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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 PMCID: PMC11229252 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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2
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Parry A, Awwad A, Lie G, Matson M, Ricketts WM. When is an AVM not an AVM? Thorax 2024:thorax-2024-221458. [PMID: 38955500 DOI: 10.1136/thorax-2024-221458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 06/08/2024] [Indexed: 07/04/2024]
Affiliation(s)
- Alice Parry
- Department of Respiratory Medicine, Barts Health NHS Trust, London, UK
| | - Amir Awwad
- Department of Radiology, St Bartholomew's Hospital, London, UK
- UCL Institute of Cardiovascular Science, London, UK
| | - Geoffrey Lie
- Department of Radiology, The Royal London Hospital, London, UK
| | - Matt Matson
- Department of Radiology, St Bartholomew's Hospital, London, UK
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3
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Guo J, Wang H, Zhang M. A massive pulmonary arteriovenous fistula complicated with coronary atherosclerotic heart disease treated by interventional therapy: a case report. J Cardiothorac Surg 2024; 19:400. [PMID: 38937815 PMCID: PMC11210114 DOI: 10.1186/s13019-024-02866-w] [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: 03/17/2024] [Accepted: 06/14/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Pulmonary arteriovenous fistula (PAVF) is a rare disease, and its symptoms lack specificity. For patients with coronary heart disease(CHD), hypertension and other common cardiovascular diseases, PAVF is easy to be ignored. We presented a case of massive PAVF complicated with coronary atherosclerotic heart disease by interventional treatment to improve the understanding of this complex disease. CASE PRESENTATION A 77-year-old female patient was admitted to the hospital due to chest tightness and shortness of breath following activities, which was diagnosed with CHD and hypoxemia in other hospitals. Coronary angiography showed that the patient had severe stenosis of coronary artery while pulmonary vascular DSA showing the patient had PAVF. After interventional therapy of both coronary artery and PAVF, the patient's symptoms were significantly improved. CONCLUSION We presented a case of massive PAVF complicated with CHD by interventional treatment. For patients with unexplained hypoxemia and symptoms similar with CHD, the possibility of PAVF often leads to oversight, and various auxiliary examinations should be improved to avoid missed diagnosis. And intervention treatment should be carried out to improve the prognosis of patients as much as possible.
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Affiliation(s)
- Jingwen Guo
- Department of Cardiology, Daping Hospital, The Third Military Medical University (Army Medical University), No. 10 Yangtze River Branch Road, Yuzhong District, Chongqing, 400042, P.R. China.
- Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing, 400010, China.
| | - Hongyong Wang
- Department of Cardiology, Daping Hospital, The Third Military Medical University (Army Medical University), No. 10 Yangtze River Branch Road, Yuzhong District, Chongqing, 400042, P.R. China
- Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing, 400010, China
| | - Mingming Zhang
- Department of Cardiology, Daping Hospital, The Third Military Medical University (Army Medical University), No. 10 Yangtze River Branch Road, Yuzhong District, Chongqing, 400042, P.R. China.
- Chongqing Key Laboratory for Hypertension Research, Chongqing Cardiovascular Clinical Research Center, Chongqing Institute of Cardiology, Chongqing, 400010, China.
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4
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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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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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Huang Y, Hsieh C, Hsie Y, Lee S. A mediastinum-tumour-like pulmonary arteriovenous malformation with association to the pulmonary artery treated with surgical resection. Respirol Case Rep 2024; 12:e01368. [PMID: 38736508 PMCID: PMC11082529 DOI: 10.1002/rcr2.1368] [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: 04/16/2024] [Accepted: 04/24/2024] [Indexed: 05/14/2024] Open
Abstract
Despite embolization being now considered the preferred treatment for PAVM, surgical intervention may be considered if the malformation involves large vessels.
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Affiliation(s)
- Yung‐Chia Huang
- Department of Pulmonary Medicine, Taoyuan General HospitalMinistry of Health and WelfareTaoyuanTaiwan
| | - Chen‐En Hsieh
- Department of Clinical Research, Taoyuan General HospitalMinistry of Health and WelfareTaoyuanTaiwan
| | - Yei‐San Hsie
- Department of Chest Surgery, Taoyuan General HospitalMinistry of Health and WelfareTaoyuanTaiwan
| | - Shih‐Wei Lee
- Department of Pulmonary Medicine, Taoyuan General HospitalMinistry of Health and WelfareTaoyuanTaiwan
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7
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Delpon JE, Greffier J, Lacombe H, Barbe A, Bouin M, De Oliveira F, Mansuy A, Delagrange L, Fargeton AE, Beregi JP, Cottin V, Dupuis-Girod S, Si-Mohamed SA. Ultra-low dose chest CT for the diagnosis of pulmonary arteriovenous malformation in patients with hereditary hemorrhagic telangiectasia. Diagn Interv Imaging 2024:S2211-5684(24)00082-2. [PMID: 38604894 DOI: 10.1016/j.diii.2024.03.006] [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: 09/28/2023] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE The purpose of this study was to compare ultra-low dose (ULD) and standard low-dose (SLD) chest computed tomography (CT) in terms of radiation exposure, image quality and diagnostic value for diagnosing pulmonary arteriovenous malformation (AVM) in patients with hereditary hemorrhagic telangiectasia (HHT). MATERIALS AND METHODS In this prospective board-approved study consecutive patients with HHT referred to a reference center for screening and/or follow-up chest CT examination were prospectively included from December 2020 to January 2022. Patients underwent two consecutive non-contrast chest CTs without dose modulation (i.e., one ULD protocol [80 kVp or 100 kVp, CTDIvol of 0.3 mGy or 0.6 mGy] and one SLD protocol [140 kVp, CTDIvol of 1.3 mGy]). Objective image noises measured at the level of tracheal carina were compared between the two protocols. Overall image quality and diagnostic confidence were scored on a 4-point Likert scale (1 = insufficient to 4 = excellent). Sensitivity, specificity, positive predictive value and negative predictive value of ULD CT for diagnosing pulmonary AVM with a feeding artery of over 2 mm in diameter were calculated along with their 95% confidence intervals (CI) using SLD images as the standard of reference. RESULTS A total of 44 consecutive patients with HHT (31 women; mean age, 42 ± 16 [standard deviation (SD)] years; body mass index, 23.2 ± 4.5 [SD] kg/m2) were included. Thirty-four pulmonary AVMs with a feeding artery of over 2 mm in diameter were found with SLD images versus 35 with ULD images. Sensitivity, specificity, predictive positive value, and predictive negative value of ULD CT for the diagnosis of PAVM were 100% (34/34; 95% CI: 90-100), 96% (18/19; 95% CI: 74-100), 97% (34/35; 95% CI: 85-100) and 100% (18/18; 95% CI: 81-100), respectively. A significant difference in diagnostic confidence scores was found between ULD (3.8 ± 0.4 [SD]) and SLD (3.9 ± 0.1 [SD]) CT images (P = 0.03). No differences in overall image quality scores were found between ULD CT examinations (3.9 ± 0.2 [SD]) and SLD (4 ± 0 [SD]) CT examinations (P = 0.77). Effective radiation dose decreased significantly by 78.8% with ULD protocol, with no significant differences in noise values between ULD CT images (16.7 ± 5.0 [SD] HU) and SLD images (17.7 ± 6.6 [SD] HU) (P = 0.07). CONCLUSION ULD chest CT provides 100% sensitivity and 96% specificity for the diagnosis of treatable pulmonary AVM with a feeding artery of over 2 mm in diameter, leading to a 78.8% dose-saving compared with a standard low-dose protocol.
