Ep. 56 Interventional Techniques for Chronic Thromboembolic Pulmonary Hypertension with Dr. Riyaz Bashir

What does it actually take to open a chronically occluded pulmonary artery without pushing the patient into reperfusion pulmonary edema? On this episode of BackTable Cardiology, Dr. Hady Lichaa interviews Dr. Riyaz Bashir, interventional cardiologist and vascular medicine specialist at Mayo Clinic in Jacksonville, about the real-world, table-side technique of balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension (CTEPH). They walk through vascular access, telescoping sheath setup, right heart catheterization, pressure wire guidance, balloon sizing, and step-by-step planning for each lobe and lesion. --- Get the BackTable app https://www.backtable.com/app --- Timestamps 00:00 - Introduction 02:48 - Procedural Setup and Vascular Access 06:31 - Sheath in Sheath Technique 11:20 - Guide Catheter Selection 17:53 - Wire Selection and Balloon Undersizing 22:12 - Crossing Chronic Total Occlusions 27:25 - Pulmonary Collaterals and Flush Occlusions 32:33 - Guide Extensions and Contrast Reduction 36:38 - Distal Perfusion Pressure Targets 41:26 - Pressure Wire Selection and Wire Management 45:54 - Balloon Sizing and Reperfusion Pulmonary Edema 54:04 - Hemoptysis and Gelatin Sponge Embolization 1:02:32 - Closing Remarks --- More about this episode Dr. Bashir describes a technique he has simplified over ten years, built around a single principle that the goal of the procedure is perfusion rather than a better looking angiogram. He explains why early sessions use deliberately undersized balloons to restore flow safely, how these lesions behave like scar tissue, and why retrograde approaches are risky in fragile pulmonary vessels. The discussion covers practical strategies for keeping distal pressure low, managing hemoptysis with balloon tamponade and gelatin sponge embolization, and staging treatment over several sessions. The discussion closes with advice on mechanical circulatory support planning and the judgment, preparation, and teamwork that make high-risk BPA safe and effective. --- Resources Mizoguchi H, Ogawa A, Munemasa M, Mikouchi H, Ito H, Matsubara H. Refined Balloon Pulmonary Angioplasty for Inoperable Patients With Chronic Thromboembolic Pulmonary Hypertension. Circ Cardiovasc Interv. 2012 https://doi.org/10.1161/CIRCINTERVENTIONS.112.971077 Auger WR, et al. Balloon Pulmonary Angioplasty for Treatment of Chronic Thromboembolic Pulmonary Hypertension: Statement From the BPA-CTEPH Alliance. JACC Cardiovasc Interv. 2026 https://doi.org/10.1016/j.jcin.2026.02.033 Nasri A, Bashir R, Lakhter V. Management of Complications of Balloon Pulmonary Angioplasty. Card Electrophysiol Clin. 2025 https://doi.org/10.1016/j.ccep.2024.12.015 Lang IM, et al. Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension: Results of an International Multicenter Prospective Registry. J Am Coll Cardiol. 2025 https://doi.org/10.1016/j.jacc.2025.04.021 Aggarwal V, et al. Status and Future Directions for Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Disease With and Without Pulmonary Hypertension. A Scientific Statement From the American Heart Association. Circulation. 2024 https://doi.org/10.1161/CIR.0000000000001197 Inami T, et al. Pulmonary Edema Predictive Scoring Index (PEPSI), a New Index to Predict Risk of Reperfusion Pulmonary Edema and Improvement of Hemodynamics in Percutaneous Transluminal Pulmonary Angioplasty. JACC Cardiovasc Interv. 2013 https://doi.org/10.1016/j.jcin.2013.03.009 BackTable Cardiology Episode 36. Understanding CTEPH, Diagnostic and Interventional Techniques https://www.backtable.com/shows/cardiology/podcasts/36/understanding-cteph-diagnostic-interventional-techniques Dr. Riyaz Bashir, Mayo Clinic, Jacksonville https://www.mayoclinic.org/biographies/bashir-riyaz-m-b-b-s-m-d/bio-20590757 Dr. Hady Lichaa, BackTable contributor page https://backtable.com/shows/vi/contributors/dr-hady-lichaa Dr. Hady Lichaa, Ascension Saint Thomas Heart https://healthcare.ascension.org/doctors/1336267533/hady-t-lichaa-murfreesboro-tn --- BackTable Cardiology is the go-to podcast for interventional cardiologists, cardiac surgeons, and other healthcare professionals that manage cardiovascular conditions. Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty. ► https://www.backtable.com/app