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Charaniya R, Shah J, M A. Unveiling the complexity: coexistence of rheumatic heart disease and pulmonary arteriovenous malformation-a unique case report. Eur Heart J Case Rep 2024; 8:ytae239. [PMID: 38845808 PMCID: PMC11156197 DOI: 10.1093/ehjcr/ytae239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/13/2024] [Accepted: 05/03/2024] [Indexed: 06/09/2024]
Abstract
Background The coexistence of rheumatic heart disease (RHD) and pulmonary arteriovenous malformation (PAVM) is a rare clinical scenario that poses diagnostic and therapeutic challenges. This case report explores the clinical presentation, diagnostic journey, and multidisciplinary management of a patient presenting with both conditions. Case summary A 47-year-old female with a history of RHD presented with symptoms of dyspnoea on exertion and cyanosis, suggestive of both cardiac involvement and pulmonary involvement. Subsequent investigations involving imaging, echocardiography, and invasive pulmonary angiography revealed the coexistence of RHD and multiple PAVM in the patient's left lower lobe of the lung. The patient underwent a tailored treatment plan, initially involving percutaneous mitral balloon valvuloplasty for RHD, followed by a staged procedure of transcatheter PAVM closure with Amplatzer™ Vascular Plug II performed 1 month later. Her saturation normalized following the intervention. The patient's progress was monitored closely, with adjustments made to the treatment plan based on evolving clinical scenarios. The patient remained well in short-term follow-up. Discussion This case highlights the complexity of managing patients having two diverse conditions RHD and PAVM coexisting together, thus emphasizing the importance of a multidisciplinary approach. The unique intersection of cardiac and pulmonary pathologies necessitates careful consideration of diagnostic nuances and tailored treatment strategies. Lessons learned from this case offer valuable insights for clinicians encountering similar scenarios and underscore the significance of individualized, patient-centred care in optimizing outcomes for those with dual pathologies.
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Affiliation(s)
- Riyaz Charaniya
- Department of cardiology, U. N. Mehta Institute of Cardiology and Research Centre (UNMICRC), Civil Hospital Campus, Asarwa, Ahmedabad 380016, Gujarat, India
| | - Jayal Shah
- Department of cardiology, U. N. Mehta Institute of Cardiology and Research Centre (UNMICRC), Civil Hospital Campus, Asarwa, Ahmedabad 380016, Gujarat, India
| | - Apoorva M
- Department of cardiology, U. N. Mehta Institute of Cardiology and Research Centre (UNMICRC), Civil Hospital Campus, Asarwa, Ahmedabad 380016, Gujarat, India
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Taxak A, Verma M, Pandey NN, Singh V, Kumar S, Jagia P. Efficacy and Safety of Venous Sac Embolization With or Without Feeding Artery Embolization Versus Feeding Artery Embolization Alone in the Management of Pulmonary Arteriovenous Malformations: A Systematic Review and Meta-analysis. J Endovasc Ther 2024; 31:421-427. [PMID: 36147015 DOI: 10.1177/15266028221125582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To evaluate by meta-analysis the safety and efficacy of venous sac embolization (VSE) with or without feeding artery embolization versus feeding artery embolization (FAE) alone in the management of pulmonary arteriovenous malformations (PAVMs). METHODS This systematic review and meta-analysis was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic literature search was performed in MEDLINE, Embase, and Scopus till August 31, 2021 to identify studies comparing the safety and efficacy of VSE with or without FAE versus FAE alone in PAVMs. The success of treatment was assessed by comparing the number of PAVMs with ≥70% decrease in the size of draining vein/sac between the 2 groups. The pooled odds ratio (OR) and 95% confidence interval (95% CI) were calculated using the random-effects inverse-variance model and were used to compare pooled therapeutic efficacy between the groups. RESULTS Three studies were found eligible for the meta-analysis. The included studies had a total of 169 patients (119 females and 50 males). The total number of PAVMs was 298, and hereditary hemorrhagic telangiectasia was present in 119 patients. The success of treatment was higher with VSE as compared to FAE (OR=3.54, 95% CI=1.66-7.56). The minor complications were similar in both groups, and one major complication occurred in the FAE group. More coils were used in the VSE group. CONCLUSIONS The present systematic review and meta-analysis has consolidated the evidence that VSE with or without FAE is more efficacious than FAE alone in the management of PAVMs without any increase in the associated risk of sac rupture or coil migration. CLINICAL IMPACT Until high-quality data from a prospective, multicentric, randomized controlled trial becomes available, the evidence consolidated by the present systematic review and meta-analysis showing the efficacy of venous sac embolization (with or without feeding artery embolization) over feeding artery embolization alone, can be used for clinical decision-making in the management of pulmonary arterio-venous malformations.
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Affiliation(s)
- Avichala Taxak
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Mansi Verma
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Niraj Nirmal Pandey
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Vishwajeet Singh
- Department of Geriatric Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Kumar
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Priya Jagia
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
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Pillai AK, Steigner ML, Aghayev A, Ahmad S, Ferencik M, Kandathil A, Kirsch DS, Lee YJ, Nagpal P, O'Neil K, Partovi S, Revels S, Ripley B, Russell RR, Saboo SS, Tannenbaum A, Thomas R, Wells BJ, Yu HS, Kalva SP. ACR Appropriateness Criteria® Pulmonary Arteriovenous Malformation (PAVM): 2023 Update. J Am Coll Radiol 2024; 21:S268-S285. [PMID: 38823949 DOI: 10.1016/j.jacr.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Pulmonary arteriovenous malformations (PAVMs) occur in 30% to 50% of patients with hereditary hemorrhagic telangiectasia. Clinical presentations vary from asymptomatic disease to complications resulting from the right to left shunting of blood through the PAVM such as paradoxical stroke, brain abscesses, hypoxemia, and cardiac failure. Radiology plays an important role both in the diagnosis and treatment of PAVM. Based on different clinical scenarios, the appropriate imaging study has been reviewed and is presented in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Anil K Pillai
- University of Texas Southwestern Medical Center, Dallas, Texas.
| | | | - Ayaz Aghayev
- Panel Vice Chair, Brigham & Women's Hospital, Boston, Massachusetts
| | - Sarah Ahmad
- University of Toronto, Toronto, Ontario, Canada; American College of Physicians
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography
| | - Asha Kandathil
- University of Texas Southwestern Medical Center, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Yoo Jin Lee
- University of California San Francisco, San Francisco, California
| | - Prashant Nagpal
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kevin O'Neil
- Wilmington Health, Wilmington, North Carolina; American College of Chest Physicians
| | | | - Sha'Shonda Revels
- UCLA Medical Center, Los Angeles, California; The Society of Thoracic Surgeons
| | - Beth Ripley
- VA Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Raymond R Russell
- The Warren Alpert School of Medicine at Brown University, Providence, Rhode Island; Nuclear cardiology expert
| | | | | | - Richard Thomas
- Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Bryan J Wells
- Emory University, Atlanta, Georgia; American Society of Echocardiography
| | - Hei Shun Yu
- Brigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER
| | - Sanjeeva P Kalva
- Specialty Chair, Massachusetts General Hospital, Boston, Massachusetts
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4
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Cancemi G, Distefano G, Vitaliti G, Milazzo D, Terzo G, Belfiore G, Di Benedetto V, Scuderi MG, Coronella M, Musumeci AG, Grippaldi D, Mauro LA, Foti PV, Basile A, Palmucci S. Congenital Lung Malformations: A Pictorial Review of Imaging Findings and a Practical Guide for Diagnosis. CHILDREN (BASEL, SWITZERLAND) 2024; 11:638. [PMID: 38929218 PMCID: PMC11201397 DOI: 10.3390/children11060638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/01/2024] [Accepted: 05/21/2024] [Indexed: 06/28/2024]
Abstract
The term congenital lung malformation (CLM) is used to describe a wide range of pathological conditions with different imaging and clinical manifestations. These anomalies stem from abnormal embryological lung development, potentially occurring across various stages of prenatal life. Their natural history can be variable, presenting in a wide range of severity levels and encompassing asymptomatic individuals who remain so until adulthood, as well as those who experience respiratory distress in the neonatal period. Through the PubMed database, we performed an extensive review of the literature in the fields of congenital lung abnormalities, including their diagnostic approach and findings. From our RIS-PACS database, we have selected cases with a final diagnosis of congenital lung malformation. Different diagnostic approaches have been selected, including clinical cases studied using plain radiograph, CT scan, prenatal ultrasound, and MR images. The most encountered anomalies can be classified into three categories: bronchopulmonary anomalies (congenital pulmonary airway malformations (CPAMs), congenital lobar hyperinflation, bronchial atresia, and bronchogenic cysts), vascular anomalies (arteriovenous malformation), and combined lung and vascular anomalies (scimitar syndrome and bronchopulmonary sequestration). CLM causes significant morbidity and mortality; therefore, the recognition of these abnormalities is necessary for optimal prenatal counseling and early peri- and postnatal management. This pictorial review aims to report relevant imaging findings in order to offer some clues for differential diagnosis both for radiologists and pediatric consultants.
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Affiliation(s)
- Giovanna Cancemi
- U.O.C. Radiodiagnostica Lentini, ASP Siracusa, 96016 Siracusa, Italy;
| | - Giulio Distefano
- Institute of Nephrology and Dialysis—Nephrological, Vascular and Internal Medicine Diagnostic Ultrasound Service, Maggiore Hospital of Modica, ASP Ragusa, 97015 Modica, Italy;
| | - Gioele Vitaliti
- Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital Policlinico G. Rodolico-San Marco, University of Catania, 95123 Catania, Italy; (G.V.); (D.M.); (G.T.); (G.B.); (M.C.); (P.V.F.); (A.B.)
| | - Dario Milazzo
- Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital Policlinico G. Rodolico-San Marco, University of Catania, 95123 Catania, Italy; (G.V.); (D.M.); (G.T.); (G.B.); (M.C.); (P.V.F.); (A.B.)
| | - Giuseppe Terzo
- Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital Policlinico G. Rodolico-San Marco, University of Catania, 95123 Catania, Italy; (G.V.); (D.M.); (G.T.); (G.B.); (M.C.); (P.V.F.); (A.B.)
| | - Giuseppe Belfiore
- Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital Policlinico G. Rodolico-San Marco, University of Catania, 95123 Catania, Italy; (G.V.); (D.M.); (G.T.); (G.B.); (M.C.); (P.V.F.); (A.B.)
| | - Vincenzo Di Benedetto
- Division of Pediatric Surgery, University Hospital Policlinico G. Rodolico-San Marco, University of Catania, 95123 Catania, Italy; (V.D.B.); (M.G.S.)
| | - Maria Grazia Scuderi
- Division of Pediatric Surgery, University Hospital Policlinico G. Rodolico-San Marco, University of Catania, 95123 Catania, Italy; (V.D.B.); (M.G.S.)
| | - Maria Coronella
- Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital Policlinico G. Rodolico-San Marco, University of Catania, 95123 Catania, Italy; (G.V.); (D.M.); (G.T.); (G.B.); (M.C.); (P.V.F.); (A.B.)
| | | | - Daniele Grippaldi
- UOSD I.P.T.R.A.-Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital Policlinico G. Rodolico-San Marco, University of Catania, 95123 Catania, Italy; (D.G.); (L.A.M.)
| | - Letizia Antonella Mauro
- UOSD I.P.T.R.A.-Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital Policlinico G. Rodolico-San Marco, University of Catania, 95123 Catania, Italy; (D.G.); (L.A.M.)
| | - Pietro Valerio Foti
- Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital Policlinico G. Rodolico-San Marco, University of Catania, 95123 Catania, Italy; (G.V.); (D.M.); (G.T.); (G.B.); (M.C.); (P.V.F.); (A.B.)
| | - Antonio Basile
- Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital Policlinico G. Rodolico-San Marco, University of Catania, 95123 Catania, Italy; (G.V.); (D.M.); (G.T.); (G.B.); (M.C.); (P.V.F.); (A.B.)
| | - Stefano Palmucci
- UOSD I.P.T.R.A.-Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital Policlinico G. Rodolico-San Marco, University of Catania, 95123 Catania, Italy; (D.G.); (L.A.M.)
