Recurrent pulmonary thrombosis after balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension

A 65-year-old man with history of chronic thromboembolic pulmonary hypertension underwent balloon pulmonary angioplasty (BPA) combined with rivaroxaban 15 mg once daily. Lung ventilation/perfusion scintigraphy using 81mKrypton and 99mTechnetium showed multiple segmental and sub-segmental mismatched perfusion defects (Panels A and B), and pulmonary artery angiography (PAG) at the time of diagnosis showed irregular vessel contour and occlusion which localized in segmental and sub-segmental pulmonary artery (Panels C and D, see Supplementary material online, Videos S1 and S2). After several times of interventions, segmental PAG showed improved flows, and the mean pulmonary artery pressure (PAP) was improved from 31 to 25 mmHg along with his symptoms improvement. However, the patient felt gradually worsening dyspnoea on exertion after discharge, and PAG 3 months after BPA showed the filling defect in left A10 pulmonary artery branches (Panel E; see Supplementary material online,...