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Pulmonary Arteriovenous Malformations: Effect of Embolization on Right-to-Left Shunt, Hypoxemia, and Exercise Tolerance in 66 Patients

P. Gupta1, C. Mordin2, J. Curtis2, J. M. B. Hughes2, C. L. Shovlin2 and J. E. Jackson1

1 Department of Imaging, Imperial College Faculty of Medicine, Hammersmith Hospital, Du Cane Rd., London W12 0NN, England.
2 Department of Respiratory Medicine, National Heart and Lung Institute, Imperial College Faculty of Medicine, Hammersmith Hospital, London W12 0NN, England.



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  		Fig. 1A. —52-year-old woman with single left basal pulmonary arteriovenous malformation. Selective left pulmonary arteriogram in right anterior oblique projection shows basal pulmonary arteriovenous malformation arising from segmental basal branch.

 


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  		Fig. 1B. —52-year-old woman with single left basal pulmonary arteriovenous malformation. Selective angiogram with catheter in segmental basal pulmonary artery branch shows rapid arteriovenous shunting and poor filling of distal pulmonary artery branches because of steal effect.

 


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  		Fig. 1C. —52-year-old woman with single left basal pulmonary arteriovenous malformation. After selective embolization of feeding vessel to pulmonary arteriovenous malformation, angiogram shows obliteration of arteriovenous shunting and preservation of normal peripheral pulmonary artery branches. Note improved filling of these vessels and of proximal branches that did not fill before embolization, as well as "negative" filling defect of aneurysmal sac.

 


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  		Fig. 2A. —48-year-old woman with large pulmonary arteriovenous malformation. Selective angiogram of segmental left basal pulmonary artery branch shows large arteriovenous malformation sac arising directly from side wall of proximal portion of this vessel with no identifiable neck. Conventional embolization of this malformation by occlusion of feeding artery would involve occlusion of large segment of normal lung.

 


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  		Fig. 2B. —48-year-old woman with large pulmonary arteriovenous malformation. Arteriogram shows that sac has been catheterized. Rapid shunting is seen into draining pulmonary vein.

 


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  		Fig. 2C. —48-year-old woman with large pulmonary arteriovenous malformation. Arteriogram after embolization shows metallic coils placed in sac to achieve occlusion while preserving parent vessel and distal normal pulmonary artery branches.

 


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  		Fig. 3A. —71-year-old woman with two right basal pulmonary arterio-venous malformations. Chest radiograph before embolization shows large rounded softtissue nodule at right lung base and another smaller rounded nodule lateral to it.

 


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  		Fig. 3B. —71-year-old woman with two right basal pulmonary arteriovenous malformations. Chest radiograph obtained 1 year after embolization shows disappearance of both venous sacs.

 


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  		Fig. 3C. —71-year-old woman with two right basal pulmonary arteriovenous malformations. Selective right pulmonary arteriogram in left anterior oblique projection shows massive basal pulmonary arteriovenous malformation with two feeding vessels. Smaller malformation is less clearly seen medially.

 


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  		Fig. 3D. —71-year-old woman with two right basal pulmonary arteriovenous malformations. Control radiograph obtained after conventional coil embolization of more superior of two feeding arteries shows 11.5-mm occlusion balloon inflated to approximately 8 mm in lower feeding vessel to occlude flow and stabilize catheter position during embolization. Embolization of lower feeding artery could not be performed through conventional angiographic catheter because of rapid flow and large communication with venous sac.

 


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  		Fig. 3E. —71-year-old woman with two right basal pulmonary arteriovenous malformations. Angiogram obtained during inflation of occlusion balloon shows anatomy of feeding artery and large communication with venous sac.

 


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  		Fig. 3F. —71-year-old woman with two right basal pulmonary arteriovenous malformations. Angiogram after embolization, obtained with coils introduced through lumen of balloon catheter during balloon inflation, shows successful occlusion.

 

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