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Affiliation(s)
- Jean-Etienne Delpon
- Department of Radiology, Hôpital Louis Pradel, Hospices Civils de Lyon, 69677, Bron, France
| | - Joel Greffier
- Department of Radiology, CHU Nîmes, University Montpellier, Medical Imaging Group Nîmes, 30029 Nîmes, France
| | - Hugo Lacombe
- Université de Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, INSERM, CREATIS UMR 5220, U1206, 69100 Villeurbanne, France; CT Clinical Science, Philips, 92150 Suresnes, France
| | - Apolline Barbe
- Imaging Department, Cellule Recherche en Imagerie, Hospices Civils de Lyon, 69677 Bron, France
| | - Morgane Bouin
- Imaging Department, Cellule Recherche en Imagerie, Hospices Civils de Lyon, 69677 Bron, France
| | - Fabien De Oliveira
- Department of Radiology, Hôpital Louis Pradel, Hospices Civils de Lyon, 69677, Bron, France; Department of Radiology, CHU Nîmes, University Montpellier, Medical Imaging Group Nîmes, 30029 Nîmes, France
| | - Adeline Mansuy
- Imaging Department, Cellule Recherche en Imagerie, Hospices Civils de Lyon, 69677 Bron, France
| | - Laura Delagrange
- Imaging Department, Cellule Recherche en Imagerie, Hospices Civils de Lyon, 69677 Bron, France
| | - Anne-Emmanuelle Fargeton
- Department of Genetics and Centre National de Référence pour la Maladie de Rendu-Osler, Hôpital Femme-Mère-Enfants, Hospices Civils de Lyon, 69677 Bron, France
| | - Jean-Paul Beregi
- Department of Radiology, CHU Nîmes, University Montpellier, Medical Imaging Group Nîmes, 30029 Nîmes, France
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon, INRAE, ERN-LUNG, Lyon, France
| | - Sophie Dupuis-Girod
- Department of Genetics and Centre National de Référence pour la Maladie de Rendu-Osler, Hôpital Femme-Mère-Enfants, Hospices Civils de Lyon, 69677 Bron, France
| | - Salim Aymeric Si-Mohamed
- Department of Radiology, Hôpital Louis Pradel, Hospices Civils de Lyon, 69677, Bron, France; Université de Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, INSERM, CREATIS UMR 5220, U1206, 69100 Villeurbanne, France.
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Park Z, Dunston R, Ranasinghe T. Personalised stroke evaluation and management: tailoring individualised patient care for hereditary haemorrhagic telangiectasia. BMJ Case Rep 2024; 17:e257682. [PMID: 38575333 PMCID: PMC11002385 DOI: 10.1136/bcr-2023-257682] [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] [Accepted: 03/01/2024] [Indexed: 04/06/2024] Open
Abstract
SummaryHereditary haemorrhagic telangiectasia (HHT) has an estimated prevalence of 1 in 5000-8000 individuals globally with pulmonary arteriovenous malformations (PAVMs) affecting approximately 15%-50% of HHT patients. Ischaemic stroke is a known complication of PAVMs that affects ≤30% of patients with PAVMs. Studies have shown that patients with PAVMs have ischaemic stroke a decade earlier than routine stroke. The predominant mechanism of ischaemic stroke in HHT patients is paradoxical embolism due to PAVMs, but most HHT-related PAVMs are asymptomatic. Additionally, HHT is often underdiagnosed in patients and poses a challenge to physicians due to its rarity. We present a case of a patient with ischaemic stroke who was subsequently diagnosed with HHT and found to have a PAVM on further evaluation. This case highlights the importance of using an individualised patient-centred stroke evaluation and screening for PAVMs in patients who had a stroke with possible or suspected HHT and definite HHT.
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Affiliation(s)
- Zackary Park
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Randy Dunston
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Neurology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Tamra Ranasinghe
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Neurology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
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Chu HH, Kim GH, Gwon DI. An Alternative Endovascular Technique for Treatment of Pulmonary Arteriovenous Malformation: Microballoon-occluded Transcatheter Embolization Using n-butyl-2-cyanoacrylate. Cardiovasc Intervent Radiol 2024:10.1007/s00270-024-03704-1. [PMID: 38565715 DOI: 10.1007/s00270-024-03704-1] [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: 11/29/2023] [Accepted: 03/06/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE To investigate the safety and efficacy of microballoon-occluded transcatheter embolization using n-butyl-2-cyanoacrylate (NBCA) in patients with a single pulmonary arteriovenous malformation (PAVM). METHODS From November 2017 to November 2020, this retrospective study included 38 previously untreated patients with a single PAVM who underwent microballoon-occluded transcatheter embolization using NBCA. All 38 patients had follow-up that included simple chest radiography and contrast-enhanced chest computed tomography (CT). RESULTS A microballoon was successfully placed in a feeding artery of the PAVM to control the delivery of the NBCA cast in all 38 patients, with complete embolization of sacs and the feeding artery achieved in all cases. The mean diameters of the feeding artery, sac, and draining vein were 3.9 ± 0.9 mm, 7.5 ± 2.6 mm, and 4.6 ± 1.3 mm, respectively. A fixed 1:2 NBCA/Lipiodol ratio was used, and the mean amount of embolic mixture per patient was 1.4 mL (range 0.6-2.2 mL). There were no complications related to microballoon adhesion and non-target embolization of the systemic circulation. Follow-up CT in all 38 patients with a mean delay of 34.5 ± 8.8 months (range 20.7-56.5 months) showed no continued perfusion of the PAVM. CONCLUSION In our hands, microballoon-occluded n-butyl-2-cyanoacrylate embolization seemed to be safe and appeared to be clinically effective in patients with simple and complex types of single PAVM. Therefore, the present technique has the potential to become a standard treatment for a single PAVM.
