There’s about maybe four or five centers around the country that are performing this. It hasn’t been around that long in the United States. I would probably venture a guess and say the last five maybe years or so.
END OF INTERVIEW
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