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Abu-El-Rub H, Shatnawi R, AbuZetun YI, Ghorab D, Shotar AM. Sudden pediatric death unveiling pulmonary arteriovenous malformations. Autops Case Rep 2024; 14:e2024489. [PMID: 38803485 PMCID: PMC11129858 DOI: 10.4322/acr.2024.489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 05/29/2024]
Abstract
Pulmonary arteriovenous malformations (PAVMs) are abnormal vascular connections between pulmonary arteries and veins, often associated with hereditary hemorrhagic telangiectasia (HHT). Most PAVMs are asymptomatic, but life-threatening complications like pulmonary hemorrhage, brain abscesses, and paradoxical emboli can emerge, so prompt diagnosis and treatment are crucial. We report a case of sudden pediatric death in a two-year-old female with no past medical history. Initial vomiting and fast deterioration resulted in a sudden cardiac arrest. The postmortem examination found histological evidence of consistent, extensive lung damage. The absence of the characteristic symptoms made for some challenges when it came to diagnosis, showing precisely that in early life, you could well have many difficulties in catching PAVMs. This case highlights the need to take PAVMs into account as a potential cause of sudden death, particularly when there are no conspicuous symptoms. Awareness among forensic pathologists and consideration of genetic analysis for HHT in such cases is crucial for accurate diagnosis and management.
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Affiliation(s)
- Hadeel Abu-El-Rub
- Yarmouk University, Forensic Medicine and Toxicology Unit, Department of Clinical Sciences, Faculty of Medicine, Irbid, Jordan
| | - Rashed Shatnawi
- Yarmouk University, Forensic Medicine and Toxicology Unit, Department of Clinical Sciences, Faculty of Medicine, Irbid, Jordan
| | - Yahia I AbuZetun
- Yarmouk University, Forensic Medicine and Toxicology Unit, Department of Clinical Sciences, Faculty of Medicine, Irbid, Jordan
| | - Doaa Ghorab
- Mansoura University, Pathology Department, Faculty of Medicine, Mansoura, Egypt
| | - Ali M. Shotar
- Jordan University of Science and Technology, Department of Legal Medicine, Toxicology and Forensic Science, School of Medicine, Irbid, Jordan
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Adams RC, Hegde S, Sutphin P, Iqbal S, Irani Z, Kalva SP. Use of Polyurethane-Covered Stents for Exclusion of Pulmonary Arteriovenous Malformations. Cardiovasc Intervent Radiol 2024; 47:360-365. [PMID: 38180506 DOI: 10.1007/s00270-023-03638-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/30/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE To evaluate the safety, technical success and short-term effectiveness of polyurethane-covered stent (PK Papyrus, BioTronik, Berlin) in the treatment of pulmonary arteriovenous malformations (PAVMs) that are not amenable to embolotherapy. MATERIALS AND METHODS In this IRB-approved, retrospective study, data from patients who received polyurethane-covered stents for exclusion of PAVMs were analyzed. The study included 5 patients (all women) with a median age of 40 years (range 25-60). Patients presented with hypoxemia, TIAs, and/or epistaxis; 4 were confirmed to have HHT. All had multiple PAVMs diagnosed on chest CT and underwent embolization with other devices in addition to the polyurethane-covered stent. The indication for stent placement in all cases was a short and/or tortuous feeding artery. Safety was assessed by immediate or short-term complications, e.g., migration, stent thrombosis, and fracture. Technical success was defined as the ability to accurately place the stent at the intended location. Effectiveness was defined as successful exclusion of PAVM with no perfusion across the AVM. RESULTS Technical success of stent placement was 100%. AVM exclusion rate was 80% after single stent deployment; in the case of incomplete exclusion, success was achieved using an overlapping stent to completely cover a second feeding artery. During the median follow-up period of 5 months (range 2-10), all stents remained patent, and AVMs were excluded without other complications. CONCLUSION Exclusion of PAVMs with polyurethane-covered stents is technically feasible, safe, and shows short-term effectiveness for PAVMs with a short/tortuous feeding artery when traditional embolization techniques are not possible.
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Affiliation(s)
- Ryan C Adams
- Interventional Radiology Division, Radiology Department, Massachusetts General Hospital, Boston, MA, USA.
| | - Siddhi Hegde
- Abdominal Radiology Division, Radiology Department, Massachusetts General Hospital, Boston, MA, USA
| | - Patrick Sutphin
- Interventional Radiology Division, Radiology Department, Massachusetts General Hospital, Boston, MA, USA
| | - Shams Iqbal
- Interventional Radiology Division, Radiology Department, Massachusetts General Hospital, Boston, MA, USA
| | - Zubin Irani
- Interventional Radiology Division, Radiology Department, Massachusetts General Hospital, Boston, MA, USA
| | - Sanjeeva P Kalva
- Interventional Radiology Division, Radiology Department, Massachusetts General Hospital, Boston, MA, USA
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Sharma A, Vijayvergiya R, Singhal M. Pulmonary Arteriovenous Malformation in an Unrepaired Tetralogy of Fallot: Diagnostic Implications. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101303. [PMID: 39131225 PMCID: PMC11307735 DOI: 10.1016/j.jscai.2024.101303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 08/13/2024]
Affiliation(s)
- Arun Sharma
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Vijayvergiya
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manphool Singhal
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Mathevosian S, Sparks HD, Cusumano LR, Roberts DG, Majumdar S, McWilliams JP. Embolization of De Novo Pulmonary Arteriovenous Malformations Using High-Volume Detachable Non-Fibered Coils: Propensity-Matched Comparison to Traditional Coils. J Clin Med 2024; 13:648. [PMID: 38337343 PMCID: PMC10856390 DOI: 10.3390/jcm13030648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/04/2024] [Accepted: 01/08/2024] [Indexed: 02/12/2024] Open
Abstract
Embolization of de novo pulmonary arteriovenous malformations (PAVMs) using high-volume detachable non-fibered (HVDNF) coils was compared to traditional non-HVDNF coils. Persistent-occlusion rates were evaluated. A total of 272 de novo (previously untreated) PAVM treatments were retrospectively stratified into those treated with non-HVDNF coils only (n = 192) and those treated with HVDNF coils with or without other coils (n = 80). Propensity score matching, followed by survival analysis and cost analysis, was performed. The overall persistent-occlusion rate was 86.0% (234/272). Persistent occlusion was achieved in 81.8% of PAVMs using non-HVDNF coils, compared with 96.3% using HVDNF coils (p = 0.0017). The mean follow-up was 30.7 ± 31.9 months versus 14.7 ± 13.4 months, respectively (p < 0.0001). Propensity-matched survival analysis demonstrated PAVMs treated with HVDNF coils recurred significantly less frequently than PAVMs treated with non-HVNDF coils (p = 0.023). The use of HVDNF coils was more expensive than standard coils, however not significantly different for the treatment of complex PAVMs. The use of high-volume detachable non-fibered coils was associated with higher persistent-occlusion rates when compared with non-HVDNF coils. HVDNF coils were more expensive on average; however, cost was similar between groups for the treatment of complex PAVMs.
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Affiliation(s)
| | | | | | | | | | - Justin P. McWilliams
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA; (S.M.)
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Oliveira Dias J, Lai AC, Rodrigues O, Martins P, Branco M, Pina R, Pires A. Massive Pulmonary Arteriovenous Malformation as a Cause of Fetal Heart Failure. Cureus 2024; 16:e52549. [PMID: 38371087 PMCID: PMC10874499 DOI: 10.7759/cureus.52549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 02/20/2024] Open
Abstract
Pulmonary arteriovenous malformations (AVMs) are abnormal connections between the pulmonary arteries and veins that can result in rapid-onset heart failure. We present a case of a fetus with pulmonary AVMs diagnosed at 22 weeks gestation. Fetal echocardiography showed cardiomegaly and dilated pulmonary arteries and veins reflecting the hemodynamic significance of the shunt. Inverted flow through the ductus arteriosus was also present. Fetal autopsy following medical termination of the pregnancy confirmed the morphological findings, including displacement of arteries and veins in proximity to the pleural surface. The genetic study was negative. This report highlights the cardiovascular impact of a rare disorder. Inverted flow through the ductus arteriosus may be another poor prognostic indicator, useful in parental counseling.
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Affiliation(s)
- Joao Oliveira Dias
- Pediatric Cardiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Ana Catarina Lai
- Pathology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Orlando Rodrigues
- Genetics Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Paula Martins
- Pediatric Cardiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Miguel Branco
- Obstetrics Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Raquel Pina
- Pathology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - António Pires
- Pediatric Cardiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
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Thapa P, Bhattarai M, Sharma Paudel B, Kunwar P, Chataut D, Bhandari S, Bhandari S, Paudel P, Sharma P. A case of hemoptysis unveiling the unlikely culprit - pulmonary arteriovenous malformation. Radiol Case Rep 2023; 18:4026-4031. [PMID: 37680652 PMCID: PMC10480646 DOI: 10.1016/j.radcr.2023.08.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/04/2023] [Accepted: 08/09/2023] [Indexed: 09/09/2023] Open
Abstract
Pulmonary arteriovenous malformation (PAVM) is a rare vascular anomaly characterized by abnormal communication between the pulmonary artery and vein. It is a rare cause of hemoptysis. Computed tomographic angiography (CTA) has become the preferred and dependable diagnostic approach for identifying PAVM. PAVM embolization is the primary recommended treatment for this condition. We present a case of a 43-year-old male with a complex PAVM in the left lower lobe presenting with hemoptysis treated with an endovascular approach. Following the procedure, the patient's symptoms resolved.
