Abstract
BackgroundEmbolization is the standard of care for treatment of pulmonary arteriovenous malformations (PAVMs). Persistence of PAVMs after embolization occurs for undefined reasons but may include inflammation related to smoking in dysregulated angiogenesis.PurposeTo determine whether patients with hereditary hemorrhagic telangiectasia (HHT) who smoke tobacco are more prone to PAVM persistence after embolization.Materials and MethodsPatients with HHT treated for PAVMs between January 2000 and August 2017 were retrospectively identified. Only PAVMs with no previous treatment and patients with both clinical and imaging follow-up were included. Age, sex, PAVM characteristics (size, complexity, and location), embolization material used, microcatheter type, smoking history, active tobacco use, and other risk factors for arterial disease were analyzed by using a multivariate Cox proportional hazards model to determine risk factors for persistence.ResultsFive-year persistence-free survival rates in nonsmokers, smokers of 1–20 pack-years, and smokers of more than 20 pack-years were 12.2%, 21.9%, and 37.4% respectively. Smokers with more than 20 pack-years relative to nonsmokers had greater risk of persistence after adjusting for arterial feeder size (hazard ratio, 3.8; 95% confidence interval [CI]: 1.5, 10.0; P = .007). Patients who reported active tobacco use at the time of PAVM embolization had a 5-year cumulative incidence of persistence of 26.3% compared with 13.5% in inactive smokers. After adjusting for arterial feeder size, the risk of persistence was greater in tobacco users versus inactive smokers at the time of treatment (hazard ratio, 2.4; 95% CI: 1.2, 4.7; P = .01).ConclusionSmoking is associated with pulmonary arteriovenous malformation persistence after embolization in patients with hereditary hemorrhagic telangiectasia. Online supplemental material is available for this article. See also the editorial by Trerotola and Pyeritz in this issue.
Highlights
His retrospective study was approved by our institutional review board
Key Points nn Relative to a patient who never smoked, the risk of persistence in pulmonary arteriovenous malformations (PAVMs) after treatment was increased for a smoker with more than 20 pack-years
A Cox proportional hazards regression model was used to assess variable associations with the risk of persistence, with the results reported as hazard ratios and 95% confidence intervals (CIs)
Summary
His retrospective study was approved by our institutional review board. All patients with HHT who were treated for pulmonary AVMs at our institution between January 2000 and August 2017 were identified. We only included patients who definitely had HHT as defined by the presence of three or more Curaçao criteria [14]. PAVMs were identified at either contrast agent–enhanced chest CT or pulmonary arteriography. A PAVM was defined by the presence of a dilated arterial vessel connected to a dilated draining vein by a PAVM sac [15]. Adequate imaging follow-up required a contrastenhanced chest CT or pulmonary arteriography performed at least 3 months after embolization and yearly after the embolization. Patients with PAVMs who were previously treated at an outside institution and patients without adequate clinical and imaging follow-up were excluded, leaving a final cohort of 103 patients (Fig 1). Demographic, clinical, procedural, anatomic, and treatment outcomes were obtained by using our institution’s electronic medical record database
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