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Affiliation(s)
- Hee Ho Chu
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Gun Ha Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
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Ryan A, Devenny A, Bradnock TJ, Sabharwal A, Culshaw S, Irwin G, Langley RJ. Unusual cause of hypoxia. Arch Dis Child Educ Pract Ed 2024:edpract-2023-326480. [PMID: 38443155 DOI: 10.1136/archdischild-2023-326480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/26/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Aoife Ryan
- Department of Paediatric Respiratory & Sleep Medicine, Royal Hospital for Children, Glasgow, UK
| | - Anne Devenny
- Department of Paediatric Respiratory & Sleep Medicine, Royal Hospital for Children, Glasgow, UK
| | | | - Atul Sabharwal
- Department of Paediatric Surgery, Royal Hospital for Children, Glasgow, UK
| | - Seamus Culshaw
- Department of Paediatric Radiology, Royal Hospital for Children, Glasgow, UK
| | - Greg Irwin
- Department of Paediatric Radiology, Royal Hospital for Children, Glasgow, UK
| | - Ross John Langley
- Department of Paediatric Respiratory & Sleep Medicine, Royal Hospital for Children, Glasgow, UK
- Department of Maternal and Child Health, University of Glasgow, Glasgow, UK
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11
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Xie Y, Wang J, Zou Y. Pulmonary arteriovenous fistula. J Vasc Surg Venous Lymphat Disord 2024; 12:101717. [PMID: 37972756 DOI: 10.1016/j.jvsv.2023.101717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/23/2023] [Accepted: 10/28/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Yong Xie
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Jian Wang
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China.
| | - Yinghua Zou
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
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12
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Jain K, McCarley SC, Mukhtar G, Ferlin A, Fleming A, Morris-Rosendahl DJ, Shovlin CL. Pathogenic Variant Frequencies in Hereditary Haemorrhagic Telangiectasia Support Clinical Evidence of Protection from Myocardial Infarction. J Clin Med 2023; 13:250. [PMID: 38202257 PMCID: PMC10779873 DOI: 10.3390/jcm13010250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/20/2023] [Accepted: 12/25/2023] [Indexed: 01/12/2024] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a vascular dysplasia inherited as an autosomal dominant trait, due to a single heterozygous loss-of-function variant, usually in ACVRL1 (encoding activin receptor-like kinase 1 [ALK1]), ENG (encoding endoglin [CD105]), or SMAD4. In a consecutive single-centre series of 37 positive clinical genetic tests performed in 2021-2023, a skewed distribution pattern was noted, with 30 of 32 variants reported only once, but ACVRL1 c.1231C>T (p.Arg411Trp) identified as the disease-causal gene in five different HHT families. In the same centre's non-overlapping 1992-2020 series where 110/134 (82.1%) HHT-causal variants were reported only once, ACVRL1 c.1231C>T (p.Arg411Trp) was identified in nine further families. In a 14-country, four-continent HHT Mutation Database where 181/250 (72.4%) HHT-causal variants were reported only once, ACVRL1 c.1231C>T (p.Arg411Trp) was reported by 12 different laboratories, the adjacent ACVRL1 c.1232G>A (p.Arg411Gln) by 14, and ACVRL1 c.1120C>T (p.Arg374Trp) by 18. Unlike the majority of HHT-causal ACVRL1 variants, these encode ALK1 protein that reaches the endothelial cell surface but fails to signal. Six variants of this type were present in the three series and were reported 6.8-25.5 (mean 8.9) times more frequently than the other ACVRL1 missense variants (all p-values < 0.0039). Noting lower rates of myocardial infarction reported in HHT, we explore potential mechanisms, including a selective paradigm relevant to ALK1's role in the initiating event of atherosclerosis, where a plausible dominant negative effect of these specific variants can be proposed. In conclusion, there is an ~9-fold excess of kinase-inactive, cell surface-expressed ACVRL1/ALK1 pathogenic missense variants in HHT. The findings support further examination of differential clinical and cellular phenotypes by HHT causal gene molecular subtypes.
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Affiliation(s)
- Kinshuk Jain
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
| | - Sarah C. McCarley
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
| | - Ghazel Mukhtar
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
| | - Anna Ferlin
- Clinical Genetics and Genomics Laboratory, Royal Brompton Hospital, Guy’s and St Thomas’ NHS Trust, London SE1 7EH, UK; (A.F.); (A.F.)
| | - Andrew Fleming
- Clinical Genetics and Genomics Laboratory, Royal Brompton Hospital, Guy’s and St Thomas’ NHS Trust, London SE1 7EH, UK; (A.F.); (A.F.)
| | - Deborah J. Morris-Rosendahl
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
- Clinical Genetics and Genomics Laboratory, Royal Brompton Hospital, Guy’s and St Thomas’ NHS Trust, London SE1 7EH, UK; (A.F.); (A.F.)
| | - Claire L. Shovlin
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
- Specialist Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK
- Social, Genetic and Environmental Determinants of Health, NIHR Imperial Biomedical Research Centre, London W2 1NY, UK
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Niklasson J, Rönnblom A, Lidian A, Thor A. Oral manifestations and dental considerations of patients with hereditary hemorrhagic telangiectasia: a scoping review. Oral Surg Oral Med Oral Pathol Oral Radiol 2023; 136:691-702. [PMID: 37752017 DOI: 10.1016/j.oooo.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/20/2023] [Accepted: 08/05/2023] [Indexed: 09/28/2023]
Abstract
OBJECTIVE We examined the range, nature, and extent of research conducted regarding the oral and dental implications of hereditary hemorrhagic telangiectasia (HHT) to identify gaps in the research and knowledge of the field. STUDY DESIGN We performed a scoping review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews and 2017 Guidance for the Conduct of Joanna Briggs Institute Scoping Reviews. We searched the MEDLINE and Web of Science databases for all full-text articles published in English from December 1946 to October 2022. RESULTS We identified 103 articles describing oral and dental considerations of patients with HHT, primarily case reports. Most reported oral telangiectasias of the tongue, lips, and palate. Many reported management of bleeding and the use or recommendation of prophylactic antibiotics before dental procedures. CONCLUSIONS Oral telangiectasias are commonly found in patients with hereditary hemorrhagic telangiectasia, and dental professionals may be the first to diagnose it in their patients. Early detection and diagnosis are important to prevent potentially fatal outcomes, and prophylactic antibiotics before procedures may be warranted.
