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Ahmed S, Ansari AI, Khan AS, Khan JA. Diffuse pulmonary arteriovenous malformation presenting with secondary polycythemia and headaches: a case report. J Med Case Rep 2024; 18:313. [PMID: 38973008 DOI: 10.1186/s13256-024-04643-8] [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: 12/18/2023] [Accepted: 06/18/2024] [Indexed: 07/09/2024] Open
Abstract
BACKGROUND Pulmonary arteriovenous malformations are a relatively uncommon medical condition, affecting roughly 1 in every 2500 individuals. Of those suffering from pulmonary arteriovenous malformations, 80% have an underlying genetic condition: hereditary hemorrhagic telangiectasia. CASE PRESENTATION We present the case of a 20-year-old Pakistani male with a history of persistent slower-onset frontal headaches that increased in severity within the course of the day. His hemoglobin was 18 g/dl, indicating polycythemia, for which he had undergone seven venesections in a month previously. His physical examination was unremarkable. His computed tomography scan depicted multiple dilated tortuous vessels with branching linear opacities in the right lower lobe of the lungs. The multiple feeding arteries were supplied by the right main pulmonary artery, and the large draining veins led to the right inferior pulmonary vein. This was identified as a diffuse pulmonary arteriovenous malformation. He was recommended for a right pulmonary artery angiogram. It showed multiple tortuous vessels with a nidus and large draining veins-features of a diffuse arteriovenous malformation in the right lower lobe of the lung consistent with the computed tomography scan. Embolization of two of these vessels feeding the arteriovenous malformation was conducted, using Amplatzer Vascular plug 2, whereas multiple pushable coils (five coils) were used for embolizing the third feeding vessel. This achieved 70-80% successful embolization of right pulmonary AVM; however, some residual flow was still seen in the arteriovenous malformation given the complexity of the lesion. Immediately after, his oxygen saturation improved from 78% to 96%. CONCLUSION Diffuse pulmonary arteriovenous malformations, as seen in this patient, are rare, accounting for less than 5% of total pulmonary arteriovenous malformations diagnosed. The patient presented with a complaint of progressive frontal headaches, which can be attributed to low oxygen saturation or the presence of a cerebral arteriovenous malformation. There was no history of hereditary hemorrhagic telangiectasia in the patient's family. Furthermore, although most patients with hereditary hemorrhagic telangiectasia and hence pulmonary arteriovenous malformation have complaints of iron-deficiency anemia, our patient in contrast was suffering from polycythemia. This can be explained as a compensatory mechanism in hypoxemic conditions. Moreover, the patient had no complaint of hemoptysis or epistaxis, giving a varied presentation in comparison with a typical pulmonary arteriovenous malformation.
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Affiliation(s)
- Salaar Ahmed
- Medical College, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan.
| | - Amna Irfan Ansari
- Medical College, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Abdullah Saeed Khan
- Medical College, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Javaid Ahmed Khan
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
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Li X, Duan L, Mu S, Dong X, Lu X, Cao D. Massive hemothorax induced by pulmonary arteriovenous malformation rupture: a case report and literature review. J Cardiothorac Surg 2024; 19:342. [PMID: 38907280 PMCID: PMC11191350 DOI: 10.1186/s13019-024-02867-9] [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: 08/30/2023] [Accepted: 06/14/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Pulmonary arteriovenous malformation (PAVM), also known as pulmonary arteriovenous fistula, is a rare vascular developmental anomaly. Most cases of PAVM are associated with hereditary hemorrhagic telangiectasia (HHT). Hemothorax associated with PAVM is even rarer, and management concerning this complication still challenges. CASE PRESENTATION A 55-year-old man with sudden onset of dyspnea and chest pain was admitted to our hospital. He had a medical history of epistaxis, intraperitoneal germ cell tumor and PAVM. Chest unenhanced CT revealed the left-sided pleural effusion together with partial passive atelectasis and gradual increase at the interval of six days. Diagnostic thoracocentesis further revealed hemorrhagic effusion. CT angiography (CTA) showed tortuously dilated lumen of the left lower pulmonary artery and PAVM with the formation of aneurysm. Due to his family's refusal of surgery, the patient underwent transcatheter embolization therapy. However, the left pleural effusion did not significantly reduce and there was a slow drop in hemoglobin value even after interventional treatment, indicating the possibility of ongoing active bleeding. Eventually, the patient received lobectomy of the left lower lobe with a satisfactory outcome. CONCLUSIONS Massive hemothorax resulting from PAVM rupture into the pleural space can lead to fatal outcomes. CTA can accurately diagnose this pathologic condition. Transcatheter embolization is frequently used in the treatment of PAVM, but it may be challenging to achieve the desirable effect in patients with hemothorax. Combined with our case and literature review, direct radical surgery can lead to a successful outcome when PAVM complicated with hemothorax and a large diameter of the draining vein.
