Successful coil embolization for diffuse, multiple pulmonary arteriovenous fistulas

Abstract

Although many patients with pulmonary arteriovenous fistulas (PAVF) remain asymptomatic in infancy and early childhood,‘* 2 symptoms and serious complications may occur in later childhood or adulthood and may necessitate some type of intervention. Previously, surgical resection was the accepted treatment for symptomatic patients with PAVF.” More recently, however, it has been shown that some of these lesions are amenable to less invasive therapy4-g such as balloon10-13 or coil spring emboiization’4-*6 that spares normal pulmonary parenchyma.r3-I5 A 24-year-old woman became aware of cyanosis and clubbing about 1 year prior to consultation after she had begun to experience fatigue on exertion. Physical examination confirmed cyanosis and marked clubbing but revealed a normal heart size and heart sounds with no cardiac or pulmonary murmur. Blood pressure was 102170 mm Hg. She had no cutaneous vascular lesions or other abnormalities. Red blood cell (RBC) count was 6.88 million, the hemoglobin was 17.5 gm, and the hematocrit was 55.9 (Table I). Oxygen saturation in room air by pulse oximetry was 87 %. The electrocardiogram and echocardiogram were normal, Chest roentgenogram revealed a heart of normal size with average pulmonary vascularity in the right lung but diffuse interstitial markings in the mid and lower left lung field, where a prominent vascular shadow was seen within the cardiac silhouette (Fig. 1, A). A diagnosis of pulmonary arteriovenous fistulas was made. Prior to cardiac catheterization, the patient underwent a ventilation-perfusion lung scan. The results, consistent with abnormality of the left lung, are seen in Table II. The images from the scan showed no segmental or subsegmental defects. There was slightly decreased perfusion in the region of the left major fissure. The distribution of radionuclide medium suggested the presence of a right-to-left shunt. Cardiac catheterization and selective arteriography of the left and right pulmonary arteries and their major branches was then carried out using intraarterial digital