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Affiliation(s)
- Julia Niklasson
- Department of Plastic and Oral and Maxillofacial Surgery, Uppsala University, Uppsala, Sweden.
| | - Anders Rönnblom
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Adnan Lidian
- Department of Otorhinolaryngology and Head and Neck Surgery, Uppsala University, Uppsala, Sweden
| | - Andreas Thor
- Department of Plastic and Oral and Maxillofacial Surgery, Uppsala University, Uppsala, Sweden
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14
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Mathavan A, Mathavan A, Reddy R, Jones K, Eagan C, Alnuaimat H, Ataya A. Pulmonary hypertension in hereditary hemorrhagic telangiectasia: A clinical review. Pulm Circ 2023; 13:e12301. [PMID: 37868718 PMCID: PMC10585978 DOI: 10.1002/pul2.12301] [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: 09/13/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant hereditary disorder characterized by recurrent spontaneous epistaxis, mucocutaneous telangiectasias, and solid organ arteriovenous malformations (AVMs). Pulmonary hypertension (PH) is an increasingly recognized complication in patients with HHT, most often precipitated by high-output heart failure in the presence of hepatic AVMs as well as pulmonary arterial hypertension in the form of a proliferative vasculopathy. The presence of PH in patients with HHT is associated with significant elevations in rates of morbidity and mortality. Additionally, there is growing recognition of a thromboembolic propensity in this population that increases the risk of chronic thromboembolic PH, posing unique clinical considerations regarding the use of anticoagulation. Patients with HHT are also at risk of PH due to disorders commonly seen in the general population, including left-sided heart and lung disease. The etiology of PH in HHT is multifaceted and complex; the diagnostic approach and treatment strategies must consider the underlying pathophysiology of HHT. This comprehensive review summarizes current knowledge of PH in HHT, detailing the pathogenesis of known etiologies, diagnostic evaluation, and suggested treatment modalities as well as emerging therapies that may be of future interest.
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Affiliation(s)
- Akash Mathavan
- Department of Internal MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Akshay Mathavan
- Department of Internal MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Renuka Reddy
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Kirk Jones
- Department of Internal MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Christina Eagan
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Hassan Alnuaimat
- Respiratory Institute Pulmonary, Critical Care, and Sleep MedicineCleveland Clinic Abu DhabiAbu DhabiUnited Arab Emirates
| | - Ali Ataya
- Division of Pulmonary, Critical Care, and Sleep MedicineUniversity of FloridaGainesvilleFloridaUSA
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Shu L, Luo L, Zuo Y. Attention to pulmonary arteriovenous fistula in a case of transient hypoxemia and cerebral infarction during pregnancy: a case report and literature review. BMC Pregnancy Childbirth 2023; 23:626. [PMID: 37653522 PMCID: PMC10469831 DOI: 10.1186/s12884-023-05946-2] [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: 09/11/2022] [Accepted: 08/22/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Pulmonary arteriovenous fistula is rare during pregnancy. Pulmonary arteriovenous fistula presents no pulmonary symptoms in most patients but can be exacerbated by pregnancy. If not diagnosed and treated promptly, pulmonary arteriovenous fistula can lead to respiratory failure, stroke, spontaneous hemothorax, or other fatal complications. CASE PRESENTATION A 29-year-old healthy pregnant woman presented with a transient drop in blood oxygen level of unknown cause during a routine examination at 34 weeks of gestation and during a cesarean section at 38 weeks of pregnancy. The patient's oxygen saturation quickly returned to normal and was not further investigated. On day 3 postpartum, the patient suddenly displayed slurred speech and right limb myasthenia. A head magnetic resonance imaging revealed cerebral infarction in the left basal ganglia. Subsequent computed tomography pulmonary arteriography revealed bilateral pulmonary arteriovenous fistula, which was likely the cause of cerebral infarction. The patient was transferred to the Department of Thoracic Surgery after one month of treatment and successfully underwent percutaneous embolization of pulmonary arteriovenous fistula. CONCLUSION Pulmonary arteriovenous fistula should not be neglected if a pregnant woman presents with transient hypoxemia and cerebral infarction. A transient decrease in pulse oxygen saturation that cannot be explained by common clinical causes can be an early warning sign of the disease. Early diagnosis and multidisciplinary management could improve the prognosis.
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Affiliation(s)
- Lijuan Shu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, P.R. China
- The Research Units of West China (2018RU012) - Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, Sichuan, P.R. China
- Department of Obstetrics and Gynecology Intensive Care Unit, West China Second University Hospital, Sichuan University, Chengdu, 610041, Sichuan, P.R. China
| | - Linli Luo
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, Sichuan, P.R. China
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, 610041, Sichuan, P.R. China
| | - Yunxia Zuo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, P.R. China.
- The Research Units of West China (2018RU012) - Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, P.R. China.
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Schmolling ÁH, Bodani V, Jaroenngarmsamer T, Andrade-Barazarte H, Radovanovic I, Krings T. Anatomical considerations regarding a high-flow arteriovenous fistula below the conus medullaris in a patient with hereditary hemorrhagic telangiectasia: Case report. Interv Neuroradiol 2023:15910199231196458. [PMID: 37621120 DOI: 10.1177/15910199231196458] [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: 08/26/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Cauda equina radicular arteriovenous fistulas are rare "low flow" shunting lesions characterized by direct communication between the radicular artery and vein of a cauda equina nerve root. None have been associated with hereditary hemorrhagic telangiectasia and a high-flow cauda equina radicular arteriovenous fistula has never been reported. We present a unique case of a high-flow cauda equina radicular arteriovenous fistula in a patient with hereditary hemorrhagic telangiectasia. Marked flow-induced vascular remodeling posed significant diagnostic and therapeutic challenges which will be highlighted in this report. CLINICAL PRESENTATION A 39-year-old female with genetically confirmed hereditary hemorrhagic telangiectasia presented with progressive thoracic myelopathy secondary to a high-flow single-hole arteriovenous fistula below the conus. The feeding artery, arising from the anterior spinal artery, and draining vein had a paramedian course, favoring the diagnosis of a cauda equina radicular arteriovenous fistula (supplied by a proximal radicular artery) over a filum terminale arteriovenous fistula. Transarterial embolization was attempted but significant elongation and tortuosity of the anterior spinal artery precluded microcatheter access to the fistulous point. Surgical disconnection was successfully performed. The intraoperative findings supported the diagnosis of cauda equina radicular arteriovenous fistula. Delayed neurologic deterioration secondary to overshooting venous thrombosis was observed. She recovered after the initiation of therapeutic anticoagulation. CONCLUSION To the best of our knowledge, we hereby report the first high-flow cauda equina radicular arteriovenous fistula. The accurate differentiation of cauda equina radicular arteriovenous fistula from filum terminale arteriovenous fistulas, while challenging, is important to avoid treatment-related complications. Careful preoperative planning, the use of specialized endovascular and surgical techniques, and meticulous postoperative care can ensure the safe and complete disconnection of high-flow cauda equina radicular arteriovenous fistulas.