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Affiliation(s)
- Xiang Li
- Department of Radiology, the First Hospital of Jilin University, No. 71 of Xinmin Street, Changchun, Jilin, 130021, China
| | - Lijun Duan
- Department of Radiology, the First Hospital of Jilin University, No. 71 of Xinmin Street, Changchun, Jilin, 130021, China
| | - Shengnan Mu
- Department of Radiology, the First Hospital of Jilin University, No. 71 of Xinmin Street, Changchun, Jilin, 130021, China
| | - Xin Dong
- Department of Radiology, the First Hospital of Jilin University, No. 71 of Xinmin Street, Changchun, Jilin, 130021, China
| | - Xiaoqian Lu
- Department of Radiology, the First Hospital of Jilin University, No. 71 of Xinmin Street, Changchun, Jilin, 130021, China
| | - Dianbo Cao
- Department of Radiology, the First Hospital of Jilin University, No. 71 of Xinmin Street, Changchun, Jilin, 130021, China.
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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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5
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Kim YS. Life-threatening hemothorax due to rupture of pulmonary arteriovenous malformation during pregnancy. J Surg Case Rep 2024; 2024:rjae139. [PMID: 38476457 PMCID: PMC10930188 DOI: 10.1093/jscr/rjae139] [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: 01/17/2024] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/14/2024] Open
Abstract
Pulmonary arteriovenous malformation (PAVM) can worsen in pregnant women due to pregnancy-related physiological changes. If a PAVM ruptures, it can become life-threatening. A 24-year-old female patient at 22 weeks of gestation presented to the hospital with chest pain and dyspnea. A simple chest radiograph revealed that the right lung was almost completely collapsed due to massive pleural effusion, and the heart was displaced to the opposite side. Closed thoracostomy was performed and 2 l of blood was drained. Chest CT revealed the presence of a PAVM in the right upper lung. Emergency surgery was performed to resect the PAVM through thoracoscopic pulmonary wedge resection. The patient experienced disseminated intravascular coagulation and acute renal insufficiency after the surgery, but eventually recovered and was discharged without any complications on the sixth postoperative day.
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Affiliation(s)
- Yeon Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Inje University Ilsan Paik Hospital, 170 Juwha-ro, Ilsansu-gu, Goyang-si, Gyeonsgi-Do, 10380, South Korea
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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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7
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Chauhan NK, Rajagopal R, Shadrach BJ, Dutt N. Pulmonary arterio-venous malformation on endobronchial ultrasound bronchoscopy. Thorax 2023; 78:214-215. [PMID: 36635031 DOI: 10.1136/thorax-2022-219398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/24/2022] [Indexed: 01/17/2023]
Affiliation(s)
| | - Rengarajan Rajagopal
- Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, India
| | | | - Naveen Dutt
- Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, India
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8
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Chen J, Zhang B. Application of contrast-enhanced ultrasound in hemothorax of hereditary hemorrhagic telangiectasia: A case report and literature review. Clin Hemorheol Microcirc 2022; 83:273-278. [PMID: 36565108 DOI: 10.3233/ch-221646] [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: 12/24/2022]
Abstract
Hereditary hemorrhagic telangiectasis (HHT) is an autosomal dominant hereditary disease, which can lead to abnormal angiogenesis. We performed contrast-enhanced ultrasound (CEUS) in a patient with HHT represented with hemothorax. After targeted embolization, the condition of hemothorax improved. In this case, we explore the use of CEUS to locate the responsible vessel of hemothorax, and found that CEUS could be used as a complementary preoperative method of localization with Computed tomography angiography (CTA).
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Affiliation(s)
- Jie Chen
- Department of Ultrasound, China-Japan Friendship Hospital, Beijing, China
| | - Bo Zhang
- Department of Ultrasound, China-Japan Friendship Hospital, Beijing, China
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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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Tessier S, Lipton BA, Ido F, Longo S, Nanda S. Pathogenesis and therapy of arteriovenous malformations: A case report and narrative review. Int J Crit Illn Inj Sci 2021; 11:167-176. [PMID: 34760664 PMCID: PMC8547675 DOI: 10.4103/ijciis.ijciis_127_20] [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: 07/22/2020] [Revised: 10/24/2020] [Accepted: 01/05/2021] [Indexed: 12/03/2022] Open
Abstract
Arteriovenous malformations (AVMs) are abnormal communications between arteries and veins that lack intervening capillary beds. They have been described in almost every organ in the body, emerging sporadically or as part of well-described syndromes. Hereditary hemorrhagic telangiectasia (HHT) is a rare, progressive, and lifelong disease characterized by AVMs and recurrent hemorrhaging. In the last 2 decades, significant advances have been made in understanding the pathogenesis of this condition. The accumulation of knowledge has led to a natural evolution of therapy, from open surgery to endovascular procedures, and now to a role for medications in certain AVMs. Here, we review a case of HHT and describe the most up-to-date clinical practice, including diagnosis of HHT, subtypes of HHT, and medical therapy.