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Affiliation(s)
- Paras Thapa
- Department of Radiology, Tribhuvan University Teaching Hospital, Institute of Medicine, Maharajgunj, Nepal
| | - Madhur Bhattarai
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Basanta Sharma Paudel
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | - Dinesh Chataut
- Department of Radiology, Tribhuvan University Teaching Hospital, Institute of Medicine, Maharajgunj, Nepal
| | | | | | | | - Prakash Sharma
- Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
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Reimann L, Mayer L, Schneider SR, Schwarz EI, Müller J, Titz A, Furian M, Carta AF, Etienne H, Battilana B, Saxer S, Pfammatter T, Frauenfelder T, Opitz I, Ulrich S, Lichtblau M. Change in Right-to-Left Shunt Fraction in Patients with Chronic Thromboembolic Pulmonary Hypertension after Pulmonary Endarterectomy. J Cardiovasc Dev Dis 2023; 10:442. [PMID: 37998500 PMCID: PMC10672130 DOI: 10.3390/jcdd10110442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/06/2023] [Accepted: 10/20/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (CTEPH) with accessible lesions. Breathing pure oxygen (hyperoxia) during right heart catheterization (RHC) allows for the calculation of the right-to-left shunt fraction (Qs/Qt). In the absence of intracardiac shunt, Qs/Qt can be used as a marker of ventilation-perfusion mismatch in patients with CTEPH. This study involved investigating Qs/Qt after PEA and its relation to other disease-specific outcomes. STUDY DESIGN AND METHODS This study is a retrospective study that focuses on patients with operable CTEPH who had Qs/Qt assessment during RHC before and 1 year after PEA. Additionally, 6 min walking distance (6MWD), WHO functional class (WHO-FC), and NT-proBNP were assessed to calculate a four-strata risk score. RESULTS Overall, 16 patients (6 females) with a median age of 66 years (quartiles 55; 74) were included. After PEA, an improvement in mean pulmonary artery pressure (38 [32; 41] to 24 [18; 28] mmHg), pulmonary vascular resistance (5.7 [4.0; 6.8] to 2.5 [1.4; 3.8] WU), oxygen saturation (92 [88; 93]% to 94 [93; 95]%), WHO-FC, and risk score was observed (all p < 0.05). No improvement in median Qs/Qt could be detected (13.7 [10.0; 17.5]% to 13.0 [11.2; 15.6]%, p = 0.679). A total of 7 patients with improved Qs/Qt had a significant reduction in risk score compared to those without improved Qs/Qt. CONCLUSION PEA did not alter Qs/Qt assessed after 1 year in operable CTEPH despite an improvement in hemodynamics and risk score, potentially indicating a persistent microvasculopathy. In patients whose shunt fraction improved with PEA, the reduced shunt was associated with an improvement in risk score.
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Affiliation(s)
- Lena Reimann
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Laura Mayer
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Simon Raphael Schneider
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Esther I. Schwarz
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Julian Müller
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Anna Titz
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Michael Furian
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Arcangelo F. Carta
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Harry Etienne
- Department of Thoracic Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Bianca Battilana
- Department of Thoracic Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Stéphanie Saxer
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
- Department of Health, Eastern Switzerland University of Applied Sciences, 9001 St. Gallen, Switzerland
| | - Thomas Pfammatter
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Mona Lichtblau
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
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Shimohira M, Kawai T, Ohta K. An Update on Embolization for Pulmonary Arteriovenous Malformations. INTERVENTIONAL RADIOLOGY (HIGASHIMATSUYAMA-SHI (JAPAN) 2023; 8:56-63. [PMID: 37485484 PMCID: PMC10359166 DOI: 10.22575/interventionalradiology.2021-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 04/26/2022] [Indexed: 07/25/2023]
Abstract
Pulmonary arteriovenous malformations are abnormal connections between a pulmonary artery and a pulmonary vein that can lead to ischemic stroke and brain abscess due to right-to-left shunting of blood. Embolization is currently considered the first treatment option for pulmonary arteriovenous malformations owing to its minimal invasiveness. This review updates the indications and techniques for the embolization of pulmonary arteriovenous malformations and determines the persistence of pulmonary arteriovenous malformations following embolization based on the most recent literature.
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Affiliation(s)
- Masashi Shimohira
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Tatsuya Kawai
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Kengo Ohta
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Japan
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13
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Chen L, Yang Y, Tang L, Zhou M, He L. Embolic Stroke Associated With a Pulmonary Arteriovenous Fistula: An Unignorable Rare Causes of Stroke. Neurologist 2023; 28:180-183. [PMID: 36125977 DOI: 10.1097/nrl.0000000000000465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Here, we described a patient with ischemic stroke due to embolism, through an isolated pulmonary arteriovenous fistula (PAVF). Our case could be a paradigm of embolic stroke of undetermined source (ESUS) with an uncommon cause, providing an etiologic investigation process in addition to diagnostic pitfalls and pearls, eventually raising neurologists' ability to treat ESUS. CASE REPORT A 37-year-old right-handed woman presented to our emergency department with sudden onset left upper limb and lower limb weakness. She denied a past medical history of hypertension, diabetes, heart diseases, and other cerebrovascular disease risk factors, and she is without a family history of stroke, previous trauma, toxic exposure, or drug use. On admission, her physical and neurological examinations were negative, except for left-sided hemiparesis. Her routine evaluations, serum autoantibody testing, and digital subtraction angiography were negative. Subsequent diffusion-weighted brain magnetic resonance imaging demonstrated acute infarction in the right frontoparietal lobe. To find the etiology of this case, more detailed examinations were performed. Finally, she was diagnosed with ESUS, which was caused by the PAVF. CONCLUSIONS This case raises the awareness of a potential important emboligenic mechanism, the existence of an isolated PAVF as a right-to-left shunt in patients with a stroke of unknown origin should not be overlooked, even if a PAVF is not suggested by the initial physical findings or chest x-ray.
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Affiliation(s)
- Lizhang Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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14
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Scarpato BM, McDonald J, Bayrak-Toydemir P, Elliott CG, Cahill BC, Emerson LL, Keenan LM. The Shunt of It. Chest 2023; 163:e201-e205. [PMID: 37164583 PMCID: PMC10206509 DOI: 10.1016/j.chest.2023.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/13/2023] [Accepted: 01/13/2023] [Indexed: 05/12/2023] Open
Abstract
Pulmonary arteriovenous malformations (PAVMs) are rare and most often identified in patients with hereditary hemorrhagic telangiectasia (HHT). We describe a patient with severe hypoxemia and orthodeoxia with imaging findings consistent with PAVMs. Resected lung pathologic findings confirmed the presence of numerous microscopic vascular abnormalities within the right lower lobe that was consistent with diffuse pulmonary arteriovenous shunts. Family history was negative for HHT but was positive for pulmonary arterial hypertension (PAH) in two second-degree relatives. A vascular malformation gene panel was negative for genes that commonly are associated with HHT but identified a pathogenic variant in the gene encoding bone morphogenetic protein receptor-2 (BMPR2 p.Cys123∗). Pathogenic variants in BMPR2 are a well-known cause of hereditary PAH; there have been several reports to date of patients with PAVMs and PAH. However, this is the first patient to be reported with a pathogenic variant in BMPR2 to have PAVMs in isolation.
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Affiliation(s)
- Brittany M Scarpato
- Division of Pulmonary and Critical Care Medicine, University of Utah Hospital, Salt Lake City, UT; Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT.
| | - Jamie McDonald
- Department of Pathology, University of Utah Hospital, Salt Lake City, UT
| | | | - C Gregory Elliott
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Pulmonary Hypertension Care Center, Intermountain Medical Center, Murray, UT
| | - Barbara C Cahill
- Division of Pulmonary and Critical Care Medicine, University of Utah Hospital, Salt Lake City, UT
| | - Lyska L Emerson
- Department of Pathology, University of Utah Hospital, Salt Lake City, UT
| | - Lynn M Keenan
- Division of Pulmonary and Critical Care Medicine, University of Utah Hospital, Salt Lake City, UT; Division of Pulmonary and Critical Care Medicine, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT
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15
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Lukic A, Cmelak L, Draženović D, Kojundzic H, Lukic IK, Gluncic V. Pulmonary Arteriovenous Malformation Unmasked by Pregnancy: A Review of Pulmonary Arteriovenous Malformations and Cardiovascular and Respiratory Changes in Pregnancy. Case Rep Pulmonol 2023; 2023:5469592. [PMID: 37026089 PMCID: PMC10072959 DOI: 10.1155/2023/5469592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/05/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Pulmonary arteriovenous malformations are abnormal, direct communications between the branches of the pulmonary artery and pulmonary veins, but without pulmonary capillaries between them. During pregnancy, PAVMs can enlarge and become symptomatic, causing even serious complications like haematothorax. To recognize the PAVM that becomes symptomatic in pregnancy, one must be able to distinguish the patient’s symptoms caused by developing complications of PAVM, as in the case we present, from physiological changes accompanying a healthy pregnancy, including their degree in relation to the stage of pregnancy. The modified early obstetric warning score charts are a very helpful tool in the assessment of (ab)normal signs and symptoms in pregnant women, especially for physicians who rarely manage pregnant women.
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16
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Nakashima M, Miki T, Takaya Y, Nakayama R, Nakagawa K, Akagi S, Toh N, Akagi T, Ito H. Pulmonary arteriovenous fistula in a rare location: The importance of excluding patent foramen ovale. J Cardiol Cases 2023; 27:124-127. [PMID: 36910040 PMCID: PMC9995680 DOI: 10.1016/j.jccase.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/02/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
A 46-year-old woman with a history of repeated thromboembolic stroke and anti-phospholipid antibody syndrome was referred to our hospital. Saline contrast transthoracic echocardiography showed that microbubbles appeared in the left atrium within 4 heartbeats. Thus, she was initially suspected as having a patent foramen ovale with associated paradoxical embolism. However, no evidence of patent foramen ovale or atrial septal defect could be found using transesophageal echocardiography. Saline contrast transesophageal echocardiography showed that microbubbles flowed into the left atrium through the left superior pulmonary vein. Ultimately, she was diagnosed as having a pulmonary arteriovenous malformation located at the upper left pulmonary lobe using contrast computed tomography and pulmonary artery angiography. Pulmonary arteriovenous malformations are typically located in the lower lobe of either lung and, in bubble studies, contrast appears in the left atrium after 4 heartbeats. Here, the pulmonary arteriovenous malformation was in the upper lobe, and contrast appeared in the left atrium at an earlier time point: one associated with patent foramen ovale. These findings made it difficult to differentiate the two diseases initially. This case suggests that pulmonary arteriovenous malformation should be carefully considered, even if microbubbles appear in the left atrium early on a saline contrast transthoracic echocardiograph. Learning objective Pulmonary arteriovenous malformation occasionally appears in the upper lobe. In these cases, microbubbles may appear in the left atrium after detection in the right atrium with a time-course that is suggestive of a patent foramen ovale. Therefore, diagnosis should be carefully confirmed by using other multimodal imaging tests, such as transesophageal echocardiography, contrast computed tomography, or pulmonary artery angiography.
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Affiliation(s)
- Mitsutaka Nakashima
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Takashi Miki
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yoichi Takaya
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Rie Nakayama
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Satoshi Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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17
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Kulkarni CB, Sutphin P, Iqbal S, Kalva SP. Diagnosis and Management of Persistent Pulmonary Arterio-venous Malformations following Embolotherapy. Acad Radiol 2023; 30:441-452. [PMID: 36089478 DOI: 10.1016/j.acra.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/06/2022] [Accepted: 08/08/2022] [Indexed: 01/25/2023]
Abstract
Embolotherapy is the primary treatment for pulmonary arterio-venous malformations (PAVMs). Approximately, 2-25% of PAVMs demonstrate persistence following embolization. Early identification and treatment of persistent PAVMs are critical to mitigating life threatening complications. The presence of prior embolic devices and complex angioarchitecture of persistent PAVMs pose technical challenges during repeat embolotherapy. In this article, we review patterns of persistence, factors affecting the persistence, endovascular treatment techniques, and outcomes.
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Affiliation(s)
- Chinmay Bhimaji Kulkarni
- Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Amrita Lane, Ponekkra. Elamakkara P.O. 682041, Kochi, Kerala, India.