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Affiliation(s)
- Ángela H Schmolling
- Division of Neuroradiology, University Medical Imaging Toronto, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Departamento de Neurorradiología Intervencionista, Servicio de Radiodiagnóstico, Hospital Clínico San Carlos, Madrid, Spain
| | - Vivek Bodani
- Division of Neuroradiology, University Medical Imaging Toronto, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Tanaporn Jaroenngarmsamer
- Division of Neuroradiology, University Medical Imaging Toronto, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Hugo Andrade-Barazarte
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Ivan Radovanovic
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Timo Krings
- Division of Neuroradiology, University Medical Imaging Toronto, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Mukhtar G, Shovlin CL. Unsupervised machine learning algorithms identify expected haemorrhage relationships but define unexplained coagulation profiles mapping to thrombotic phenotypes in hereditary haemorrhagic telangiectasia. EJHAEM 2023; 4:602-611. [PMID: 37601877 PMCID: PMC10435691 DOI: 10.1002/jha2.746] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 08/22/2023]
Abstract
Hereditary haemorrhagic telangiectasia (HHT) can result in challenging anaemia and thrombosis phenotypes. Clinical presentations of HHT vary for relatives with identical casual mutations, suggesting other factors may modify severity. To examine objectively, we developed unsupervised machine learning algorithms to test whether haematological data at presentation could be categorised into sub-groupings and fitted to known biological factors. With ethical approval, we examined 10 complete blood count (CBC) variables, four iron index variables, four coagulation variables and eight iron/coagulation indices combined from 336 genotyped HHT patients (40% male, 60% female, 86.5% not using iron supplementation) at a single centre. T-SNE unsupervised, dimension reduction, machine learning algorithms assigned each high-dimensional datapoint to a location in a two-dimensional plane. k-Means clustering algorithms grouped into profiles, enabling visualisation and inter-profile comparisons of patients' clinical and genetic features. The unsupervised machine learning algorithms using t-SNE and k-Means identified two distinct CBC profiles, two iron profiles, four clotting profiles and three combined profiles. Validating the methodology, profiles for CBC or iron indices fitted expected patterns for haemorrhage. Distinct coagulation profiles displayed no association with age, sex, C-reactive protein, pulmonary arteriovenous malformations (AVMs), ENG/ACVRL1 genotype or epistaxis severity. The most distinct profiles were from t-SNE/k-Means analyses of combined iron-coagulation indices and mapped to three risk states - for venous thromboembolism in HHT; for ischaemic stroke attributed to paradoxical emboli through pulmonary AVMs in HHT; and for cerebral abscess attributed to odontogenic bacteremias in immunocompetent HHT patients with right-to-left shunting through pulmonary AVMs. In conclusion, unsupervised machine learning algorithms categorise HHT haematological indices into distinct, clinically relevant profiles which are independent of age, sex or HHT genotype. Further evaluation may inform prophylaxis and management for HHT patients' haemorrhagic and thrombotic phenotypes.
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Affiliation(s)
- Ghazel Mukhtar
- National Heart and Lung InstituteImperial College LondonLondonUK
- Imperial College School of MedicineLondonUK
| | - Claire L. Shovlin
- National Heart and Lung InstituteImperial College LondonLondonUK
- Specialist MedicineImperial College Healthcare NHS TrustLondonUK
- NIHR Imperial Biomedical Research CentreLondonUK
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18
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Irie T, Ishibashi O, Kuramochi M, Ichimura H, Endo K. Retrospective single-arm cohort study of video-assisted thoracic surgery for treatment of idiopathic peripherally located simple type pulmonary arteriovenous malformation in 23 consecutive patients. J Cardiothorac Surg 2023; 18:213. [PMID: 37403112 DOI: 10.1186/s13019-023-02335-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 06/29/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Although case reports of video-assisted thoracic surgery (VATS) for pulmonary arteriovenous malformation (PAVM) have been published, studies analyzing more than 10 cases were limited. A retrospective single-arm cohort study was performed to investigate the efficacy of VATS in 23 consecutive patients with idiopathic peripherally located simple type PAVM. METHODS VATS was performed for wedge resection of 24 PAVMs in 23 patients, which included 4 males and 19 females with an age range of 25 to 80 years (mean: 59.6 ± 13.0). Two patients underwent simultaneous resection of lung carcinoma, one by wedge resection and another by lobectomy. Each medical record was analyzed according to the resected specimen, bleeding volume, postsurgical hospital stay length, duration of chest tube placement, and VATS time. The distance between pleural surface/fissure and PAVM was measured on CT, and the influence of this distance on identification of PAVM was investigated. RESULTS In all 23 patients, VATS was successfully performed, and the venous sac was included in each resected specimen. Bleeding volume was less than 10mL in all but one with 1900 mL bleeding volume due to simultaneous lobectomy for carcinoma, not wedge resection of PAVM. Postsurgical hospital stay length, duration of chest tube placement, and VATS time were 5.0 ± 1.4 days, 2.7 ± 0.7 days, and 49.3 ± 39.9 min, respectively. In 21 PAVMs with a distance of 1 mm or less, purple vessel or pleural bulge of PAVM was identified soon after insertion of a thoracoscope. In the remaining 3 PAVMs with a distance of 2.5 mm or more, additional efforts were needed for identification. CONCLUSION VATS was found to be a safe and effective to treatment for idiopathic peripherally located simple type PAVM. When the distance between pleural surface/fissure and PAVM was 2.5 mm or more, a plan and strategy for identification of PAVM should be prepared before VATS.
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Affiliation(s)
- Toshiyuki Irie
- Department of Radiology, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Miyamachi 3-2-7, Mito City, 310-0015, Ibaraki prefecture, Japan.
| | - Osamu Ishibashi
- Department of Thoracic Surgery, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Mito City, Japan
| | - Masashi Kuramochi
- Department of Radiology, Hitachi General Hospital, Hitachi City, Japan
| | - Hideo Ichimura
- Department of Thoracic Surgery, Hitachi General Hospital, Hitachi City, Japan
| | - Katsuyuki Endo
- Department of Thoracic Surgery, Hitachi General Hospital, Hitachi City, Japan
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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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20
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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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21
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Parrot A, Barral M, Amiot X, Bachmeyer C, Wagner I, Eyries M, Alamowitch S, Ederhy S, Epaud R, Dupuis-Girod S, Cadranel J. [Hereditary hemorrhagic telangiectasia]. Rev Mal Respir 2023; 40:391-405. [PMID: 37062633 DOI: 10.1016/j.rmr.2023.02.007] [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: 12/14/2022] [Accepted: 02/26/2023] [Indexed: 04/18/2023]
Abstract
Hereditary hemorrhagic telangiectasia, also known as Rendu-Osler - Weber disease, is a rare, autosomal dominant vascular disease, with prevalence of 1/5,000. The condition is characterized by muco-cutaneous telangiectasias, which are responsible for a hemorrhagic syndrome of variable severity, as well as arteriovenous malformations (AVMs) appearing in the lungs, the liver, and the nervous system. They can be the source of shunts, which may be associated with high morbidity (neurological ischemic stroke, brain abscess, high-output heart failure, biliary ischemia…). It is therefore crucial to establish a clinical diagnosis using the Curaçao criteria or molecular diagnosis based on genetic analysis of the ENG, ACVRL1, SMAD4 and GDF2 genes. In most cases, multidisciplinary management allows patients to have normal life expectancy. Advances in interventional radiology and better understanding of the pathophysiology of angiogenesis have resulted in improved therapeutic management. Anti-angiogenic treatments, such as bevacizumab (BVZ, an anti-VEGF antibody), have proven to be effective in cases involving bleeding complications and severe liver damage with cardiac repercussions. Other anti-angiogenic agents are currently being investigated, including tyrosine kinase inhibitors.