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Affiliation(s)
- Steven Tessier
- Lewis Katz School of Medicine, Temple University, Philadelphia, USA
| | - Brooke A Lipton
- Lewis Katz School of Medicine, Temple University, Philadelphia, USA
| | - Firas Ido
- Department of Pulmonary and Critical Care, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Santo Longo
- Department of Pathology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Sudip Nanda
- Department of Cardiology, St. Luke's University Health Network, Bethlehem, PA, USA
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Droege F, Stang A, Thangavelu K, Lueb C, Lang S, Xydakis M, Geisthoff U. Restless Leg Syndrome Is Underdiagnosed in Hereditary Hemorrhagic Telangiectasia-Results of an Online Survey. J Clin Med 2021; 10:jcm10091993. [PMID: 34066446 PMCID: PMC8125616 DOI: 10.3390/jcm10091993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/25/2021] [Accepted: 04/28/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Recurrent bleeding in patients with hereditary hemorrhagic telangiectasia (HHT) can lead to chronic iron deficiency anemia (CIDA). Existing research points to CIDA as a contributing factor in restless leg syndrome (RLS). The association between HHT-related symptoms and the prevalence of RLS was analyzed. METHODS An online survey was conducted whereby the standardized RLS-Diagnostic Index questionnaire (RLS-DI) was supplemented with 82 additional questions relating to HHT. RESULTS A total of 474 persons responded to the survey and completed responses for questions pertaining to RLS (mean age: 56 years, 68% females). Per RLS-DI criteria, 48 patients (48/322, 15%; 95% confidence interval (CI): 11-19%) self-identified as having RLS. An analysis of physician-diagnosed RLS and the RLS-DI revealed a relative frequency of RLS in HHT patients of 22% (95% CI: 18-27%). In fact, 8% (25/322; 95% CI: 5-11%) of the HHT patients had RLS which had not been diagnosed before. This equals 35% of the total amount of patients diagnosed with RLS (25/72; 95% CI: 25-46%). HHT patients with a history of gastrointestinal bleeding (prevalence ratio (PR) = 2.70, 95% CI: 1.53-4.77), blood transfusions (PR = 1.90, 95% CI: 1.27-2.86), or iron intake (PR = 2.05, 95% CI: 0.99-4.26) had an increased prevalence of RLS. CONCLUSIONS Our data suggest that RLS is underdiagnosed in HHT. In addition, physicians should assess CIDA parameters for possible iron supplementation.
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Affiliation(s)
- Freya Droege
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Andreas Stang
- Institute of Medical Informatics, Biometry and Epidemiology, Essen University Hospital, Hufelandstrasse 55, 45122 Essen, Germany
| | - Kruthika Thangavelu
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-Universität Marburg, Baldingerstrasse, 35042 Marburg, Germany
| | - Carolin Lueb
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Stephan Lang
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Michael Xydakis
- Air Force Research Lab, 2245 Monahan Way, Wright Patterson AFB, Dayton, OH 45433, USA
| | - Urban Geisthoff
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-Universität Marburg, Baldingerstrasse, 35042 Marburg, Germany
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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:ijms22073471. [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] [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
- Correspondence: ; Tel.: +31-883203000
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Droege F, Kuerten CHL, Kaiser C, Dingemann J, Kaster F, Dahlfrancis PM, Lueb C, Zioga E, Thangavelu K, Lang S, Geisthoff U. [Hereditary hemorrhagic telangiectasia: symptoms and diagnostic latency]. Laryngorhinootologie 2021; 100:443-452. [PMID: 33761571 DOI: 10.1055/a-1408-5160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Patients with hereditary hemorrhagic Telangiectasia (HHT) suffer from a rare and systemic disease which is characterized by vascular malformations leading to a variety of different symptoms. MATERIAL AND METHODS A retrospective review of patients who were referred to our new HHT Center of Excellence (HHT COE) for evaluation and treatment between April 2014 and August 2019 was performed. RESULTS 235 patients were treated at the West German HHT Center. 83 % of these were diagnosed with definite HHT (235/282, 83 %) and 9 % with possible HHT (26/282). The average latency between first manifestation and definite diagnosis of HHT was 18 years. Several initial symptoms were direct or indirect signs of bleeding (224/241, 93 %). In 83 % of the patients HHT was reported having caused their degree of disability. Older, female patients and those with severe epistaxis suffered from chronic iron deficiency anemia, took iron preparations (148/261, 57 %) and received 9 blood transfusions on average (± standard deviation: 41, minimum - maximum: 0-400, number of patients: 218). 10 % of all patients tolerated anticoagulant or antiplatelet agents. 74 % of patients with HHT used nasal creams/sprays/oils (177/238) and reported fewer bleedings compared to patients without nasal care (ESS: T-Test: 3.193; p = 0.003; anemia: Chi-square: 5.173; p = 0.023). CONCLUSIONS The diagnostic latency of HHT was almost two decades. Patients with HHT particularly suffered from recurrent epistaxis, which was mostly treated with nasal care and coagulative therapies. Antiplatelet or anticoagulant agents can be used in patients with HHT with caution if indicated.
