Case report
Therapeutic embolization of the pulmonary artery in pulmonary arteriovenous fistula

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Abstract

A 35 year old white man was admitted in January 1976 for further treatment of pulmonary A-V fistula. In 1975, he had dyspnea, cyanosis and clubbing; pulmonary angiogram showed a fistula in the lower lobe of the left lung and one in the upper lobe of the right lung; the arterial oxygen tension (PaO2) was 54 mm Hg and the calculated intrapulmonary shunt was 25 per cent of the cardiac output; a lobectomy of the left lung was performed. On this admission, dyspnea, cyanosis and clubbing were still present: the PaO2 was 67 mm Hg and the intrapulmonary shunt 14 per cent. Since it was possible to show angiographically that, by balloon inflation during Swan-Ganz catheterization of the upper lobe of the right lung, the single pulmonary A-V fistula was completely obliterated with correction of the intrapulmonary shunt, mechanical occlusion was attempted as an alternative to further surgery. Through a No. 7 French catheter inserted via a femoral vein into the pulmonary artery of the upper lobe of the right lung and with the help of repeated selective angiography, six mechanical occluding devices (each consisting of a 5 cm segment of steel guidewire with 3 cm wool tails) were placed into the vessels feeding the fistula. Twenty minutes after placement of the last two coils, the fistula was almost totally occluded on angiogram; the PaO2 was 79 mm Hg and the intrapulmonary shunt was 7 per cent; over the following three weeks, without further manipulation, these returned to normal (91 mm Hg and 4 per cent, respectively). No complications have been noted. The patient has been symptom free during 12 months of close follow-up; results of oxygen studies have remained normal; on chest film the six coils have not changed position. The procedure described here, to our knowledge performed for the first time for correction of pulmonary A-V fistula, should be considered in preference to surgical resection in selected patients with this condition.

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From the Pulmonary Research Laboratories and Radiology Department of the West Tenth Street Veterans Administration Hospital and the Indiana University School of Medicine, Indianapolis, Indiana.

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