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18
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Muacevic A, Adler JR. A Case of Paradoxical Cerebral Embolism Due to Pulmonary Arteriovenous Fistula Mimicking Vertebral Artery Dissection With Wallenberg Syndrome. Cureus 2023; 15:e34564. [PMID: 36743906 PMCID: PMC9896129 DOI: 10.7759/cureus.34564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 02/05/2023] Open
Abstract
Pulmonary arteriovenous fistula (PAVF) leads to paradoxical cerebral embolism, which can be fatal if left untreated. We report a rare case of brainstem infarction with acute severe headache and Wallenberg syndrome caused by a PAVF mimicking vertebral artery (VA) dissection. A 40-year-old man presented with a sudden occipital headache accompanied by right hemisensory disturbance. Magnetic resonance imaging revealed left lateral medullary infarction and poor depiction of the left VA. However, it was clearly recanalized on day six, and there were no findings of VA dissection. Whole-body contrast-enhanced computed tomography (CT) revealed a PAVF in the right lung and a thrombus in the feeding artery. The patient was diagnosed with hereditary hemorrhagic telangiectasia due to recurrent epistaxis and peripheral vasodilation of the tongue. An anticoagulant was administered for preventing further ischemic stroke, and a follow-up CT confirmed the disappearance of the thrombus in three months. Thoracoscopic partial lung resection was performed five months after the onset, and no recurrence of ischemic stroke was observed.
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19
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Onorato EM, Salvia J, Becchina M, Cipolla T, Anzola GP. Can aura migraine be elicited by isolated pulmonary arteriovenous fistula?-A case report. Front Neurol 2022; 13:1079959. [PMID: 36588875 PMCID: PMC9797860 DOI: 10.3389/fneur.2022.1079959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/22/2022] [Indexed: 12/23/2022] Open
Abstract
A pulmonary arteriovenous fistula (PAVM) is an abnormal blood vessel that creates a direct connection between a pulmonary artery and its tributary vein bypassing capillary filter, establishing as a consequence of a low-resistance right-to-left shunting (RLS). The vast majority of PAVMs are congenital appearing more often in females than in males. A great number of patients with PAVMs is suffering concurrently from hereditary hemorrhagic telangiectasia (HHT) whose incidence is around 1 in 5,000. Very few cases of acquired PAVMs have been described in the literature. Paradoxical embolism through PAVMs can cause systemic desaturation, cyanosis, and serious cerebrovascular ischemic events (transient ischemic attacks, strokes, and intracranial abscess), even when the abnormal blood vessel is small (diameter <3 mm). Notably, it has been reported a high prevalence of aura migraine (MHA) symptoms in patients with PAVMs and concomitant HHT. We described in this study the case of a young aura migraineur female patient without HHT in whom isolated PAVM below the detection limit of pulmonary angiography and chest computed tomography angiography (CTA) has been documented by contrast Transthoracic and Transesophageal Echocardiography (cTTE/TEE) showing a delayed (>17 s) RLS coming from left pulmonary veins to left atrium while a patent foramen ovale (PFO), small atrial septal defects or septum primum fenestration could not be detected despite several attempts. Contrast Transcranial Doppler (cTCD) confirmed a delayed (>16 s) RLS with two short "shower" patterns corroborating the diagnosis of an extra-cardiac RLS. During the right heart catheterization and pulmonary angiography, it was impossible to cross the interatrial septum with a multipurpose catheter. The patient was finally discharged with off-label thienopyridine agents (clopidogrel 75 mg die) in terms of primary prophylaxis for paradoxical right-to-left embolization of thrombotic material ultimately. Aura migraine symptoms were nearly abolished by P2Y12 platelet inhibition, suggesting a platelet-based mechanism. During 2 years of clinical follow-up on thienopyridine therapy, the resolution of aura migraine episodes was definitively accomplished with significant improvement in her quality of life.
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Affiliation(s)
- Eustaquio Maria Onorato
- R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio GSD, Milan, Italy,*Correspondence: Eustaquio Maria Onorato
| | - Josephal Salvia
- Cardiology Department, Istituto Fondazione G. Giglio di Cefalù, Palermo, Italy
| | - Mariano Becchina
- Cardiology Department, Istituto Fondazione G. Giglio di Cefalù, Palermo, Italy
| | - Tommaso Cipolla
- Cardiology Department, Istituto Fondazione G. Giglio di Cefalù, Palermo, Italy
| | - Gian Paolo Anzola
- Neurology Clinic and Rehabilitation Department, Casa di Cura Villa Barbarano, Brescia, Italy
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20
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Spontaneous hemothorax in pregnant patient with pulmonary arteriovenous malformation. Radiol Case Rep 2022; 18:679-684. [PMID: 36504878 PMCID: PMC9731827 DOI: 10.1016/j.radcr.2022.10.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/29/2022] [Indexed: 12/12/2022] Open
Abstract
We present a case of a 34-year-old pregnant patient at 26 weeks' gestation by in vitro fertilization with past medical history of hypertension and infertility who presented to the hospital with abdominal pain. The patient stated her pain was in her left upper quadrant. The morning before arriving to the hospital the patient stated she woke up at 0300 with increasingly severe pain in the same area. A computed tomography angiogram of the chest demonstrated a left-sided pulmonary arteriovenous malformation with adjacent complex left effusion on chest suspicious for a hemothorax. The hemothorax was thought to be brought about by rupture of the arteriovenous malformation with likely intermittent small volume hemorrhages into the pleural space. Thoracic Surgery and Interventional radiology (IR) were each consulted for management of the arteriovenous malformation. Due to the patient's stable hemodynamic status and concern that an invasive procedure might enable a larger rupture and more substantial hemorrhage, the decision was made for embolization of the arteriovenous malformation.
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21
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Na YO, Park HK, Lee JK, Kho BG, Kim TO, Shin HJ, Kwon YS, Kim YI, Lim SC, Oh HJ, Park CK, Oh IJ, Kim YC, Park HY. Risk factors for cerebral complications in patients with pulmonary arteriovenous malformations: A multicenter retrospective cohort study. PLoS One 2022; 17:e0278610. [PMID: 36454973 PMCID: PMC9714939 DOI: 10.1371/journal.pone.0278610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 11/18/2022] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE Pulmonary arteriovenous malformation (PAVM) is a rare pulmonary disease. Although most patients with PAVMs are asymptomatic, cerebral complications associated with PAVMs are often fatal. This study aimed to evaluate the risk factors for cerebral complications in patients with PAVMs. METHODS We retrospectively reviewed the medical charts of patients with PAVMs between 2003 and 2021 at two tertiary referral hospitals and one secondary hospital. RESULTS Fifty-five patients diagnosed with PAVMs were enrolled in this study. Most patients were female (89.1%), and the median age was 53 years. Thirty patients (54.5%) had incidentally detected PAVMs without symptoms. Twenty-four patients (43.7%) with PAVMs were treated with embolotherapy or surgery. Thirteen patients (23.6%) had cerebral complications. There was no significant difference in the development of cerebral complications according to treatment; however, older age (≥ 65 years) was associated with the development of new cerebral complications in untreated patients with PAVMs (odds ratio, 17.09; 95% confidence interval, 1.16-250.31; P = 0.038). CONCLUSION Older age (≥ 65 years) was a risk factor for the development of cerebral complications in patients with PAVMs; therefore, treatment should be considered in older patients with PAVMs.
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Affiliation(s)
- Young-Ok Na
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hwa Kyung Park
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Jae-Kyeong Lee
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Bo-Gun Kho
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Tae-Ok Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hong-Joon Shin
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
- * E-mail:
| | - Yong-Soo Kwon
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Yu-Il Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Sung-Chul Lim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hyung-Joo Oh
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Cheol-Kyu Park
- Chonnam National University Medical School, Gwangju, Republic of Korea
- Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Joennam, Republic of Korea
| | - In-Jae Oh
- Chonnam National University Medical School, Gwangju, Republic of Korea
- Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Joennam, Republic of Korea
| | - Young-Chul Kim
- Chonnam National University Medical School, Gwangju, Republic of Korea
- Lung and Esophageal Cancer Clinic, Chonnam National University Hwasun Hospital, Joennam, Republic of Korea
| | - Ha-Young Park
- Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Internal Medicine, Chonnam National University Bitgoeul Hospital, Gwangju, Republic of Korea
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22
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Ryan KM, Siegler E. Pyogenic brain abscess associated with an incidental pulmonary arteriovenous malformation. BMJ Case Rep 2022; 15:e252794. [PMID: 36384884 PMCID: PMC9670921 DOI: 10.1136/bcr-2022-252794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pulmonary arteriovenous malformations (PAVMs) are rare and often asymptomatic vascular anomalies that can be associated with serious neurological consequences due to right-to-left shunting. We report a case of a woman in her 80s without substantial medical history who presented with a headache, weakness and personality changes, and was found to have a pyogenic brain abscess requiring emergent neurosurgical evacuation. The abscess grew oral flora, suspected to have reached the brain via an incidentally discovered PAVM. With drainage and antibiotics, the patient achieved a full recovery and the PAVM was embolised. To our knowledge, this is the oldest presentation of a PAVM-associated brain abscess in the published literature. Older patients may present without the typical signs and symptoms of a given illness, which complicates accurate diagnosis and treatment. Primary care physicians can help facilitate timely care and positive clinical outcomes.
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Affiliation(s)
- Kara Morgan Ryan
- Internal Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Eugenia Siegler
- Geriatrics, Weill Cornell Medical College, New York, New York, USA
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Yap CW, Wee BBK, Yee SY, Tiong V, Chua YX, Teo L, Lohan R, Tan A, Singh P, Rajendran PC, Yang C, Yee YC, Anil G, Ong SJ. The Role of Interventional Radiology in the Diagnosis and Treatment of Pulmonary Arteriovenous Malformations. J Clin Med 2022; 11:6282. [PMID: 36362510 PMCID: PMC9655058 DOI: 10.3390/jcm11216282] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/18/2022] [Accepted: 10/22/2022] [Indexed: 09/12/2023] Open
Abstract
Pulmonary arteriovenous malformations (PAVMs) are uncommon, predominantly congenital direct fistulous connections between the pulmonary arteries and pulmonary veins, resulting in a right to left shunt. Patients with PAVMs are usually asymptomatic with lesions detected incidentally when radiological imaging is performed for other indications. In this review, we discuss the classification and radiological features of PAVMs as well as their treatment and follow-up options, with a particular focus on percutaneous endovascular techniques and the evolution of the available equipment for treatment.