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Affiliation(s)
- Freya Droege
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | | | - Christina Kaiser
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Julia Dingemann
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Friederike Kaster
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | | | - Carolin Lueb
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Eleni Zioga
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | | | - Stephan Lang
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Essen, Germany
| | - Urban Geisthoff
- Klinik für Hals-Nasen-Ohrenheilkunde, Philipps-Universität Marburg, Germany
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张 娟, 童 笑, 王 雪, 邢 燕. [Sudden convulsion with multiple pulmonary nodules in a girl aged 15 years]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:288-293. [PMID: 33691924 PMCID: PMC7969192 DOI: 10.7499/j.issn.1008-8830.2010094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/03/2021] [Indexed: 06/12/2023]
Abstract
A girl, aged 15 years, was admitted due to sudden convulsion once and multiple pulmonary nodules on lung CT. Acrocyanosis or acropachy/toe deformity was not observed. Laboratory examinations showed an increase in hemoglobin (162 g/L) and a reduction in arterial partial pressure of oxygen (61.5 mm Hg). Lung CT showed irregular slightly high-density nodules in the middle lobe of the right lung, and contrast-enhanced CT scan showed obvious enhancement with thick vascular shadow locally. An investigation of medical history revealed that the girl's mother had a history of epistaxis and resection of pulmonary mass and the girl presented with tongue telangiectasia. The girl was diagnosed with hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformation. she was given interventional embolization therapy. Transcutaneous oxygen saturation reached 98% without oxygen inhalation on the day after surgery. Pulmonary angiography at 3 months after surgery showed the recurrence of pulmonary vascular malformation, and embolization of pulmonary arterial fistula was not performed since the guide wire could not enter the branch artery. There was still a need for long-term follow-up.
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Affiliation(s)
- 娟 张
- />北京大学第三医院儿科, 北京 100191Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China
| | - 笑梅 童
- />北京大学第三医院儿科, 北京 100191Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China
| | - 雪梅 王
- />北京大学第三医院儿科, 北京 100191Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China
| | - 燕 邢
- />北京大学第三医院儿科, 北京 100191Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China
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15
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Safety of Catheter Embolization of Pulmonary Arteriovenous Malformations-Evaluation of Possible Cerebrovascular Embolism after Catheter Embolization of Pulmonary Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia/Osler Disease by Pre- and Post-Interventional DWI. J Clin Med 2021; 10:jcm10040887. [PMID: 33671708 PMCID: PMC7926997 DOI: 10.3390/jcm10040887] [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: 01/18/2021] [Revised: 02/11/2021] [Accepted: 02/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background. This paper aimed to prospectively evaluate the safety of embolization therapy of pulmonary arteriovenous malformations (PAVMs) for the detection of cerebral infarctions by pre- and post-interventional MRI. Method One hundred and five patients (male/female = 44/61; mean age 48.6+/−15.8; range 5–86) with pre-diagnosed PAVMs on contrast-enhanced MRA underwent embolization therapy. The number of PAVMs treated in each patient ranged from 1–8 PAVMs. Depending on the size and localization of the feeding arteries, either Nester-Coils or Amplatzer vascular plugs were used for embolization therapy. cMRI was performed immediately before, and at the 4 h and 3-month post-embolization therapy. Detection of peri-interventional cerebral emboli was performed via T2w and DWI sequences using three different b-values, with calculation of ADC maps. Results Embolization did not show any post-/peri-interventional, newly developed ischemic lesions in the brain. Only one patient who underwent re-embolization and was previously treated with tungsten coils that corroded over time showed newly developed, small, diffuse emboli in the post-interventional DWI sequence. This patient already had several episodes of brain emboli before re-treatment due to the corroded coils, and during treatment, when passing the corroded coils, experienced additional small, clinically inconspicuous brain emboli. However, this complication was anticipated but accepted, since the vessel had to be occluded distally. Conclusion Catheter-based embolization of PAVMs is a safe method for treatment and does not result in clinically inconspicuous cerebral ischemia, which was not demonstrated previously.