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Affiliation(s)
- A Parrot
- Service de pneumologie, centre de compétence de la maladie de Rendu-Osler, hôpital Tenon, AP-HP, 75020 Paris, France.
| | - M Barral
- Service de radiologie, hôpital Tenon, AP-HP, 75020 Paris, France; UFR médecine, Sorbonne université, 75006 Paris, France
| | - X Amiot
- Service de gastroentérologie, hôpital Tenon, AP-HP, 75020 Paris, France
| | - C Bachmeyer
- Service de médecine interne, hôpital Tenon, AP-HP, 75020 Paris, France
| | - I Wagner
- Service d'ORL, hôpital Tenon, AP-HP, 75020 Paris, France
| | - M Eyries
- Service de génétique, hôpital de la Pitié-Salpetrière, AP-HP, 75020 Paris, France
| | - S Alamowitch
- Service des urgences cérébrovasculaires, hôpital de la Pitié-Salpetrière, AP-HP, 75020 Paris, France
| | - S Ederhy
- Service de cardiologie et GRC no 27, hôpital Saint-Antoine, AP-HP, 75020 Paris, France
| | - R Epaud
- Service de pédiatrie, centre intercommunaux de Créteil, Créteil, France
| | - S Dupuis-Girod
- Service de génétique, centre de référence pour la maladie de Rendu-Osler, hospices civils de Lyon, hôpital Mère-Enfant, 69500 Bron, France
| | - J Cadranel
- Service de pneumologie, centre de compétence de la maladie de Rendu-Osler, hôpital Tenon, AP-HP, 75020 Paris, France; UFR médecine, Sorbonne université, 75006 Paris, France
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22
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Nationwide Awareness Campaign and Call for Dental Screening for Hereditary Hemorrhagic Telangiectasia in Germany. Int J Dent 2023; 2023:8737727. [PMID: 36820363 PMCID: PMC9938772 DOI: 10.1155/2023/8737727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 10/25/2022] [Accepted: 01/22/2023] [Indexed: 02/13/2023] Open
Abstract
Objectives Hereditary hemorrhagic telangiectasia (HHT) is a rare disorder encompassing facial and oral telangiectasias and visceral vascular malformations (VMs). Pulmonary VMs can lead to paradoxical embolism of thrombi or bacteria, e.g., due to dental procedures. Early detection can reduce morbidity and mortality and is recommended. However, diagnosis is often delayed for decades. Our study is assessing the feasibility and effect of a nationwide awareness campaign for early diagnosis of HHT addressing all dentists in Germany. Methods In 2018, one article and two reminders about HHT were published in a nationwide awareness campaign. As a proxy for the effectiveness of the campaign, researchers measured the number of first-time inquiries from patients and physicians about HHT documented by the German HHT self-help group from September 2016 until September 2019. Results A total of 411 first contacts with the German self-help group were documented, mainly via Internet platforms (Internet forum (n = 130) and Facebook® (n = 189)). For 9% of those patients (n = 36/411), the physician or dentist (physician: (n = 31/36, 86%; dentist: n = 5/36, 14%) informed patients about the disease HHT and the self-help group. Before publishing the first article about HHT, no dentist referred patients to the German self-help group; afterwards, 5 patients received information about HHT from their dentist and contacted the patient organization for the first time. After each publication in June, September, and December 2018, the number of new contacts increased. Contacts via phone and e-mail had the highest relative increase. Conclusions The repeated call for dental screening for HHT in Germany led to increased awareness of this rare disease; more patients with possible HHT received information about the condition. The authors conclude that targeted campaigns may contribute to a shorter diagnostic latency resulting in increased quality of life and life expectancy in HHT. This trial is registered with CT03549949.
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23
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Inoue S, Fujita A, Kurihara E, Sasayama T. Mechanical thrombectomy for acute paradoxical cerebral embolism due to pulmonary arteriovenous malformation: A case report and review of literature. Surg Neurol Int 2023; 14:13. [PMID: 36751447 PMCID: PMC9899467 DOI: 10.25259/sni_987_2022] [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: 10/27/2022] [Accepted: 12/23/2022] [Indexed: 01/14/2023] Open
Abstract
Background We report a case of acute occlusion of the middle cerebral artery (MCA) due to pulmonary arteriovenous malformation (PAVM), for which mechanical thrombectomy was performed and a good outcome was achieved. Case Description A 59-year-old woman presented with severe right hemiplegia and dysarthria, and a National Institutes of Health Stroke Scale (NIHSS) score of 10. Magnetic resonance imaging (MRI) diffusion-weighted imaging revealed high-signal areas in the left lenticular nucleus to the corona radiata, and right temporal lobe. Magnetic resonance angiography revealed the left MCA occlusion. Chest plain computed tomography (CT) revealed PAVM in the lower lobe of the left lung. Transvenous thrombolytic therapy was started 2 h after onset, and mechanical cerebral thrombectomy was performed with an aspiration catheter and stent retriever. A red thrombus was retrieved in one pass and complete recanalization was achieved. After treatment, her symptoms improved markedly, but a symptomatic intracerebral hematoma was observed in the contralateral right temporal lobe. The patient underwent embolization for PAVM on day 24 and was transferred for rehabilitation (NIHSS score = 2). Conclusion Although rare, PAVM is a treatable cause of stroke in relatively young adults; thus, it is important to keep in mind the possibility of its presence.
