{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T11:17:09Z","timestamp":1788434229661,"version":"build-2803163510"},"reference-count":71,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T00:00:00Z","timestamp":1788393600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Cardiovasc. Dev. Dis.","JCDD"],"abstract":"<jats:p>Chronic thromboembolic pulmonary hypertension (CTEPH) is a treatable yet frequently underdiagnosed late complication of acute pulmonary embolism, in which incompletely resolved thromboemboli organise into fibrotic obstructions of the pulmonary arteries and, together with a secondary small-vessel arteriopathy affecting both obstructed and non-obstructed territories, raise pulmonary vascular resistance, impose right ventricular pressure overload, and\u2014if left untreated\u2014progress to right heart failure and death. Three established therapies address the disease at distinct anatomical levels: pulmonary endarterectomy, the potentially curative treatment of choice for surgically accessible disease; balloon pulmonary angioplasty, for distal inoperable lesions or residual disease; and pulmonary hypertension-targeted medical therapy, for the accompanying microvasculopathy. Their evaluation in randomised controlled trials and large registries has produced a multimodal paradigm in which these treatments are combined and sequenced according to operability and lesion distribution. This narrative review synthesises evidence published through January 2026 to accomplish the following: (i) summarise and critically appraise the contemporary evidence for each modality, distinguishing guideline-supported recommendations from observational, proof-of-concept, and expert-opinion-based practice; (ii) describe how treatments are selected, sequenced, and bridged in relation to operability and to residual or recurrent pulmonary hypertension after endarterectomy; and (iii) situate treatment within the broader chronic thromboembolic pulmonary disease spectrum and the case-finding pathway after pulmonary embolism. Rather than proposing a validated algorithm, it emphasises that, because each modality carries distinct indications and risks, decisions should be individualised through multidisciplinary assessment at expert centres, with early referral central to optimising outcomes.<\/jats:p>","DOI":"10.3390\/jcdd13090433","type":"journal-article","created":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T10:10:33Z","timestamp":1788430233000},"page":"433","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Multimodal Management of Chronic Thromboembolic Pulmonary Hypertension: A Narrative Review of Treatment Selection and Sequencing"],"prefix":"10.3390","volume":"13","author":[{"given":"Houda","family":"Gharsalli","sequence":"first","affiliation":[{"name":"Pulmonology Department, Aseer Central Hospital, Abha 62523, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammed","family":"Alshahrani","sequence":"additional","affiliation":[{"name":"Pulmonology Department, Aseer Central Hospital, Abha 62523, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Olfa","family":"Harbi","sequence":"additional","affiliation":[{"name":"Pulmonology Section, Medical Department, Imam Abdulrahman Al-Faisal Hospital, Riyadh 11461, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nawal","family":"Alwadai","sequence":"additional","affiliation":[{"name":"Pulmonology Department, Aseer Central Hospital, Abha 62523, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdalla M.","family":"Al-Asiri","sequence":"additional","affiliation":[{"name":"Pulmonology Department, Aseer Central Hospital, Abha 62523, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fatmah","family":"Alahmari","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Aseer Central Hospital, Abha 62523, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amal","family":"Alqahtani","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Aseer Central Hospital, Abha 62523, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-3164-2785","authenticated-orcid":false,"given":"Najla","family":"Al-Jahash","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Aseer Central Hospital, Abha 62523, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lobna","family":"Abbag","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Aseer Central Hospital, Abha 62523, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-2091-2642","authenticated-orcid":false,"given":"Saud","family":"Alqahtani","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Aseer Central Hospital, Abha 62523, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2931-7039","authenticated-orcid":false,"given":"Khaled Abdulwahab","family":"Amer","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Aseer Central Hospital, Abha 62523, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"460","DOI":"10.1080\/00325481.2016.1188664","article-title":"Update on pulmonary arterial hypertension pharmacotherapy","volume":"128","author":"Velayati","year":"2016","journal-title":"Postgrad. 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