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Zhou X, Li A, Yin D, Huang XP, Tian J, Lv TW, Yi QJ, Xiang P. Clinical Analysis of Transcatheter Embolotherapy for Congenital Pulmonary Arteriovenous Fistulas in Children. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2020. [DOI: 10.15212/cvia.2019.0593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective: To summarize the clinical features and therapeutic effects of transcatheter embolotherapy for congenital pulmonary arteriovenous fistulas (PAVFs) in children, and to explore the method and therapeutic principle of transcatheter embolotherapy for congenital PAVFs in
children.Method: We retrospectively reviewed nine patients with PAVF who underwent transcatheter embolotherapy in the Children’s Hospital of Chongqing Medical University from July 2004 to July 2019, including the demographic characteristics, clinical manifestations, efficiency
of closure, and follow-up.Results: Transcatheter embolotherapy was successful in all cases, and the symptom remission rate was 100% during the follow-up. No residual shunts or other complications occurred during the follow-up period. Compared with before embolotherapy, there were
significant changes in the percentage of saturated oxyhemoglobin and total hemoglobin level at the last follow-up (t=10.06, P=0.000; t=3.055, P=0.0076). No significant difference was observed in pulmonary artery pressure before and after embolotherapy (t=0.13, P=0.90).Conclusions:
Transcatheter embolotherapy offers the advantages of safety, with a decreased risk of trauma and a specific effect of treatment, and therefore is recommended as the first-line treatment for congenital PAVFs in children. However, continued research is necessary to understand the full potential
of transcatheter embolotherapy.
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Affiliation(s)
- Xue Zhou
- Department of Cardiology, The Children’s Hospital of Chongqing Medical University, 136 Zhongshan Er Rold, Yu Zhong District, Chongqing 400014, China
| | - Ang Li
- The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing 400016, China
| | - Dan Yin
- The Children’s Hospital of Chongqing Medical University, 136 Zhongshan Er Rold, Yu Zhong District, Chongqing 400014, China
| | - Xu-pei Huang
- Department of Biomedical Science, Charlie E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road, Boca Raton, FL 33431, USA
| | - Jie Tian
- Department of Cardiology, The Children’s Hospital of Chongqing Medical University, 136 Zhongshan Er Rold, Yu Zhong District, Chongqing 400014, China
| | - Tie-wei Lv
- Department of Cardiology, The Children’s Hospital of Chongqing Medical University, 136 Zhongshan Er Rold, Yu Zhong District, Chongqing 400014, China
| | - Qi-jian Yi
- Department of Cardiology, The Children’s Hospital of Chongqing Medical University, 136 Zhongshan Er Rold, Yu Zhong District, Chongqing 400014, China
| | - Ping Xiang
- Department of Cardiology, The Children’s Hospital of Chongqing Medical University, 136 Zhongshan Er Rold, Yu Zhong District, Chongqing 400014, China
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17
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Majumdar S, McWilliams JP. Approach to Pulmonary Arteriovenous Malformations: A Comprehensive Update. J Clin Med 2020; 9:E1927. [PMID: 32575535 PMCID: PMC7356967 DOI: 10.3390/jcm9061927] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 02/07/2023] Open
Abstract
Pulmonary arteriovenous malformations (PAVMs) are abnormal direct vascular communications between pulmonary arteries and veins which create high-flow right-to-left shunts. They are most frequently congenital, usually in the setting of hereditary hemorrhagic telangiectasia (HHT). PAVMs may be asymptomatic or present with a wide variety of clinical manifestations such as dyspnea, hypoxemia, or chest pain. Even when asymptomatic, presence of PAVMs increases patients' risk of serious, potentially preventable complications including stroke or brain abscess. Transcatheter embolotherapy is considered the gold standard for treatment of PAVMs. Though previous guidelines have been published regarding the management of PAVMs, several aspects of PAVM screening and management remain debated among the experts, suggesting the need for thorough reexamination of the current literature. The authors of this review present an updated approach to the diagnostic workup and management of PAVMs, with an emphasis on areas of controversy, based on the latest literature and our institutional experience.
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18
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Takao S, Masuda T, Yamada T, Yamaguchi K, Sakamoto S, Matsushima H, Horimasu Y, Nakashima T, Miyamoto S, Iwamoto H, Fujitaka K, Hamada H, Hattori N. Pulmonary arteriovenous malformation exhibiting recanalization >10 years after coil embolization: Two case reports. Medicine (Baltimore) 2020; 99:e18694. [PMID: 31914070 PMCID: PMC6959888 DOI: 10.1097/md.0000000000018694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Some patients with pulmonary arteriovenous malformation (PAVM) present with hypoxemia and life-threatening complications, including stroke and cerebral abscess. Catheter embolization is currently the preferred treatment for PAVM. However, previous studies have revealed that the incidence of PAVM recanalization is approximately 10% 5 to 7 years after embolization. In contrast, there are no studies where recanalization has occurred over 10 years after embolization. PATIENT CONCERNS Herein, we report 2 cases diagnosed with cerebral embolism due to PAVM recanalization 13 years and 30 years after catheter treatment, in case I and II, respectively. DIAGNOSES Both cases were diagnosed with PAVM recanalization on chest computed tomography (CT) examination performed after cerebral embolism development. Furthermore, pulmonary artery angiography revealed blood flow from the pulmonary artery to the vein in the PAVM, confirming PAVM recanalization. INTERVENTIONS Coil re-embolization was performed for the all recanalized PAVM. OUTCOMES All the target lesions were successfully re-embolized in both cases. However, in case I, the second recanalization of embolized PAVM was confirmed 1 year after coil re-embolization. Consequently, the third embolization was performed in case I. In contrast to case I, the patient in case II was followed up without recanalization for 2 years after embolization. LESSONS We described the first 2 cases diagnosed with PAVM recanalization >10 years after the first catheter embolization. These cases suggest that patients with PAVMs should undergo life-long follow-up after catheter embolization.