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Affiliation(s)
- Satoshi Inoue
- Department of Neurosurgery, Junshin Hospital, Kakogawa, Japan.,Corresponding author: Satoshi Inoue, Department of Neurosurgery, Junshin Hospital, Kakogawa, Japan.
| | - Atsushi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Eiji Kurihara
- Department of Neurosurgery, Junshin Hospital, Kakogawa, Japan
| | - Takashi Sasayama
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
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24
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Salibe-Filho W, Oliveira FRD, Terra-Filho M. Update on pulmonary arteriovenous malformations. J Bras Pneumol 2023; 49:e20220359. [PMID: 37132738 PMCID: PMC10171268 DOI: 10.36416/1806-3756/e20220359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/26/2023] [Indexed: 05/04/2023] Open
Abstract
This review aimed to provide an overview of pulmonary arteriovenous malformations, including the major clinical and radiological presentations, investigation, and treatment algorithm of the condition. The primary etiology of pulmonary arteriovenous malformations is hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, with mutations in the ENG gene on chromosome 9 (HHT type 1) or in the ACVRL1/ALK1 complex (HHT type 2). Epistaxis should always be evaluated when repeated, when associated with anemia, and in some cases of hypoxemia. In the investigation, contrast echocardiography and chest CT are essential for evaluating this condition. Embolization is the best treatment choice, especially for correction in cases of hypoxemia or to avoid systemic infections. Finally, disease management was addressed in special conditions such as pregnancy. CT follow-up should be performed every 3-5 years, depending on the size of the afferent and efferent vessels, and antibiotic prophylactic care should always be oriented. Ultimately, knowledge of the disease by health professionals is a crucial point for the early diagnosis of these patients in clinical practice, which can potentially modify the natural course of the disease.
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Affiliation(s)
- William Salibe-Filho
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Francini Rossetto de Oliveira
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Mario Terra-Filho
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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25
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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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26
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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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27
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Lau KK, Steinke K, Reis S, Cherukuri SP, Cejna M. Current trends in image-guided chest interventions. Respirology 2022; 27:581-599. [PMID: 35758539 PMCID: PMC9545252 DOI: 10.1111/resp.14315] [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: 03/07/2022] [Accepted: 05/18/2022] [Indexed: 02/06/2023]
Abstract
Interventional radiology (IR) is a rapidly expanding medical subspecialty and refers to a range of image‐guided procedural techniques. The image guidance allows real‐time visualization and precision placement of a needle, catheter, wire and device to deep body structures through small incisions. Advantages include reduced risks, faster recovery and shorter hospital stays, lower costs and less patient discomfort. The range of chest interventional procedures keeps on expanding due to improved imaging facilities, better percutaneous assess devices and advancing ablation and embolization techniques. These advances permit procedures to be undertaken safely, simultaneously and effectively, hence escalating the role of IR in the treatment of chest disorders. This review article aims to cover the latest developments in some image‐guided techniques of the chest, including thermal ablation therapy of lung malignancy, targeted therapy of pulmonary embolism, angioplasty and stenting of mediastinal venous/superior vena cava occlusion, pulmonary arteriovenous malformation treatment and bronchial artery embolization for haemoptysis.
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Affiliation(s)
- Kenneth K Lau
- Monash Imaging, Monash Health, Clayton, Victoria, Australia.,School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Karin Steinke
- Department of Medical Imaging, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,University of Queensland School of Medicine, St Lucia, Queensland, Australia
| | - Stephen Reis
- Division of Interventional Radiology, Department of Radiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Srinivas P Cherukuri
- Division of Interventional Radiology, Department of Radiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Manfred Cejna
- Institute for Diagnostic and Interventional Radiology, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
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28
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Joyce KE, Onabanjo E, Brownlow S, Nur F, Olupona K, Fakayode K, Sroya M, Thomas GA, Ferguson T, Redhead J, Millar CM, Cooper N, Layton DM, Boardman-Pretty F, Caulfield MJ, Shovlin CL. Whole genome sequences discriminate hereditary hemorrhagic telangiectasia phenotypes by non-HHT deleterious DNA variation. Blood Adv 2022; 6:3956-3969. [PMID: 35316832 PMCID: PMC9278305 DOI: 10.1182/bloodadvances.2022007136] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/21/2022] [Indexed: 11/20/2022] Open
Abstract
The abnormal vascular structures of hereditary hemorrhagic telangiectasia (HHT) often cause severe anemia due to recurrent hemorrhage, but HHT causal genes do not predict the severity of hematological complications. We tested for chance inheritance and clinical associations of rare deleterious variants in which loss-of-function causes bleeding or hemolytic disorders in the general population. In double-blinded analyses, all 104 patients with HHT from a single reference center recruited to the 100 000 Genomes Project were categorized on new MALO (more/as-expected/less/opposite) sub-phenotype severity scales, and whole genome sequencing data were tested for high impact variants in 75 HHT-independent genes encoding coagulation factors, or platelet, hemoglobin, erythrocyte enzyme, and erythrocyte membrane constituents. Rare variants (all gnomAD allele frequencies <0.003) were identified in 56 (75%) of these 75 HHT-unrelated genes. Deleteriousness assignments by Combined Annotation Dependent Depletion (CADD) scores >15 were supported by gene-level mutation significance cutoff scores. CADD >15 variants were identified in 38/104 (36.5%) patients with HHT, found for 1 in 10 patients within platelet genes; 1 in 8 within coagulation genes; and 1 in 4 within erythrocyte hemolytic genes. In blinded analyses, patients with greater hemorrhagic severity that had been attributed solely to HHT vessels had more CADD-deleterious variants in platelet (Spearman ρ = 0.25; P = .008) and coagulation (Spearman ρ = 0.21; P = .024) genes. However, the HHT cohort had 60% fewer deleterious variants in platelet and coagulation genes than expected (Mann-Whitney test P = .021). In conclusion, patients with HHT commonly have rare variants in genes of relevance to their phenotype, offering new therapeutic targets and opportunities for informed, personalized medicine strategies.