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Affiliation(s)
- Chee Woei Yap
- National University Hospital, National University Health Systems, Singapore 119228, Singapore
| | - Bernard B. K. Wee
- Ng Teng Fong General Hospital, National University Health Systems, Singapore 609606, Singapore
| | - Sze Ying Yee
- National University Hospital, National University Health Systems, Singapore 119228, Singapore
| | - Vincent Tiong
- Ng Teng Fong General Hospital, National University Health Systems, Singapore 609606, Singapore
| | - Yi Xiu Chua
- Ng Teng Fong General Hospital, National University Health Systems, Singapore 609606, Singapore
| | - Lycia Teo
- Ng Teng Fong General Hospital, National University Health Systems, Singapore 609606, Singapore
| | - Rahul Lohan
- National University Hospital, National University Health Systems, Singapore 119228, Singapore
| | - Amos Tan
- National University Hospital, National University Health Systems, Singapore 119228, Singapore
| | - Pavel Singh
- National University Hospital, National University Health Systems, Singapore 119228, Singapore
| | | | - Cunli Yang
- National University Hospital, National University Health Systems, Singapore 119228, Singapore
| | - Yong Chen Yee
- National University Hospital, National University Health Systems, Singapore 119228, Singapore
| | - Gopinathan Anil
- National University Hospital, National University Health Systems, Singapore 119228, Singapore
| | - Shao Jin Ong
- National University Hospital, National University Health Systems, Singapore 119228, Singapore
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Lim KH, Kim SM, Park SJ, Kim EK, Chang SA, Lee SC, Park SW, Choe YH. Significance of transesophageal contrast echocardiography with the agitated saline test for diagnosing pulmonary arteriovenous malformations. Front Cardiovasc Med 2022; 9:975901. [PMID: 36158804 PMCID: PMC9497879 DOI: 10.3389/fcvm.2022.975901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/01/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives This study evaluated the diagnostic value of transesophageal contrast echocardiography (TECE) with the agitated saline test for diagnosing pulmonary arteriovenous malformations (PAVMs) in comparison with chest CT or pulmonary angiography. Background Although transthoracic contrast echocardiography (TTCE) is the recommended screening test for diagnosing PAVMs, it has low specificity and positive predictive value. TECE is expected to offer improved sensitivity and specificity compared with TTCE, but no studies have reported the diagnostic accuracy and clinical significance of TECE in detecting PAVMs. Methods and results In total, 1,809 patients underwent TECE with the agitated saline test to evaluate symptoms of a suspected right to left shunt. Patients with hereditary hemorrhagic telangiectasia (HHT) were excluded. A total of 387 patients showed transpulmonary bubble passage, indicating a PAVM. Among them, 182 patients had additional chest CT or pulmonary angiography. Those patients were divided into two groups according to the presence of a PAVM in the radiologic imaging. A total of 18 patients (9.8%) were confirmed for the PAVM group. Only 13 patients required embolization for their PAVMs. The TECE with saline test results were divided into four grades according to the number of bubbles: grade 1 (n = 91), grade 2 (n = 47), grade 3 (n = 35), and grade 4 (n = 9). None of the patients in the PAVM group had grade 1 shunts in their TECE results. The positive predictive values for the presence of a PAVM according to the TECE grade scale were 10.6% for grade 2, 22.8% for grade 3, and 55.6% for grade 4. Conclusion TECE with a grade scale is a useful method for initially diagnosing PAVMs in non-HHT patients with a suspected right to left shunt. The findings of this study also suggest that patients with a small grade (<10 bubbles) shunt in their TECE findings should be spared unnecessary radiation exposure from CT scans or pulmonary angiography.
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Affiliation(s)
- Kyung Hee Lim
- Division of Cardiology, Department of Internal Medicine, Dong-A University Hospital, Busan, South Korea
| | - Sung Mok Kim
- Department of Radiology, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- *Correspondence: Sung-Ji Park,
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung-A Chang
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung Woo Park
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yeon Hyeon Choe
- Department of Radiology, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Ananiadis T, Faughnan ME, Clark D, Prabhudesai V, Kim H, Lawton MT, Vozoris NT. Neurovascular Complications and Pulmonary Arteriovenous Malformation Feeding Artery Size. Ann Am Thorac Soc 2022; 19:1432-1435. [PMID: 35442860 PMCID: PMC9353961 DOI: 10.1513/annalsats.202202-130rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Dewi Clark
- University of TorontoToronto, Ontario, Canada
| | | | - Helen Kim
- University of California San FranciscoSan Francisco, California
| | | | - Nicholas T. Vozoris
- University of TorontoToronto, Ontario, Canada
- ICES (formerly known as Institute of Clinical Evaluative Sciences)Toronto, Ontario, Canada
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Giliberti P, De Rose DU, Landolfo F, Columbo C, Pugnaloni F, Santisi A, Conforti A, Secinaro A, Francalanci P, Bozza P, Chukhlantseva N, Savignoni F, Caforio L, Toscano A, Novelli A, Dotta A, Capolupo I, Bagolan P. Hemodynamic Assessment of a Large Pulmonary Arteriovenous Malformation in a Neonate: Case Report and Review of Literature. Pediatr Cardiol 2022; 43:1383-1391. [PMID: 35260923 DOI: 10.1007/s00246-022-02862-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/24/2022] [Indexed: 11/28/2022]
Abstract
Herein we report the case of a neonate with a prenatally diagnosed large pulmonary arteriovenous malformation, managed with minimally invasive hemodynamic monitoring in our Neonatal Intensive Care Unit. The combination of Near-Infrared Spectroscopy and Pressure Recording Analytical Method could guide neonatal management of critical cases of vascular anomalies: immediate data are offered to clinicians, from which therapeutic decisions such as timing of surgical resection are made to achieve a positive outcome. We also systemically collected and summarized information on patients' characteristics of previous cases reported in literature to data, and we compared them to our case.
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Affiliation(s)
- Paola Giliberti
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant-"Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Domenico Umberto De Rose
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant-"Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Francesca Landolfo
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant-"Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy.
| | - Claudia Columbo
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant-"Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Flaminia Pugnaloni
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant-"Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Alessandra Santisi
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant-"Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Andrea Conforti
- Newborn Surgery Unit, Medical and Surgical Department of Fetus, Newborn and Infant-"Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Aurelio Secinaro
- Advanced Cardiovascular Imaging Unit, Department of Imaging, "Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Paola Francalanci
- Department of Pathology, "Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Patrizia Bozza
- Department of Anesthesia and Critical Care, "Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Natalia Chukhlantseva
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant-"Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Ferdinando Savignoni
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant-"Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Leonardo Caforio
- Fetal Medicine and Surgery Unit, Medical and Surgical Department of Fetus, Newborn and Infant-"Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Alessandra Toscano
- Perinatal Cardiology Unit, Medical and Surgical Department of Fetus, Newborn and Infant-"Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Antonio Novelli
- Medical Genetics Laboratory, "Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant-"Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Irma Capolupo
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant-"Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
| | - Pietro Bagolan
- Newborn Surgery Unit, Medical and Surgical Department of Fetus, Newborn and Infant-"Bambino Gesù" Children's Hospital IRCCS, 00165, Rome, Italy
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Hong J, Lee SY, Lim JK, Lee J, Park J, Cha JG, Lee HJ, Kim D. Feasibility of Single-Shot Whole Thoracic Time-Resolved MR Angiography to Evaluate Patients with Multiple Pulmonary Arteriovenous Malformations. Korean J Radiol 2022; 23:794-802. [PMID: 35914744 PMCID: PMC9340233 DOI: 10.3348/kjr.2022.0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/27/2022] [Accepted: 06/06/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the feasibility of single-shot whole thoracic time-resolved MR angiography (TR-MRA) to identify the feeding arteries of pulmonary arteriovenous malformations (PAVMs) and reperfusion of the lesion after embolization in patients with multiple PAVMs. MATERIALS AND METHODS Nine patients (8 females and 1 male; age range, 23-65 years) with a total of 62 PAVMs who underwent percutaneous embolization for multiple PAVMs and were subsequently followed up using TR-MRA and CT obtained within 6 months from each other were retrospectively reviewed. All imaging analyses were performed by two independent readers blinded to clinical information. The visibility of the feeding arteries on maximum intensity projection (MIP) reconstruction and multiplanar reconstruction (MPR) TR-MRA images was evaluated by comparing them to CT as a reference. The accuracy of TR-MRA for diagnosing reperfusion of the PAVM after embolization was assessed in a subgroup with angiographic confirmation. The reliability between the readers in interpreting the TR-MRA results was analyzed using kappa (κ) statistics. RESULTS Feeding arteries were visible on the original MIP images of TR-MRA in 82.3% (51/62) and 85.5% (53/62) of readers 1 and 2, respectively. Using the MPR, the rates increased to 93.5% (58/62) and 95.2% (59/62), respectively (κ = 0.760 and 0.792, respectively). Factors for invisibility were the course of feeding arteries in the anteroposterior plane, proximity to large enhancing vessels, adjacency to the chest wall, pulsation of the heart, and small feeding arteries. Thirty-seven PAVMs in five patients had angiographic confirmation of reperfusion status after embolization (32 occlusions and 5 reperfusions). TR-MRA showed 100% (5/5) sensitivity and 100% (32/32, including three cases in which the feeding arteries were not visible on TR-MRA) specificity for both readers. CONCLUSION Single-shot whole thoracic TR-MRA with MPR showed good visibility of the feeding arteries of PAVMs and high accuracy in diagnosing reperfusion after embolization. Single-shot whole thoracic TR-MRA may be a feasible method for the follow-up of patients with multiple PAVMs.
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Affiliation(s)
- Jihoon Hong
- Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Sang Yub Lee
- Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea.
| | - Jae-Kwang Lim
- Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Jongmin Lee
- Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Jongmin Park
- Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Jung Guen Cha
- Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Hui Joong Lee
- Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Donghyeon Kim
- Department of Radiology, Gyeongbuk Regional Rehabilitation Hospital, Gyeongsan, Korea
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28
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Neurologic Complications in HHT with Pulmonary Arteriovenous Malformations: Systematic Review. Neurol Sci 2022:1-12. [PMID: 35686303 DOI: 10.1017/cjn.2022.80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Ma X, Li LL, Yu D, Jie B, Jiang S. Management of pulmonary arteriovenous malformations involves additional factors aside from the diameter of feeding arteries: a 3-year case-case retrospective analysis. Respir Res 2022; 23:107. [PMID: 35501913 PMCID: PMC9063074 DOI: 10.1186/s12931-022-02030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 04/21/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pulmonary arteriovenous malformations (PAVMs) are rare but cause various manifestations. Although the diameter of feeding arteries has been linked to treatment decisions, relationships among the characteristics of PAVMs, clinical symptoms, and treatment effect remain unclear. The present study was performed to investigate how collective characteristics of PAVMs relate to clinical symptoms and to provide proper treatment recommendations for patients with PAVMs.
Methods
We retrospectively analysed 838,447 patients’ radiographic data and medical records from January 2018 to December 2020. Patients were included if a PAVM was radiographically detected for the first time in our hospital. Ordered multivariable logistic regression and hierarchical multiple regression were performed to analyse the relationships between characteristics of PAVMs and various clinical symptoms. We investigated the management of PAVMs in four tertiary university hospitals.
Results
Detection rate of PAVMs was 0.025% (207/838,447), and 37.6% of patients (78/207) also had hereditary haemorrhagic telangiectasia. Eight patients were diagnosed with bilateral diffuse PAVMs. Two hundred thirty-six lesions were detected in 199 patients, and the mean diameter of the feeding artery was 4.13 ± 1.92 mm. Most PAVMs were the simple type and located in the peripheral pulmonary area. In total, 34.3% of patients (71/207) were symptom-free; remaining patients showed various manifestations, and respiratory symptoms were most common (dyspnoea on exertion, 47.8%). The diameter of the feeding artery and the type and the number of PAVMs were correlated with hypoxaemia (P < 0.001, P < 0.001, and P = 0.037, respectively). The collective characteristics of PAVMs were not related to the severity of central nervous system symptoms (largest diameter of feeding artery, P = 0.8; largest diameter of sac, P = 0.42; number of PAVMs, P = 0.35; type of PAVMs, P = 0.99). Various symptoms were greatly relieved after treatment. The hospital investigation showed that management of PAVMs was not generally appreciated in clinical practice.