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Affiliation(s)
- Shun Takao
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Minami-ku
| | - Takeshi Masuda
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Minami-ku
| | - Takahiro Yamada
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Minami-ku
| | - Kakuhiro Yamaguchi
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Minami-ku
| | - Shinjiro Sakamoto
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Minami-ku
| | - Hayato Matsushima
- Department of Neurology, Suiseikai Kajikawa Hospital, Naka-ku, Hiroshima, Japan
| | - Yasushi Horimasu
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Minami-ku
| | - Taku Nakashima
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Minami-ku
| | - Shintaro Miyamoto
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Minami-ku
| | - Hiroshi Iwamoto
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Minami-ku
| | - Kazunori Fujitaka
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Minami-ku
| | - Hironobu Hamada
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Minami-ku
| | - Noboru Hattori
- Department of Respiratory Internal Medicine, Hiroshima University Hospital, Minami-ku
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19
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Montrivade S, Maneesow P, Osotthanakorn T, Chattranukulchai P. Severe pulmonary hypertension associated with hepatic arteriovenous malformation in a patient with hereditary haemorrhagic telangiectasia. BMJ Case Rep 2018; 2018:bcr-2018-226067. [PMID: 30232072 DOI: 10.1136/bcr-2018-226067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
We report a case of 46-year-old Asian woman with a history of recurrent epistaxis who presented with dyspnoea on exertion. Physical examination revealed mucocutaneous telangiectasias and signs of heart failure. Further evaluation showed huge hepatic arteriovenous malformation and severe pulmonary hypertension. This case demonstrates an uncommon manifestation of hereditary haemorrhagic telangiectasia presented with severe pulmonary hypertension.
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Affiliation(s)
- Sakolwat Montrivade
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Patinya Maneesow
- Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Thamonwan Osotthanakorn
- Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pairoj Chattranukulchai
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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20
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Saboo SS, Chamarthy M, Bhalla S, Park H, Sutphin P, Kay F, Battaile J, Kalva SP. Pulmonary arteriovenous malformations: diagnosis. Cardiovasc Diagn Ther 2018; 8:325-337. [PMID: 30057879 DOI: 10.21037/cdt.2018.06.01] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Pulmonary arteriovenous malformations (PAVMs) are rare, abnormal low resistance vascular structures that connect a pulmonary artery to a pulmonary vein, thereby bypassing the normal pulmonary capillary bed and resulting in an intrapulmonary right-to-left shunt. The spectrum of PAVMs extends from microscopic lesions causing profound hypoxemia and ground glass appearance on computed tomography (CT) but with normal catheter angiographic findings to classic pulmonary aneurysmal connections that abnormally connect pulmonary veins and arteries. These malformations most commonly are seen in hereditary hemorrhagic telangiectasia (HHT). They are rarely due to secondary conditions such as post congenital heart disease surgery or hepatopulmonary syndrome (HPS). The main complications of PAVM result from intrapulmonary shunt and include stroke, brain abscess, and hypoxemia. Local pulmonary complications include PAVM rupture leading to life-threatening hemoptysis or hemothorax. The preferred screening test for PAVM is transthoracic contrast echocardiography (TTCE). CT has become the gold standard imaging test to establish the presence of PAVM. Endovascular occlusion of the feeding artery is the treatment of choice. Collateralization and recanalization of PAVM following treatment may occur, and hence long term clinical and imaging follow-up is required to assess PAVM enlargement and PAVM reperfusion.
