Aug. 22, 2026
Mayo Clinic Cardiovascular Medicine specialists helped create the first U.S. consensus statement on balloon pulmonary angioplasty (BPA) for treatment of chronic thromboembolic pulmonary hypertension (CTEPH).
The state-of-the-art paper from the BPA-CTEPH Alliance reviews the role of BPA in this rare but potentially life threatening form of pulmonary hypertension. It offers a framework for the safe and effective use of BPA, a catheter-based endovascular treatment. The statement was published in JACC: Cardiovascular Interventions.
BPA emerging
CTEPH is characterized by fibrothrombotic pulmonary vascular obstruction and associated small vessel vasculopathy. The result is a progressive increase in pulmonary vascular resistance and right heart failure.
The first line treatment is pulmonary thromboendarterectomy (PTE) in patients with surgically accessible disease. However, for patients with inoperable CTEPH and those with persistent or recurrent pulmonary hypertension after PTE surgery, BPA is an effective treatment.
"Balloon pulmonary angioplasty has become an essential component of multimodality CTEPH care, but its rapid growth has created a need for greater standardization. The statement brings together experts from multiple disciplines to address patient selection, procedural technique, complication management, operator training and the infrastructure required to develop a successful BPA program," says Riyaz Bashir, M.B.B.S., M.D., an interventional cardiologist and director of Vascular and Endovascular Medicine at Mayo Clinic in Jacksonville, Florida. Dr. Bashir is senior author of the statement. He works in Mayo's multidisciplinary Pulmonary Hypertension Clinic, an accredited Pulmonary Hypertension Association Center of Comprehensive Care.
"The safety of BPA has improved substantially. Earlier procedures were associated with significant rates of pulmonary vascular injury and lung injury. More-refined techniques — including careful lesion selection, conservative balloon sizing, staged treatment, improved imaging and appropriate medical optimization — have markedly reduced these risks. Operator experience and the ability to manage complications remain critical," Dr. Bashir says.
According to the consensus statement, studies from the U.S. and Europe have reported 42% to 45% decreases in pulmonary vascular resistance and 18% to 29% reductions in mean pulmonary artery pressure after BPA.
Expanding treatment options
One of the few forms of pulmonary hypertension with the potential for cure is CTEPH. "Pulmonary thromboendarterectomy remains the standard treatment for appropriately selected patients because it is the only therapy capable of removing the chronic thromboembolic material obstructing the pulmonary arteries. Early recognition and referral to an experienced CTEPH center are essential to achieving the best outcomes," says Mauricio A. Villavicencio, M.D., M.B.A., a cardiovascular and transplant surgeon at Mayo Clinic in Rochester, Minnesota. Dr. Villavicencio, an expert in CTEPH surgery, is Mayo Clinic Cardiovascular Surgery's surgical director of Heart and Lung Transplantation and Mechanical Circulatory Support.
"Balloon pulmonary angioplasty plays a critical role in addressing the needs of patients who are not candidates for surgery or who have residual or recurrent pulmonary hypertension following surgery. BPA offers a minimally invasive treatment option that can improve pulmonary blood flow, reduce pulmonary vascular resistance, alleviate symptoms and enhance functional capacity," Dr. Villavicencio says.
As part of a comprehensive CTEPH program, BPA expands treatment opportunities and improves outcomes for patients who previously had limited therapeutic options. BPA is a highly specialized technique that is ideally performed within multidisciplinary CTEPH centers.
Statement recommendations:
- Patients with suspected or confirmed CTEPH should be evaluated by a multidisciplinary CTEPH team with expertise in PTE, BPA and pulmonary hypertension-targeted medical therapy.
- BPA should not be viewed as a replacement for surgery.
- Treatment decisions should be individualized according to anatomy, hemodynamics, comorbidities and patient preferences.
- BPA programs need to include structured training, experienced operators, standardized procedural and periprocedural protocols, appropriate institutional resources, and ongoing evaluation of outcomes.
Collaborative care
Mayo Clinic's multidisciplinary CTEPH center offers a full range of integrated care. Specialists in pulmonary hypertension, cardiovascular medicine, cardiothoracic surgery, interventional cardiology, radiology and other disciplines review each patient together and determine the best treatment strategy.
Multidisciplinary collaboration is fundamental to successful CTEPH care. By bringing together experts from multiple specialties, Mayo Clinic ensures comprehensive evaluation and individualized treatment planning for every patient. "This coordinated approach enables timely diagnosis, selection of the most appropriate intervention, and seamless integration of surgical, interventional and medical therapies," Dr. Villavicencio says. "Effective treatment relieves pressure on the right side of the heart, reverses or prevents right heart failure, improves prognosis, and leads to better long-term patient outcomes."
CTEPH screening
CTEPH is often underrecognized and undertreated. "Many patients with a diagnosis of CTEPH do not have a clinical history of previous pulmonary embolism or of known venous thromboembolic events. It's critical to think of CTEPH in the evaluation of dyspnea or pulmonary hypertension irrespective of the clinical history," says Lisa Mielniczuk, M.D., F.R.C.P.C., F.C.C.S., a cardiologist at Mayo Clinic in Rochester, Minnesota. Dr. Mielniczuk works in Mayo's Pulmonary Hypertension Clinic and the Circulatory Failure Program. "Early symptoms of pulmonary hypertension such as progressive exertional dyspnea, fatigue and exercise intolerance are often nonspecific and may be attributed to shortness of breath caused by parenchymal lung disease, obesity or other comorbidities. Without a clinical index of suspicion for CTEPH, there may be a significant delay in a diagnosis."
There are also challenges in diagnosing CTEPH. Contrast CT scans are often used to identify CTEPH. However, they may lack the sensitivity for small vessel disease, which can only be identified with ventilation/perfusion (V/Q) scanning.
"Mayo Clinic's Pulmonary Hypertension Clinic and CTEPH program provide comprehensive diagnostics including advanced imaging with V/Q scanning, 3D echocardiography, cardiac MRI and invasive right heart catheterization with concurrent rotational pulmonary angiography," Dr. Mielniczuk says.
Mayo Clinic specialists diagnose and treat about 8,000 people with pulmonary hypertension each year. Mayo experts routinely screen for CTEPH when evaluating a patient with pulmonary hypertension.
Looking ahead
Mayo Clinic emphasizes team-based care, standardized pathways for CTEPH referrals and active participation in clinical research and registries.
"National registries, prospective randomized controlled trials and collaboration among expert centers will be essential," Dr. Bashir says. "Ultimately, every patient with CTEPH should have access to a multidisciplinary team capable of considering all available therapies rather than receiving treatment based solely on what is available locally."
Future priorities include:
- Increasing awareness so that patients are diagnosed and referred earlier.
- Expanding access to comprehensive CTEPH centers while ensuring that increases in use of BPA occur safely and responsibly.
- Defining optimal treatment goals.
- Identifying the best sequencing and combinations of surgery, BPA and medical therapy.
- Establishing standardized outcome measures.
- Collecting long-term data.
"Mayo Clinic's ability to collaborate across its campuses allows us to offer the full spectrum of care, including pulmonary thromboendarterectomy, BPA, medical therapy and, when appropriate, combinations of these treatments," Dr. Bashir says. "Our goal is not simply to perform a procedure but to develop an individualized pathway that produces the best possible long-term outcome for each patient."
For more information
Auger WR, et al. Balloon pulmonary angioplasty for treatment of chronic thromboembolic pulmonary hypertension statement from the BPA-CTEPH Alliance. JACC: Cardiovascular Interventions. 2026;19:923.
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