Conclusions
Our study revealed a low detection rate of PAVMs and a low degree of association with hereditary haemorrhagic telangiectasia in the general population. Considering the connection between collective characteristics of PAVMs and various clinical symptoms, clinicians should consider the type and number of PAVMs, the largest diameter of the feeding artery, and clinical symptoms when managing patients with PAVMs.
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Muhammad A, Rauf Z, Shahid J, Iqbal J, Haq TU, Zafar U. Endovascular Embolisation of Pulmonary Arteriovenous Malformation Using Amplatzer Vascular Plugs. Cureus 2022; 14:e24214. [PMID: 35602848 PMCID: PMC9113524 DOI: 10.7759/cureus.24214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 11/24/2022] Open
Abstract
Pulmonary arteriovenous malformation (PAVMs) are abnormal communications between pulmonary arteries and veins. The rarity of their occurrence, coupled with the risks they pose, including brain abscess, embolic stroke, and myocardial infarction, mandates that they should not be overlooked in the differential diagnosis of patients presenting with haemoptysis, dyspnea, clubbing, cyanosis, hypoxemia, or epistaxis. We present the case of a 41-year-old local female who presented to our hospital as an outpatient with decreased oxygen saturation (SpO2) of 70%-80% for the past two years with a final diagnosis of PAVM. The initial baseline workup showed polycythemia with a hemoglobin level of 19 mg/dL and raised hematocrit. She had extensive workup in the past two years for her polycythemia including gene mutation testing and cardiac workup which all turned out normal. Her chest X-ray (CXR) showed right lung opacity which was initially considered to be infective but it did not respond to antibiotic treatment. Later on, a CT scan of the chest was performed and findings were typical of a large PAVM which had two feeding arteries. The patient was referred to a cardiothoracic surgeon who sent the patient to the interventional radiology section for endovascular management. The embolization procedure was then performed and both feeders were successfully embolised. After the procedure, the patient's SpO2 levels were restored to 95%-96%, and no post-procedure complications were noted.
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31
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Hou H, Guo C, Que C, Nie L, Zhang Q, Zhao H, Nong L, Ma W, Wang Q, Liang Z, Wang B, Ma J, Wang G. Diffuse large B-cell lymphoma presenting as reversible intrapulmonary arteriovenous shunts with hypoxia, fever and progressive jaundice: a case report and literature review. BMC Pulm Med 2022; 22:89. [PMID: 35292006 PMCID: PMC8922084 DOI: 10.1186/s12890-022-01881-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 03/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background Intrapulmonary arteriovenous shunts is rare seen in a patient without lung involvement. Case presentation This is the first report of reversible intrapulmonary arteriovenous shunts secondary to extrapulmonary lymphoma as one initial symptom. The patient presented as fever of unknown origin and dyspnea, and examinations of infection were negative. Diagnosis of DLBCL was finally confirmed through bone marrow and splenic biopsies. Intrapulmonary arteriovenous shunts were diagnosed through 100% oxygen inhalation test and transthoracic contrast echocardiography (TTCE). After the treatment of lymphoma, his respiratory failure was relieved. We rechecked the 100% oxygen inhalation test and TTCE, which both indicated that his intrapulmonary arteriovenous shunts had resolved. Conclusions We speculated the prominent inflammation from active DLBCL was the most possible mechanism associated with the reversible intrapulmonary shunt in this patient. These findings will assist us to better understand the mechanism of intrapulmonary shunts.
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Affiliation(s)
- Huan Hou
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Cuiyan Guo
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Chengli Que
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Ligong Nie
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Qi Zhang
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Hong Zhao
- Department of Infectious Diseases, Center for Liver Disease, Peking University First Hospital, Beijing, China
| | - Lin Nong
- Department of Pathology, Peking University First Hospital, Beijing, China
| | - Wei Ma
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Qian Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Zeyin Liang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Bingjie Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Jing Ma
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China.
| | - Guangfa Wang
- Department of Respiratory and Critical Care Medicine, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing, 100034, China
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Carta AF, Lichtblau M, Berlier C, Saxer S, Schneider SR, Schwarz EI, Furian M, Bloch KE, Ulrich S. The Impact of Breathing Hypoxic Gas and Oxygen on Pulmonary Hemodynamics in Patients With Pulmonary Hypertension. Front Med (Lausanne) 2022; 9:791423. [PMID: 35223898 PMCID: PMC8878983 DOI: 10.3389/fmed.2022.791423] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPure oxygen breathing (hyperoxia) may improve hemodynamics in patients with pulmonary hypertension (PH) and allows to calculate right-to-left shunt fraction (Qs/Qt), whereas breathing normobaric hypoxia may accelerate hypoxic pulmonary vasoconstriction (HPV). This study investigates how hyperoxia and hypoxia affect mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) in patients with PH and whether Qs/Qt influences the changes of mPAP and PVR.Study Design and MethodsAdults with pulmonary arterial or chronic thromboembolic PH (PAH/CTEPH) underwent repetitive hemodynamic and blood gas measurements during right heart catheterization (RHC) under normoxia [fractions of inspiratory oxygen (FiO2) 0.21], hypoxia (FiO2 0.15), and hyperoxia (FiO2 1.0) for at least 10 min.ResultsWe included 149 patients (79/70 PAH/CTEPH, 59% women, mean ± SD 60 ± 17 years). Multivariable regressions (mean change, CI) showed that hypoxia did not affect mPAP and cardiac index, but increased PVR [0.4 (0.1–0.7) WU, p = 0.021] due to decreased pulmonary artery wedge pressure [−0.54 (−0.92 to −0.162), p = 0.005]. Hyperoxia significantly decreased mPAP [−4.4 (−5.5 to −3.3) mmHg, p < 0.001] and PVR [−0.4 (−0.7 to −0.1) WU, p = 0.006] compared with normoxia. The Qs/Qt (14 ± 6%) was >10 in 75% of subjects but changes of mPAP and PVR under hyperoxia and hypoxia were independent of Qs/Qt.ConclusionAcute exposure to hypoxia did not relevantly alter pulmonary hemodynamics indicating a blunted HPV-response in PH. In contrast, hyperoxia remarkably reduced mPAP and PVR, indicating a preserved vasodilator response to oxygen and possibly supporting the oxygen therapy in patients with PH. A high proportion of patients with PH showed increased Qs/Qt, which, however, was not associated with changes in pulmonary hemodynamics in response to changes in FiO2.
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Retrograde Transseptal Pulmonary Vein Transcatheter Plug Closure for Pulmonary Arteriovenous Malformation. JACC Case Rep 2022; 4:150-153. [PMID: 35199006 PMCID: PMC8853956 DOI: 10.1016/j.jaccas.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/01/2021] [Accepted: 12/07/2021] [Indexed: 11/24/2022]
Abstract
Pulmonary arteriovenous malformations (PAVMs) may manifest with bleeding or embolic events necessitating intervention. Transcatheter coil embolization through the pulmonary artery (PA) is an established approach. We present a case of recurrent PAVMs despite numerous PA coil embolizations. PAVM occlusion was achieved through plug placement by a transseptal and pulmonary venous approach. (Level of Difficulty: Advanced.)
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Goto C, Yatsu S, Wada H, Suwa S. Venous thrombosis via pulmonary arteriovenous malformation causing acute myocardial infarction in a relatively young female patient. BMJ Case Rep 2022; 15:15/2/e247846. [PMID: 35228242 PMCID: PMC8886400 DOI: 10.1136/bcr-2021-247846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pulmonary arteriovenous malformation (PAVM) is a probable cause of thromboembolic diseases such as acute myocardial infarction (MI); however, few cases have been reported. A woman in her early 40s developed acute-onset chest pain; an ECG showed ST-elevated MI. Emergency catheter angiography showed that the culprit lesion was a thrombus that was treated successfully with aspiration. She had a history of deep venous thrombosis and CT revealed PAVM. It was likely that the venous thrombus had moved into the coronary artery through the PAVM. Catheter embolisation of the PAVM was performed and she did not experience any other cardiac event until 6 months after embolisation.
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Affiliation(s)
- China Goto
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Shoichiro Yatsu
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Hideki Wada
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Satoru Suwa
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
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Kawasaki Y, Nojiri M, Oikawa T, Nishiki K, Nakase K, Takahara Y, Mizuno S. Acquired pulmonary arteriovenous malformation associated with bronchiectasis: a case report. J Med Case Rep 2022; 16:24. [PMID: 35057821 PMCID: PMC8780241 DOI: 10.1186/s13256-021-03233-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 12/17/2021] [Indexed: 11/14/2022] Open
Abstract
Background Pulmonary arteriovenous malformations are mostly caused by congenitally abnormal shunts between pulmonary arteries and pulmonary veins. Case presentation A 74-year-old Japanese woman with a history of bronchiectasis was admitted to our hospital because of dyspnea on exertion. Pulmonary angiography and reconstructed three-dimensional contrast-enhanced computed tomography images showed shunts between pulmonary arteries and pulmonary veins, indicating a diagnosis of pulmonary arteriovenous malformations. Coil embolization of the shunts was successful. Conclusions Our findings imply that bronchiectasis can cause pulmonary arteriovenous malformations, and thus patients who present with hypoxemia with bronchiectasis should be carefully evaluated.
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Lee HN, Hyun D. Pulmonary Arteriovenous Malformation and Its Vascular Mimickers. Korean J Radiol 2022; 23:202-217. [PMID: 35029077 PMCID: PMC8814702 DOI: 10.3348/kjr.2021.0417] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/30/2021] [Accepted: 10/22/2021] [Indexed: 11/15/2022] Open
Abstract
Pulmonary arteriovenous malformation (AVM) is a congenital vascular disease in which interventional radiologists can play both diagnostic and therapeutic roles in patient management. The diagnosis of pulmonary AVM is simple and can usually be made based on CT images. Endovascular treatment, that is, selective embolization of the pulmonary artery feeding the nidus of the pulmonary AVM, and/or selectively either the nidus or draining vein, has become a first-line treatment with advances in interventional devices. However, some vascular diseases can simulate pulmonary AVMs on CT and pulmonary angiography. This subset can confuse interventional radiologists and referring physicians. Vascular mimickers of pulmonary AVM have not been widely known and described in detail in the literature, although some of these require surgical correction, while others require regular follow-up. This article reviews the clinical and radiologic features of pulmonary AVMs and their mimickers.
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Affiliation(s)
- Hyoung Nam Lee
- Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Dongho Hyun
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Hamamoto K, Chiba E, Oyama-Manabe N, Yuzawa H, Shinmoto H. Assessment of pulmonary arteriovenous malformation with ultra-short echo time magnetic resonance imaging. Eur J Radiol 2022; 147:110144. [PMID: 34999474 DOI: 10.1016/j.ejrad.2021.110144] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/15/2021] [Accepted: 12/29/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the diagnostic performance of ultra-short echo time magnetic resonance imaging (UTE MRI) in the assessment of pulmonary arteriovenous malformation (PAVM). METHODS Eighteen consecutive patients (mean [± standard deviation] age, 48.6 ± 16.8 years) with 46 untreated PAVMs who underwent and thin-section computed tomography (CT) and UTE MRI with a 1.5-Tesla and 3-Tesla unit were retrospectively assessed. Two radiologists evaluated the diagnostic capabilities of UTE MRI for the detection and classification of PAVMs with reference to CT. Sensitivity, specificity, and kappa statistics were calculated with reference to CT. We also compared the differences in PAVM measurements between CT and MRI. RESULTS The sensitivity and specificity of UTE-MRI for the detection of PAVMs were 89.1% and 100%, respectively, for reader 1 and 87.0% and 100%, respectively, for reader 2. In the classification of PAVMs, inter-modality agreement in reader 1 and 2 were both substantial (κ = 0.78 and 0.69, respectively). The measurements of the PAVM feeding artery and sac on CT and MRI were strongly correlated in both readers 1 and 2 (R2 = 0.981 and 0.983, respectively). Both readers 1 and 2 slightly underestimated the diameter of the PAVM feeding artery and sac on UTE MRI (p < 0.001). CONCLUSION This study indicates that UTE MRI is a feasible and promising modality for noninvasive assessment of PAVMs.