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Affiliation(s)
- Sachin S Saboo
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Murthy Chamarthy
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Sanjeev Bhalla
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Harold Park
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Patrick Sutphin
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Fernando Kay
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - John Battaile
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Sanjeeva P Kalva
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
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21
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Vorselaars VMM, Velthuis S, Huitema MP, Hosman AE, Westermann CJJ, Snijder RJ, Mager JJ, Post MC. Reproducibility of right-to-left shunt quantification using transthoracic contrast echocardiography in hereditary haemorrhagic telangiectasia. Neth Heart J 2018; 26:203-209. [PMID: 29497946 PMCID: PMC5876176 DOI: 10.1007/s12471-018-1094-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Aim Transthoracic contrast echocardiography (TTCE) is recommended for screening of pulmonary arteriovenous malformations (PAVMs) in hereditary haemorrhagic telangiectasia. Shunt quantification is used to find treatable PAVMs. So far, there has been no study investigating the reproducibility of this diagnostic test. Therefore, this study aimed to describe inter-observer and inter-injection variability of TTCE. Methods We conducted a prospective single centre study. We included all consecutive persons screened for presence of PAVMs in association with hereditary haemorrhagic telangiectasia in 2015. The videos of two contrast injections per patient were divided and reviewed by two cardiologists blinded for patient data. Pulmonary right-to-left shunts were graded using a three-grade scale. Inter-observer and inter-injection agreement was calculated with κ statistics for the presence and grade of pulmonary right-to-left shunts. Results We included 107 persons (accounting for 214 injections) (49.5% male, mean age 45.0 ± 16.6 years). A pulmonary right-to-left shunt was present in 136 (63.6%) and 131 (61.2%) injections for observer 1 and 2, respectively. Inter-injection agreement for the presence of pulmonary right-to-left shunts was 0.96 (95% confidence interval (CI) 0.9–1.0) and 0.98 (95% CI 0.94–1.00) for observer 1 and 2, respectively. Inter-injection agreement for pulmonary right-to-left shunt grade was 0.96 (95% CI 0.93–0.99) and 0.95 (95% CI 0.92–0.98) respectively. There was disagreement in right-to-left shunt grade between the contrast injections in 11 patients (10.3%). Inter-observer variability for presence and grade of the pulmonary right-to-left shunt was 0.95 (95% CI 0.91–0.99) and 0.97 (95% CI 0.95–0.99) respectively. Conclusion TTCE has an excellent inter-injection and inter-observer agreement for both the presence and grade of pulmonary right-to-left shunts. Electronic supplementary material The online version of this article (10.1007/s12471-018-1094-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- V M M Vorselaars
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - S Velthuis
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M P Huitema
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - A E Hosman
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - C J J Westermann
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - R J Snijder
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J J Mager
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M C Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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22
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Roman BL, Cuttica MJ. Classifying Pulmonary Hypertension in Hereditary Hemorrhagic Telangiectasia. Hemodynamics Matter. Am J Respir Crit Care Med 2017; 196:1244-1246. [PMID: 29140123 DOI: 10.1164/rccm.201704-0765ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Beth L Roman
- 1 Department of Human Genetics University of Pittsburgh Graduate School of Public Health Pittsburgh, Pennsylvania and
| | - Michael J Cuttica
- 2 Division of Pulmonary and Critical Care Medicine Northwestern University Feinberg School of Medicine Chicago, Illinois
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23
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Dupuis-Girod S, Cottin V, Shovlin CL. The Lung in Hereditary Hemorrhagic Telangiectasia. Respiration 2017; 94:315-330. [PMID: 28850955 DOI: 10.1159/000479632] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a dominantly inherited genetic vascular disorder with an estimated prevalence of 1 in 6,000, characterized by recurrent epistaxis, cutaneous telangiectasia, and arteriovenous malformations (AVMs) that affect many organs including the lungs, gastrointestinal tract, liver, and brain. Its diagnosis is based on the Curaçao criteria, and is considered definite if at least 3 of the 4 following criteria are fulfilled: (1) spontaneous and recurrent epistaxis, (2) telangiectasia, (3) a family history, and (4) pulmonary, liver, cerebral, spinal, or gastrointestinal AVMs. The focus of this review is on delineating how HHT affects the lung.
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Affiliation(s)
- Sophie Dupuis-Girod
- Service de génétique - centre de référence national pour la maladie de Rendu-Osler, Hôpital Femme-Mère-Enfants, Hospices Civils de Lyon, Bron, France
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24
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Fang J, Chen X, Zhu B, Ye H, Zhang W, Guan J, Su K. Thalidomide for Epistaxis in Patients with Hereditary Hemorrhagic Telangiectasia: A Preliminary Study. Otolaryngol Head Neck Surg 2017; 157:217-221. [PMID: 28418273 DOI: 10.1177/0194599817700573] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
To evaluate the effectiveness of thalidomide for epistaxis in hereditary hemorrhagic telangiectasia (HHT), 7 HHT patients with recurrent epistaxis were treated with thalidomide at an initial dose of 50 mg/d, gradually increasing to 100 mg/d if needed. The Epistaxis Severity Score (ESS) was used to evaluate the treatment effects. Patients reported that epistaxis improved 1 to 3 weeks after starting thalidomide. The mean ESS before treatment, at the end of treatment, and 3 months after stopping treatment was 5.03 ± 2.05, 0.90 ± 0.84 ( P = .003), and 1.98 ± 1.33 ( P = .006), respectively. Four patients reported mild to moderate side effects, including drowsiness, dizziness, constipation, nausea, and peripheral neuropathy. Two patients stopped the treatment because of adverse effects. Those results showed that thalidomide may be a treatment choice for recurrent epistaxis in HHT patients, although the side effects should be considered. Further study should focus on guidelines for dosing and course and investigate how to reduce the adverse effects.
