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            "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Balloon pulmonary angioplasty of segment A7 &#43; 8 of the left lower lobe&#46; &#40;A&#41; Selective pulmonary angiography demonstrating total occlusion of the A8 segment &#40;yellow arrow&#41; and a web at the bifurcation of segment 7 &#40;&#42;&#41;&#59; &#40;B&#41; passage of a Whisper MS guidewire &#40;Abbot Vascular&#44; Santa Clara&#44; CA&#44; USA&#41;&#44; through the occlusion in segment A8&#59; &#40;C&#41; vessel dilation with a semicompliant 4&#46;0&#47;20 Pantera Pro balloon &#40;Biotronik SE &#38; Co KG&#44; Berlin&#44; Germany&#41;&#59; &#40;D&#41; selective pulmonary angiography showing a good final result in segment A8 and segment A7 not yet treated &#40;&#42;&#41;&#59; &#40;E&#41; following dilation of segment A7 at the level of the web &#40;&#42;&#41;&#44; a good final angiographic result is achieved&#44; with increased arterial flow&#59; &#40;F&#41; venous return observed &#40;red arrow&#41; on final selective angiography of segment A7 &#43; 8 documenting pulmonary flow grade 3&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Balloon pulmonary angioplasty &#40;BPA&#41; is a complex endovascular technique with a demanding learning curve that is rapidly expanding for the treatment of chronic thromboembolic pulmonary hypertension &#40;CTEPH&#41; patients not eligible for surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Pulmonary endarterectomy &#40;PEA&#41; remains the treatment of choice&#44; as it is potentially curative with established short- and long-term benefits&#44; but is not possible in 40&#37; of patients due to distal disease or comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Moreover&#44; up to 30&#37; of operated patients may have persistent pulmonary hypertension &#40;PH&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> In both cases&#44; pulmonary arterial hypertension &#40;PAH&#41;-targeted therapy has proven&#44; albeit limited&#44; efficacy&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the last five years&#44; increasing observational data have documented the efficacy of BPA in inoperable CTEPH patients&#44; consistently demonstrating improved hemodynamic&#44; clinical and biomarker parameters&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Complications following BPA are not rare and have been a matter of concern in the past&#46; Complication rates have improved in recent series and do not exceed 11&#37; except for one series with 36&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Periprocedural mortality is usually less than 2&#37;&#46; More recently treated patients have greater hemodynamic improvements with fewer complications&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Lung injury is the principal complication following BPA and is associated with vascular injury and severely impaired hemodynamics&#46; Advances in the BPA technique and strategy have succeeded in reducing vascular injury&#44; improving the safety of the procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The article by Cal&#233; et al&#46; in the current issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> is the first reported experience in Portugal of BPA for the treatment of CTEPH patients and an example of successful implementation of a BPA program on the part of a multidisciplinary CTEPH team&#46; A series of 11 CTEPH patients&#44; inoperable or with persistent&#47;recurrent PH&#44; underwent BPA in a total of 57 sessions&#46; Assessment at baseline and at six-month follow-up enabled assessment of efficacy and safety&#46; The results are in line with those reported in larger contemporary series showing clinical and hemodynamic improvement&#46; Minor complications were recorded in 25&#37; of patients&#44; but no major complications or mortality&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite growing experience and progressively improving results with the BPA technique&#44; several important issues remain to be clarified&#46; One is the need for a better understanding of the mechanisms involved in the vascular effects of BPA&#44; somewhere between one week and several months after the procedure&#46; New treatment goals are also being proposed that challenge the standard of achieving a mean pulmonary artery pressure below 35 mmHg while addressing all accessible lesions&#46; Different populations&#44; such as the elderly&#44; might need different goals&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Clarifying these aspects will certainly improve patient selection and strategy&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">As experience increases&#44; the issue of appropriate patient selection for BPA is becoming more and more important&#46; There may be an overlap between BPA and PEA regarding accessible lesions at segmental and subsegmental level&#46; In addition&#44; some data are beginning to suggest similar results between BPA and PEA&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> New target BPA populations&#44; like operable patients with high surgical risk&#44; and different hybrid strategies combining BPA and PEA are starting to be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The role of PAH-targeted therapy in conjunction with BPA is also an open question&#46; In most contemporary series&#44; including the one reported in this issue&#44; the majority of patients undergoing BPA are already on specific PAH therapy&#46; The fact that these different therapeutic modalities target different territories&#44; and that a less severe baseline hemodynamic state influences the safety of BPA&#44; are good arguments in favor of this practice&#44; but there is no definite evidence in this field&#46; Comparisons between BPA and riociguat for inoperable CTEPH based on meta-analyses and one multicenter controlled trial point to a superior effect for BPA&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Properly addressing all the current questions regarding CTEPH treatment will in many cases require randomized controlled trials&#44; if possible with head-to-head comparisons between therapies&#46; The expertise and sample volume required would be expected to limit such trials to high-volume centers&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Advances in imaging and interventional catheter techniques are likely to emerge in the near future and will certainly result in better BPA results&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">CTEPH is a complex and severe disease involving different pathological mechanisms that coexist in variable degrees and are yet to be fully understood&#46; At present there are three established therapeutic modalities targeting different pathological compartments that may be associated in multiple ways&#46; Generating robust evidence and defining safe and effective rules leading to hybrid strategies is a challenging task&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Epidemiological data classify CTEPH as a rare disease&#46; Taking into consideration both the fact that CTEPH is underdiagnosed and undertreated<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> and the growing awareness developing around this disease&#44; it is reasonable to expect a rise in CTEPH incidence that will inevitably cause more difficulties in the near future&#46; The development of BPA programs like the one reported here is certainly a step in the right direction for improved care and resources&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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