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Affiliation(s)
- Kohei Hamamoto
- Department of Radiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan; Department of Radiology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama 330-8503, Japan.
| | - Emiko Chiba
- Department of Radiology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1, Ogawahigashi, Kodaira, Tokyo 187-8551, Japan
| | - Noriko Oyama-Manabe
- Department of Radiology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama 330-8503, Japan
| | - Hironao Yuzawa
- Department of Radiology, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama 330-8503, Japan
| | - Hiroshi Shinmoto
- Department of Radiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
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Rothman R, Saini V, Min Z, Bhanot N. Brain abscess associated with Mycoplasma faucium – The initial presentation of pulmonary arteriovenous malformation. IDCases 2022; 29:e01575. [PMID: 35865084 PMCID: PMC9294263 DOI: 10.1016/j.idcr.2022.e01575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 11/05/2022] Open
Abstract
Brain abscesses represent a pathology with significant morbidity and mortality. An underlying predisposing condition may not be apparent or identifiable in some instances. We present a patient with cerebral abscess who was found to have, previously undiagnosed, pulmonary arteriovenous malformations (PAVMs). PAVMs are rare pulmonary vascular anomalies resulting in intrapulmonary right to left shunt. These have been implicated in the development of brain abscesses. Conventional cultures from the lesion were non-revealing; hence, sample was sent for next-generation sequencing (NGS) which revealed multiple organisms, with predominance of Mycoplasma faucium, a bacterium initially felt to be a commensal of the oropharynx, but recently implicated as a human pathogen. This case, along with other documented associations between brain abscesses and pulmonary AVMs, highlights that brain abscess could be an initial clinical presentation in asymptomatic PAVMs. Additionally, novel testing such as NGS should be utilized in select settings where microbiological diagnosis can be elusive. This will help institute pathogen-directed specific antimicrobial therapy for favorable clinical outcomes.
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Sobrepera S, Monroe E, Gemmete JJ, Hallam D, Pinchot JW, Kaufman C. Imaging to intervention: a review of what the Interventionalist needs to Know about Hereditary Hemorrhagic Telangiectasia. CVIR Endovasc 2021; 4:84. [PMID: 34882285 PMCID: PMC8660943 DOI: 10.1186/s42155-021-00270-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/19/2021] [Indexed: 12/17/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a disorder that affects 1 in 5000-10,000 people worldwide and can result in devastating complications such as cerebral abscess, stroke, massive hemorrhage, and even death. HHT is an autosomal dominant disorder that leads to the formation of abnormal communication between the arteries and veins with a resultant spectrum of vascular anomalies. The disorder affects many organ systems and thus requires a dedicated multidisciplinary approach. Interventional radiologists are vital members of this team providing expertise not only in disease management, but in complex embolotherapy, helping to maintain the health of these patients. This article reviews clinical manifestations, screening guidelines, diagnostic criteria, and endovascular management of HHT.
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Affiliation(s)
- Stephanie Sobrepera
- Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Eric Monroe
- Department of Radiology, University of Wisconsin, 1675 Highland Avenue, Madison, WI, 53792, USA
| | - Joseph J Gemmete
- Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Danial Hallam
- Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Jason W Pinchot
- Department of Radiology, University of Wisconsin, 1675 Highland Avenue, Madison, WI, 53792, USA
| | - Claire Kaufman
- Department of Radiology & Imaging Sciences, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132-2140, USA.
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Al-Ammouri I, Rabadi A, Abdel Hafez S, Al-Taher R, Bani Hani A, Samara OA, Abu Abeeleh M. Complex, Isolated Pulmonary Arteriovenous Malformation in Two Children With Severe Cyanosis. World J Pediatr Congenit Heart Surg 2021; 13:387-388. [PMID: 34825608 DOI: 10.1177/21501351211053582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We present two cases of Isolated complex pulmonary arteriovenous malformations in two children presenting with cyanosis and exercise intolerance. We present the anatomical features and the management of each case. One patient was treated with surgical ligation of the draining vein, and one patient was treated percutaneously by closure of the feeding segmental artery.
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41
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Cusumano LR, Tesoriero JA, Wilsen CB, Sayre J, Quirk M, McWilliams JP. Predictors of heart failure symptoms in hereditary hemorrhagic telangiectasia patients with hepatic arteriovenous malformations. Orphanet J Rare Dis 2021; 16:478. [PMID: 34794458 PMCID: PMC8600745 DOI: 10.1186/s13023-021-02109-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hepatic arteriovenous malformations (AVMs) in hereditary hemorrhagic telangiectasia (HHT) patients are most commonly hepatic artery to hepatic venous shunts which can result in high-output heart failure. This condition can be debilitating and is a leading cause of liver transplantation in HHT patients. However, it is not known what characteristics can discriminate between asymptomatic patients and those who will develop heart failure symptoms. RESULTS 176 patients with HHT were evaluated with computed tomography angiography (CTA) between April 2004 and February 2019 at our HHT Center of Excellence. 63/176 (35.8%) patients were found to have hepatic AVMs on CTA. 18 of these patients were excluded because of the presence of another condition which could confound evaluation of heart failure symptoms. In the remaining 45 patients included in our cohort, 25/45 (55.6%) patients were classified as asymptomatic and 20/45 (44.4%) were classified as symptomatic, and these groups were compared. In symptomatic patients, mean common hepatic artery (CHA) diameter was significantly higher (11.1 versus 8.4 mm) and mean hemoglobin levels were significantly lower (10.7 vs 12.6 g/dL). A stepwise multiple logistic regression analysis demonstrated that both CHA diameter and hemoglobin level were independent predictors of heart failure symptoms with ORs of 2.554 (95% CI 1.372-4.754) and 0.489 (95% CI 0.299-0.799), respectively. The receiver operator characteristic (ROC) curve of our analysis demonstrated an AUC of 0.906 (95% CI 0.816-0.996), sensitivity 80.0% (95% CI 55.7-93.4%), and specificity 75.0% (95% CI 52.9-89.4%). CONCLUSIONS CTA is an effective and easily reproducible method to evaluate hepatic involvement of HHT. Utilizing CTA, clinical, and laboratory data we determined CHA diameter and hemoglobin level were independent predictors of heart failure symptoms.
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Affiliation(s)
- Lucas R Cusumano
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA
| | - Joseph A Tesoriero
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA
| | - Craig B Wilsen
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA
| | - James Sayre
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Matthew Quirk
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA
| | - Justin P McWilliams
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, 2nd Floor, Room 2125, Los Angeles, CA, 90095, USA.
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Zhan J, Dong C, Li M, Zhan L, Chen H, Lu L, Liu J. Cryptogenic Stroke Caused by Pulmonary Arterial Venous Malformation with Massive Right-to-Left Shunt: A Case Report. Neurol Ther 2021; 10:1135-1142. [PMID: 34478123 PMCID: PMC8571431 DOI: 10.1007/s40120-021-00275-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 08/17/2021] [Indexed: 11/25/2022] Open
Abstract
Background Pulmonary arterial venous malformation (PAVM) is an abnormal vascular malformation between pulmonary arteries and veins characterized by varying degrees of right-to-left shunts (RLS). Cryptogenic stroke (CS) due to paradoxical embolism (PE) caused by PAVM is relatively rare in the clinic. Case Presentation We report the case of a 54-year-old right-handed woman who presented with sudden-onset left-sided limb weakness for 2 h. A physical examination revealed normal vital signs but weakness in her left upper and lower limbs, graded as 1/5 using the Medical Research Council scale. Her National Institutes of Health Stroke Scale (NIHSS) score was 8, and her modified Rankin scale (mRS) was 4. Brain diffusion-weighted imaging showed acute infarction in the right basal ganglia and the radiation crown but brain magnetic resonance angiography found no obvious abnormality. A transcranial Doppler ultrasound with bubble study (TCD-b) found the rain curtain sign of microbubbles in the left middle cerebral artery, reflecting significant RLS. Transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) were conducted to distinguish between intra- and extracardiac shunts. A pulmonary computerized tomography angiogram (CTA) demonstrated a PAVM. We considered the patient had CS due to PE caused by PAVM. Thrombolytic therapy within the time window was performed. Then, transcatheter device occlusion of the arteriovenous fistula was successfully undertaken, and the patient carried on with rehabilitation training. At a 15-month follow-up, there were no catheter-related complications or recurrent stroke, and her NIHSS and mRS scores were both 0. Conclusions PAVM is an important risk factor for PE and CS and should not be ignored as a possible etiology in stroke patients without any other risk factors. CTA of the pulmonary artery is the recommended gold standard for diagnosing and locating a PAVM. Thrombolytic therapy within the time window combined with transcatheter device occlusion of arteriovenous malformation and rehabilitation training may benefit the recovery of patients with CS caused by PE resulting from PAVM. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-021-00275-y.
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Affiliation(s)
- Jie Zhan
- Postdoctoral research station, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China.,Department of Rehabilitation, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, China
| | - Cong Dong
- Department of Rehabilitation, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, China
| | - Mei Li
- Department of Rehabilitation, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, China
| | - Lechang Zhan
- Department of Rehabilitation, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, China
| | - Hongxia Chen
- Department of Rehabilitation, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, China
| | - Liming Lu
- Clinical Research and Data Center, South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, 510120, China.
| | - Jianhua Liu
- Research Team for Acupuncture Effect and Mechanism, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China.
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Lam S, Guthrie KS, Latif MA, Weiss CR. Genetic counseling and testing for hereditary hemorrhagic telangiectasia. Clin Genet 2021; 101:275-284. [PMID: 34415050 DOI: 10.1111/cge.14050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 08/04/2021] [Accepted: 08/15/2021] [Indexed: 12/13/2022]
Abstract
Genetic counseling is an important means of identifying a patient's genetic risk of hereditary hemorrhagic telangiectasia (HHT) and assisting patients in making informed decisions about their health. With an increase in understanding of the genetic mechanisms underlying HHT over the last decade, genetic counseling is increasingly being incorporated into the care of patients affected by HHT. In addition to refining the diagnosis of symptomatic patients, genetic testing can help to distinguish asymptomatic, at-risk patients from those who are unaffected by HHT. The purpose of this review article is to summarize the current knowledge regarding the role of genetic counseling and genetic testing in identifying and managing HHT in at-risk populations. This article also reviews the guidelines, outcomes, risks, and challenges of genetic counseling and testing for HHT in various patient populations, and provides an algorithm for the use of genetic counseling in symptomatic and asymptomatic patients.