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Affiliation(s)
- Jia Fang
- Department of Otolaryngology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Xiaomeng Chen
- Department of Otolaryngology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Bijun Zhu
- Department of Otolaryngology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Haibo Ye
- Department of Otolaryngology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Weitian Zhang
- Department of Otolaryngology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Jian Guan
- Department of Otolaryngology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
| | - Kaiming Su
- Department of Otolaryngology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
- Department of Otolaryngology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, South Campus, Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
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Robaina Cabrera DM, Verde González MP, Tarazona Chocano B, Amado Fernández C, Zarrabeitia Puente R. Telangiectasia hemorrágica hereditaria: enfermedad de Rendu-Osler-Weber. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.fmc.2016.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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26
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Parra JA, Cuesta JM, Zarrabeitia R, Fariñas-Álvarez C, Bueno J, Marqués S, Parra-Fariñas C, Botella ML, Bernabéu C, Zarauza J. Screening pulmonary arteriovenous malformations in a large cohort of Spanish patients with hemorrhagic hereditary telangiectasia. Int J Cardiol 2016; 218:240-245. [DOI: 10.1016/j.ijcard.2016.05.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 04/06/2016] [Accepted: 05/12/2016] [Indexed: 11/26/2022]
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27
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Prevalence and nature of dyspnea in patients with hereditary hemorrhagic telangiectasia (HHT). Respir Med 2015; 109:768-77. [DOI: 10.1016/j.rmed.2015.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 03/17/2015] [Accepted: 04/07/2015] [Indexed: 01/23/2023]
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Vorselaars VMM, Velthuis S, Snijder RJ, Vos JA, Mager JJ, Post MC. Pulmonary hypertension in hereditary haemorrhagic telangiectasia. World J Cardiol 2015; 7:230-237. [PMID: 26015855 PMCID: PMC4438464 DOI: 10.4330/wjc.v7.i5.230] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 12/26/2014] [Accepted: 02/11/2015] [Indexed: 02/06/2023] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant inherited disorder characterised by vascular malformations in predominantly the brain, liver and lungs. Pulmonary hypertension (PH) is increasingly recognised as a severe complication of HHT. PH may be categorised into two distinct types in patients with HHT. Post-capillary PH most often results from a high pulmonary blood flow that accompanies the high cardiac output state associated with liver arteriovenous malformations. Less frequently, the HHT-related gene mutations in ENG or ACVRL1 appear to predispose patients with HHT to develop pre-capillary pulmonary arterial hypertension. Differentiation between both forms of PH by right heart catheterisation is essential, since both entities are associated with severe morbidity and mortality with different treatment options. Therefore all HHT patients should be referred to an HHT centre.
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Shovlin CL. Pulmonary arteriovenous malformations. Am J Respir Crit Care Med 2014; 190:1217-28. [PMID: 25420112 PMCID: PMC4315816 DOI: 10.1164/rccm.201407-1254ci] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 10/20/2014] [Indexed: 11/16/2022] Open
Abstract
Within the past decade, pulmonary arteriovenous malformations (PAVMs) have evolved from rare curiosities to not uncommon clinical states, with the latest estimates suggesting a prevalence of ~1 in 2,600. PAVMs provide anatomic right-to-left shunts, allowing systemic venous blood to bypass gas exchange and pulmonary capillary bed processing. Hypoxemia and enhanced ventilatory demands result, although both are usually asymptomatic. Paradoxical emboli lead to strokes and cerebral abscesses, and these commonly occur in individuals with previously undiagnosed PAVMs. PAVM hemorrhage is rare but is the main cause of maternal death in pregnancy. PAVM occlusion by embolization is the standard of care to reduce these risks. However, recent data demonstrate that currently recommended management protocols can result in levels of radiation exposure that would be classified as harmful. Recent publications also provide a better appreciation of the hematologic and cardiovascular demands required to maintain arterial oxygen content and oxygen consumption in hypoxemic patients, identify patient subgroups at higher risk of complications, and emphasize the proportion of radiologically visible PAVMs too small to treat by embolization. This review, therefore, outlines medical states that exacerbate the consequences of PAVMs. Chief among these is iron deficiency, which is commonly present due to concurrent hereditary hemorrhagic telangiectasia: iron deficiency impairs hypoxemia compensations by restricting erythropoiesis and increases the risk of ischemic strokes. Management of periodontal disease, dental interventions, pulmonary hypertension, and pregnancy also requires specific consideration in the setting of PAVMs. The review concludes by discussing to what extent previously recommended protocols may benefit from modification or revision.
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Affiliation(s)
- Claire L. Shovlin
- NHLI Cardiovascular Sciences, Imperial College, London; and
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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