Clinical Studies
Clinical and Anatomic Outcomes after Embolotherapy of Pulmonary Arteriovenous Malformations

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PURPOSE

To assess long-term clinical and imaging results of technically successful pulmonary arteriovenous malformation (AVM) embolization.

MATERIALS AND METHODS

One hundred fifty-five patients with pulmonary AVMs underwent embolization during a period of 3 years. Recommended follow-up included clinical assessment, helical computed tomography, and physiologic evaluation within 1 year and then every 5 years.

RESULTS

Hereditary hemorrhagic telangiectasia was present in 148 patients (95%). Four hundred fifteen pulmonary AVMs were occluded during 205 procedures. Clinical follow-up was available in all patients over 3–7 years and imaging follow-up was available in 144 patients (393 lesions) over 1–7 years (mean, 2.9 y). Problems related to pulmonary AVMs occurred in 35 patients (23%) at 42 time points: 22 patients with 23 symptomatic events and 17 patients with 19 asymptomatic events. Symptoms resulted from growth of nonembolized pulmonary AVMs (n = 19), residual embolized pulmonary AVMs (n = 5), or both (n = 2). Symptoms consisted of respiratory manifestations (n = 13), cerebral ischemia (n = 4), brain abscess (n = 5), hemoptysis (n = 3), and seizure (n = 1). Imaging showed pulmonary AVM involution in 97% of embolized lesions and 11 residual lesions (2.8%) in 10 patients (6.9%). These were caused by recanalization (n = 7), presence of an accessory feeding artery (n = 1), pulmonary collateral vessels (n = 1), and bronchial collateral vessels (n = 2). CT detected 10 of the 11 residual lesions. Imaging detected 97 previously small pulmonary AVMs that had enlarged to a significant size in 28 patients (18%), 15 of whom were symptomatic and 13 of whom were asymptomatic.

CONCLUSION

Clinical and anatomic evaluation after pulmonary AVM embolization is important to detect persistent or reperfused lesions and enlarging lesions, with the latter more common. Patients with persistent, reperfused, or enlarging lesions often have symptoms, but a significant minority of patients are asymptomatic. More frequent assessment may improve detection before the onset of symptoms.

Section snippets

Patients

Previously unreported patients were enrolled in this prospective study over a 3-year period from July 1, 1996, to June 30, 1999. Approval from our institutional review board (Human Investigation Committee) was obtained. Patients underwent evaluation for manifestations of pulmonary AVM and HHT. This consisted of a thorough history and physical examination, baseline pulse oximetry for oxygen saturation, often an arterial blood gas analysis for oxygen tension, and an imaging evaluation. Imaging

Patients and Embolization Data

One hundred fifty-five patients had embolization of pulmonary AVMs during the study period, of whom 148 (95%) had HHT. There were 65 male patients and 90 female patients, with a mean age of 45 years (range, 7–77 y). Seven patients were children younger than 18 years of age, with ages ranging from 7 to 18 years and a mean of 12 years. Information on clinical manifestations is available for 154 of these patients (Table 1).

Four hundred fifteen pulmonary AVMs were embolized in 205 procedures; 50

DISCUSSION

Pulmonary AVMs are well-known to predispose patients to significant morbidity other than just the effects of hypoxemia (3, 6, 24). In this study, one third of patients had a history of stroke or transient ischemic attack, whereas 9% had previous brain abscesses, 6% had other infections, and 3% had previous lung hemorrhage. The danger of leaving a pulmonary AVM alone after it has been diagnosed has also been demonstrated by Swanson et al (7), who found that five of 15 patients available for

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    • Cited by (0)

    R.I.W. and K.J.H. are supported in part by grants from the March of Dimes (grant HHT-FY04-677), the Josephine Lawrence Hopkins Foundation, and Yale– New Haven Hospital General Clinical Research Unit Grant NIH M01-RR-00125. None of the authors have identified a conflict of interest.

    1

    Current address: Department of Radiology, Massachusetts General Hospital, Boston, MA.

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