Endovascular treatment of pulmonary arteriovenous malformations in hereditary haemorrhagic telangiectasia

Endovascular Embolisation of Pulmonary Arteriovenous Malformation Using Amplatzer Vascular Plugs

Pulmonary arteriovenous malformation (PAVMs) are abnormal communications between pulmonary arteries and veins. The rarity of their occurrence, coupled with the risks they pose, including brain abscess, embolic stroke, and myocardial infarction, mandates that they should not be overlooked in the differential diagnosis of patients presenting with haemoptysis, dyspnea, clubbing, cyanosis, hypoxemia, or epistaxis.

We present the case of a 41-year-old local female who presented to our hospital as an outpatient with decreased oxygen saturation (SpO₂) of 70%-80% for the past two years with a final diagnosis of PAVM. The initial baseline workup showed polycythemia with a hemoglobin level of 19 mg/dL and raised hematocrit. She had extensive workup in the past two years for her polycythemia including gene mutation testing and cardiac workup which all turned out normal. Her chest X-ray (CXR) showed right lung opacity which was initially considered to be infective but it did not respond to antibiotic treatment. Later on, a CT scan of the chest was performed and findings were typical of a large PAVM which had two feeding arteries. The patient was referred to a cardiothoracic surgeon who sent the patient to the interventional radiology section for endovascular management.

The embolization procedure was then performed and both feeders were successfully embolised. After the procedure, the patient's SpO₂ levels were restored to 95%-96%, and no post-procedure complications were noted.

Evaluation of percutaneous transcatheter embolization for pulmonary arteriovenous malformations

BACKGROUND

The purpose of this study was to assess the safety and efficacy of percutaneous transcatheter embolization (TCE) for the treatment of pulmonary arteriovenous malformations (PAVMs).

METHODS

Forty-three consecutive patients (n = 17 males; n = 26 females) with 72 untreated PAVMs underwent coil and/or plug embolization between January 2010 and February 2018. The mean patient age was 42 ± 14 years (range 19-71 years). The median size of the feeding artery was 7.9 ± 2.9 mm (range 3.5-14.0 mm). The arterial blood gas level and cardiac function of all patients were analysed. The technical success rate, recanalization rate, and complications were evaluated. Computed tomography angiography (CTA) examinations were scheduled for 12 months after treatment and every 2-4 years thereafter.

RESULTS

Twenty-five PAVMs were treated with coils alone, twenty-one were treated with plugs alone, and twenty-six were treated with both coils and plugs. The technical success rate was 100%. There were no complications during operation. However, one patient (2.3%) had pulmonary thrombosis and embolism post-operation. The patients' pre-operative and post-operative PaO₂ and SaO₂ levels were significantly different (p < 0.01). A comparison of the New York Heart Association (NYHA) grade before and after embolization in all patients showed a significant decrease in the post-operative grade (p < 0.01). The 72 PAVMs were divided into three groups (coils only group [n = 25], plugs only group [n = 21], and coils/plugs combined group [n = 26]). After 12 months of follow-up, there were seven reperfusion PAVMs in the coil group, seven reperfusion PAVMs in the plug group, and 1 reperfusion PAVM in the combined group. There were significant differences between the two groups and the combined group.

CONCLUSION

Percutaneous TCE is safe and effective for the treatment of PAVMs. A combination of coils and vascular plugs may be useful for preventing recanalization after the embolization of PAVMs.

[Pulmonary arteriovenous shunt - a rare cause of recurrent stroke due to paradoxical embolism]

Paradoxical embolism is one of the mechanisms of ischemic stroke in patients younger than 45 years of age, due to opening between the right and left chambers of the heart through a patent foramen ovale, an atrial or ventricular septal defect, pulmonary arteriovenous malformations (PAVMs), etc. The PAVMs are structurally abnormal vessels that provide direct capillary-free communication between the pulmonary and systemic circulations, and hence an anatomic "right-to-left" shunt. Most pulmonary malformations are congenital and associated with hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease). This publication highlights the issues of pathogenesis, clinical presentation, diagnosis and treatment of this pathology, and also describes a clinical case in which multiple PAVMs caused repeated ischemic strokes.

Embolisation of pulmonary arteriovenous malformations using high-frequency jet ventilation: benefits of minimising respiratory motion

Background

To evaluate patient radiation dose and procedural duration recorded during pulmonary arteriovenous malformation (PAVM) embolisation performed using high-frequency jet ventilation (HFJV) as compared with conventional intermittent positive pressure ventilation (IPPV)

Methods

Patients undergoing PAVM embolisation with HFJV assistance after April 2017 were retrospectively identified as group A, and those treated with IPPV before April 2017 as group B. Primary outcomes were patient radiation dose and procedural duration between groups A and B. Secondary outcomes were difference in diaphragmatic excursion between groups A and B, in group A with/without HFJ assistance, technical/clinical success, and complications.

Results

Twelve PAVMs were embolised in 5 patients from group A, and 15 PAVMs in 10 patients from group B. Mean patient radiation was significantly lower in group A than in group B (54,307 ± 33,823 mGy cm² [mean ± standard deviation] versus 100,704 ± 43,930 mGy cm²; p = 0.022). Procedural duration was 33.4 ± 16.1 min in group A versus 57.4 ± 14.9 min in group B (p = 0.062). Diaphragmatic excursion was significantly lower in group A (1.3 ± 0.4 mm) than in group B (19.7 ± 5.2 mm; p < 0.001) and lower with near statistical significance in group A with HFJV than without HFJV (1.3 ± 0.4 mm versus 10.9 ± 3.1 mm; p = 0.062). Technical and clinical success was 100% in both groups, without relevant complications.

Conclusion

HFJV-assisted PAVM embolisation is a safe, feasible technique resulting in reduced patient radiation doses and procedural time.