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Affiliation(s)
- Shravika Lam
- Russel H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Kelsey S Guthrie
- Institute of Genetic Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Muhammad A Latif
- Russel H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Clifford R Weiss
- Russel H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Azimi-Ghomi O, Ramirez M, Brummund D, Gibber M, Mawad MR. Traumatic Pulmonary Arteriovenous Malformation Presenting as Spontaneous Hemothorax. Cureus 2021; 13:e16072. [PMID: 34345554 PMCID: PMC8324253 DOI: 10.7759/cureus.16072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 11/07/2022] Open
Abstract
Pulmonary arteriovenous malformations (PAVM), also known as pulmonary arteriovenous fistulas, are abnormal connections between the pulmonary arterial and venous systems. The majority occur secondary to the congenital syndrome hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease. Trauma is an extremely rare etiology of PAVM, comprising less than 1% of all reported cases. Trauma can be associated with both immediate and delayed development of PAVM, and present similarly to PAVM associated with HHT. We report a case of a traumatic PAVM that developed in a patient one year following blunt thoracic trauma with a rib fracture. The patient subsequently developed a rupture of the PAVM, resulting in spontaneous hemothorax. She required multi-unit blood transfusion and multiple thoracostomy tube placements. The patient subsequently underwent a failed attempt at angioembolization of the PAVM. She eventually required a thoracotomy for surgical excision of the PAVM. We discuss the traumatic etiologies, clinical presentation, diagnostic assessments, and therapeutic modalities for the management of PAVM.
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Affiliation(s)
| | - Marcela Ramirez
- Department of General Surgery, Kendall Regional Medical Center, Miami, USA
| | - Dieter Brummund
- Department of General Surgery, Kendall Regional Medical Center, Miami, USA
| | - Marc Gibber
- Department of Cardiothoracic Surgery, Aventura Hospital and Medical Center, Aventura, USA.,Department of Cardiothoracic Surgery, Kendall Regional Medical Center, Miami, USA
| | - Maurice R Mawad
- Department of Cardiothoracic Surgery, Kendall Regional Medical Center, Miami, USA.,Department of Cardiothoracic Surgery, Aventura Hospital and Medical Center, Aventura, USA
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45
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Sen G, Lwin MT, Smith L, Weir N. Young stroke due to pulmonary arteriovenous malformation. BMJ Case Rep 2021; 14:14/6/e242581. [PMID: 34155023 DOI: 10.1136/bcr-2021-242581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Young patients presenting with cryptogenic stroke should be investigated for cardiac and extra-cardiac sources of emboli. We present a patient who was investigated for a cardiac source of emboli, following multiple ischaemic strokes and migraine with aura over a period of 17 years. The events were initially thought to be related to a patent foramen ovale (PFO) on bubble contrast echocardiography, however, due to an unusual flow pattern to the left heart, she underwent a CT angiogram to exclude intrapulmonary shunting. This confirmed the presence of a moderate sized congenital pulmonary arteriovenous fistula in the left lung. Transcatheter occlusion of the vascular malformation has resolution of her symptoms. Bubble contrast echocardiography is routinely used to diagnose a PFO in these cases, but extreme caution is required during the procedure to differentiate the pattern of flow seen in patients with a pulmonary arteriovenous malformation.
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Affiliation(s)
- Gautam Sen
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Myo T Lwin
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Lindsay Smith
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nicolas Weir
- Neurology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Sano Y, Kuwajima H, Kanai H, Baba C, Azami K, Matsuda K. A bronchopulmonary artery fistula in a horse. J Vet Med Sci 2021; 83:1225-1228. [PMID: 34108306 PMCID: PMC8437714 DOI: 10.1292/jvms.21-0221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A 24-year-old, Thoroughbred gelding presented with difficulty breathing for a few days and intermittent nose bleeding before dying. At necropsy, the bronchoesophageal artery and the bronchial artery that flowed into the left anterior lobe were tortuous and dilated, and it was found that dilated tortuous branches of the bronchial artery ran over the dorsal and ventral surfaces of the left anterior lobe. Histopathologically, an anastomosis between a muscular artery and an elastic artery were demonstrated, which were identified as bronchial and pulmonary arteries, respectively. Based on the gross and histopathological findings, a bronchopulmonary artery fistula was diagnosed. To the best of our knowledge, this is the first case report of a pulmonary vascular anastomosis in a horse.
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Affiliation(s)
- Yuto Sano
- Department of Veterinary Pathology, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8501, Japan
| | - Hikaru Kuwajima
- Department of Veterinary Pathology, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8501, Japan
| | - Hiroki Kanai
- Department of Veterinary Pathology, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8501, Japan
| | - Chiemi Baba
- Department of Veterinary Pathology, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8501, Japan
| | - Kohei Azami
- Department of Veterinary Pathology, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8501, Japan
| | - Kazuya Matsuda
- Department of Veterinary Pathology, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8501, Japan
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Huynh R, Morgan L, Yiannikas J. Haemoptysis: just another case of endocarditis? A case report. Eur Heart J Case Rep 2021; 5:ytab226. [PMID: 34263124 PMCID: PMC8274648 DOI: 10.1093/ehjcr/ytab226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/18/2021] [Accepted: 05/12/2021] [Indexed: 11/25/2022]
Abstract
Background Pulmonary arteriovenous malformations (PAVM) are rare, and most cases are congenital. They require prompt recognition and management particularly in patients presenting with hypoxia and haemoptysis. We describe a unique case of recurrent endocarditis causing pulmonary artery aneurysms (PAAs) and formation of PAVM. Case summary A 60-year-old woman presented with dyspnoea, haemoptysis, and severe hypoxia. Her background was significant for previous pacemaker lead infection, refractory heart failure secondary to severe tricuspid valve distortion by her pacemaker lead, tricuspid and mitral valve replacements complicated by recurrent endocarditis over several years. Two years prior to her current presentation computed tomography (CT) scanning revealed new small PAAs thought possibly to be mycotic in origin. After her current presentation, prompt high-resolution CT scanning of her chest with contrast revealed significant pulmonary haemorrhage and new clusters of PAVM. Urgent pulmonary angiography confirmed PAVM and was successfully treated with coil embolization. Her dyspnoea, pulmonary haemorrhage, and hypoxia resolved. Discussion Acquired causes account for a very small percentage of PAVM and the mechanism of their development is unknown. As she had recurrent right-sided endocarditis and her PAAs developed following this, with new PAVM developing 2 years later; we hypothesize that they were causally related. We believe this is the first case of recurrent left- and right-sided endocarditis leading to formation of PAAs and development of PAVM presenting with significant hypoxia and haemoptysis requiring prompt intervention.
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Affiliation(s)
- Ronald Huynh
- Department of Cardiology, Concord Repatriation General Hospital, 1 Hospital Rd, Concord West, New South Wales 2139, Australia
| | - Lucy Morgan
- Department of Respiratory Medicine, Concord Clinical School, Faculty of Medicine, University of Sydney, 1 Hospital Rd, Concord West, New South Wales 2139, Australia
| | - John Yiannikas
- Department of Cardiology, Concord Repatriation General Hospital, 1 Hospital Rd, Concord West, New South Wales 2139, Australia.,Department of Cardiology, Concord Clinical School, Faculty of Medicine, University of Sydney, 1 Hospital Rd, Concord West, New South Wales 2139, Australia
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48
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Kramdhari H, Valakkada J, Ayyappan A. Diagnosis and endovascular management of pulmonary arteriovenous malformations. Br J Radiol 2021; 94:20200695. [PMID: 34038182 DOI: 10.1259/bjr.20200695] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Pulmonary arteriovenous malformations (PAVM) are abnormal communication of a branch of the pulmonary artery and pulmonary vein circumventing the intervening pulmonary capillaries. This results in a right-to-left (R-L) shunt and its related manifestations, which include hampered gas exchange leading to hypoxaemia, dyspnoea, paradoxical emboli leading to stroke, cerebral abscess, myocardial infarction and pulmonary haemorrhage due to rupture of the PAVM. Endovascular transcatheter embolization of the feeding vessels with coils or occlusion devices is the current standard care of treatment and preferred treatment modality. The articles aim to provide insights into the current trends in diagnosis, the current recommendations, approach and management options for patients with PAVM.
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Affiliation(s)
- Harshit Kramdhari
- Department of imaging sciences and interventional radiology, Sreechitra institute of medical sciences and technology, Trivandrum - 695011, Kerala, India
| | - Jineesh Valakkada
- Department of imaging sciences and interventional radiology, Sreechitra institute of medical sciences and technology, Trivandrum - 695011, Kerala, India
| | - Anoop Ayyappan
- Department of imaging sciences and interventional radiology, Sreechitra institute of medical sciences and technology, Trivandrum - 695011, Kerala, India
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Cardosa MF, Mingas O, Ramos R, Araújo AR. Persistent hypoxaemia after a pneumonia: a rare cause to consider. BMJ Case Rep 2021; 14:14/5/e241491. [PMID: 33975841 PMCID: PMC8117980 DOI: 10.1136/bcr-2020-241491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Odete Mingas
- Department of Pediatric Cardiology, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Rita Ramos
- Department of Pediatrics, Hospital Garcia de Orta EPE, Almada, Portugal
| | - Ana R Araújo
- Department of Pediatric Cardiology, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
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Bofarid S, Hosman AE, Mager JJ, Snijder RJ, Post MC. Pulmonary Vascular Complications in Hereditary Hemorrhagic Telangiectasia and the Underlying Pathophysiology. Int J Mol Sci 2021; 22:3471. [PMID: 33801690 PMCID: PMC8038106 DOI: 10.3390/ijms22073471] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/23/2021] [Accepted: 03/25/2021] [Indexed: 12/15/2022] Open
Abstract
In this review, we discuss the role of transforming growth factor-beta (TGF-β) in the development of pulmonary vascular disease (PVD), both pulmonary arteriovenous malformations (AVM) and pulmonary hypertension (PH), in hereditary hemorrhagic telangiectasia (HHT). HHT or Rendu-Osler-Weber disease is an autosomal dominant genetic disorder with an estimated prevalence of 1 in 5000 persons and characterized by epistaxis, telangiectasia and AVMs in more than 80% of cases, HHT is caused by a mutation in the ENG gene on chromosome 9 encoding for the protein endoglin or activin receptor-like kinase 1 (ACVRL1) gene on chromosome 12 encoding for the protein ALK-1, resulting in HHT type 1 or HHT type 2, respectively. A third disease-causing mutation has been found in the SMAD-4 gene, causing a combination of HHT and juvenile polyposis coli. All three genes play a role in the TGF-β signaling pathway that is essential in angiogenesis where it plays a pivotal role in neoangiogenesis, vessel maturation and stabilization. PH is characterized by elevated mean pulmonary arterial pressure caused by a variety of different underlying pathologies. HHT carries an additional increased risk of PH because of high cardiac output as a result of anemia and shunting through hepatic AVMs, or development of pulmonary arterial hypertension due to interference of the TGF-β pathway. HHT in combination with PH is associated with a worse prognosis due to right-sided cardiac failure. The treatment of PVD in HHT includes medical or interventional therapy.
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Affiliation(s)
- Sala Bofarid
- Department of Cardiology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands;
| | - Anna E. Hosman
- Department of Pulmonology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands; (A.E.H.); (J.J.M.); (R.J.S.)
| | - Johannes J. Mager
- Department of Pulmonology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands; (A.E.H.); (J.J.M.); (R.J.S.)
| | - Repke J. Snijder
- Department of Pulmonology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands; (A.E.H.); (J.J.M.); (R.J.S.)
| | - Marco C. Post
- Department of Cardiology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands;
- Department of Cardiology, University Medical Center Utrecht, 3584 CM Utrecht, The Netherlands
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