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Affiliation(s)
- Katie E. Joyce
- Imperial College School of Medicine, Imperial College, London, United Kingdom
- Genomics England Respiratory Clinical Interpretation Partnership (GeCIP), London, United Kingdom
| | - Ebun Onabanjo
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sheila Brownlow
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fadumo Nur
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kike Olupona
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kehinde Fakayode
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Manveer Sroya
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | | | - Teena Ferguson
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Julian Redhead
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Carolyn M. Millar
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | - Nichola Cooper
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | - D. Mark Layton
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | | | - Mark J. Caulfield
- Genomics England Research Consortium, Genomics England, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; and
| | | | - Claire L. Shovlin
- Genomics England Respiratory Clinical Interpretation Partnership (GeCIP), London, United Kingdom
- West London Genomic Medicine Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
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29
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Embolization of Recurrent Pulmonary Arteriovenous Malformations by Ethylene Vinyl Alcohol Copolymer (Onyx®) in Hereditary Hemorrhagic Telangiectasia: Safety and Efficacy. J Pers Med 2022; 12:jpm12071091. [PMID: 35887588 PMCID: PMC9321323 DOI: 10.3390/jpm12071091] [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: 05/15/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/21/2022] Open
Abstract
Objectives: To evaluate short- and long-term safety and efficacy of embolization with Onyx® for recurrent pulmonary arteriovenous malformations (PAVMs) in hereditary hemorrhagic telangiectasia (HHT). Methods: In total, 45 consecutive patients (51% women, mean (SD) age 53 (18) years) with HHT referred to a reference center for treatment of recurrent PAVM were retrospectively included from April 2014 to July 2021. Inclusion criteria included evidence of PAVM recurrence on CT or angiography, embolization using Onyx® and a minimal 1-year-follow-up CT or angiography. Success was defined based on the standard of reference criteria on unenhanced CT or pulmonary angiography if a recurrence was suspected. PAVMs were analyzed in consensus by two radiologists. The absence of safety distance, as defined by a too-short distance for coil/plug deployment, i.e., between 0.5 and 1 cm, between the proximal extremity of the primary embolic material used and a healthy upstream artery branch, was reported. Results: In total, 70 PAVM were analyzed. Mean (SD) follow-up was 3 (1.3) years. Safety distance criteria were missing in 33 (47%) PAVMs. All procedures were technically successful, with a short-term occlusion rate of 100% using a mean (SD) of 0.6 (0.5) mL of Onyx®. The long-term occlusion rate was 60%. No immediate complication directly related to embolization was reported, nor was any severe long-term complication such as strokes or cerebral abscesses. Conclusions: In HHT, treatment of recurrent PAVM with Onyx® showed satisfactory safety and efficacy, with an immediate occlusion rate of 100% and a long-term rate of 60%.
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30
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Carrington M, Pereira AR, Mendes IC, Anjos R. Intracardiac versus extracardiac shunt in a young man with ischaemic stroke. BMJ Case Rep 2022; 15:e247877. [PMID: 35260403 PMCID: PMC8905973 DOI: 10.1136/bcr-2021-247877] [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] [Accepted: 01/26/2022] [Indexed: 11/03/2022] Open
Abstract
A 24-year-old man with a history of recent ischaemic stroke was diagnosed with patent foramen ovale (PFO) and referred for closure at our hospital. At admission, besides low peripheral oxygen saturation (88%), physical examination was otherwise normal. We performed intraprocedural transoesophageal echocardiogram that revealed no PFO, although agitated saline injection demonstrated bubbles lately on the left atrium. The atrial septum could not be crossed. We suspected an extracardiac shunt, so pulmonary angiograms were performed that revealed the presence of a left pulmonary arteriovenous malformation (PAVM). A Konar-MF Occluder was used to occlude the PAVM, with a satisfactory result. At 6 months follow-up, the patient had normal peripheral oxygen saturation and a new pulmonary angiogram showed no residual shunt. Intrapulmonary shunts are a rare and under-recognised cause of paradoxical emboli in young patients; physicians should be aware of this diagnosis as percutaneous occlusion is indicated and critical to avoid recurrent ischaemic episodes.
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Affiliation(s)
| | | | - Inês Carmo Mendes
- Pediatric Cardiology Department and Reference Center for Congenital Heart Diseases, Centro Hospitalar de Lisboa Ocidental EPE Hospital de Santa Cruz, Lisboa, Portugal
| | - Rui Anjos
- Pediatric Cardiology Department and Reference Center for Congenital Heart Diseases, Centro Hospitalar de Lisboa Ocidental EPE Hospital de Santa Cruz, Lisboa, Portugal
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31
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Anderson E, Sharma L, Alsafi A, Shovlin CL. Pulmonary arteriovenous malformations may be the only clinical criterion present in genetically confirmed hereditary haemorrhagic telangiectasia. Thorax 2022; 77:628-630. [PMID: 35165143 PMCID: PMC9120382 DOI: 10.1136/thoraxjnl-2021-218332] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/14/2022] [Indexed: 11/03/2022]
Abstract
Pulmonary arteriovenous malformations (PAVMs) result in preventable complications demanding specialty care. Underlying hereditary haemorrhagic telangiectasia (HHT) can be identified by genetic testing, if the diagnosis is considered. Retrospectively reviewing 152 unrelated adults with genetically confirmed HHT due to ACVRL1, ENG or SMAD4, we found that only 104/152 (68%) met a clinical diagnosis of HHT with three Curaçao criteria. The genetic diagnostic rate was similar for patients with three (104/137, 76%) or one to two (48/71, 68%; p=0.25) criteria. Of 83 unrelated probands with PAVM(s) and genetically-confirmed HHT, 20/83 (24%) had few, if any, features of HHT. Enhanced clinical suspicion, as well as HHT genetic testing, is recommended if one or more PAVMs are present.
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Affiliation(s)
- Emily Anderson
- Department of Clinical Genetics, Liverpool Women's NHS Foundation Trust, Liverpool, UK
- Genomics England Respiratory Clinical Interpretation Partnership (GeCIP), London, UK
| | - Lakshya Sharma
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ali Alsafi
- Department of Imaging, Imperial College Healthcare NHS Trust, London, UK
| | - Claire L Shovlin
- Genomics England Respiratory Clinical Interpretation Partnership (GeCIP), London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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32
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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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33
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Topiwala KK, Patel SD, Saver JL, Streib CD, Shovlin CL. Ischemic Stroke and Pulmonary Arteriovenous Malformations: A Review. Neurology 2022; 98:188-198. [PMID: 34880092 PMCID: PMC8826462 DOI: 10.1212/wnl.0000000000013169] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 11/12/2021] [Indexed: 02/03/2023] Open
Abstract
The potential of covert pulmonary arteriovenous malformations (PAVMs) to cause early onset, preventable ischemic strokes is not well known to neurologists. This is evident by their lack of mention in serial American Heart Association/American Stroke Association (AHA/ASA) Guidelines and the single case report biased literature of recent years. We performed PubMed and Cochrane database searches for major studies on ischemic stroke and PAVMs published from January 1, 1974, through April 3, 2021. This identified 24 major observational studies, 3 societal guidelines, 1 nationwide analysis, 3 systematic reviews, 21 other review/opinion articles, and 18 recent (2017-2021) case reports/series that were synthesized. Key points are that patients with PAVMs have ischemic stroke a decade earlier than routine stroke, losing 9 extra healthy life-years per patient in the recent US nationwide analysis (2005-2014). Large-scale thoracic CT screens of the general population in Japan estimate PAVM prevalence to be 38/100,000 (95% confidence interval 18-76), with ischemic stroke rates exceeding 10% across PAVM series dating back to the 1950s, with most PAVMs remaining undiagnosed until the time of clinical stroke. Notably, the rate of PAVM diagnoses doubled in US ischemic stroke hospitalizations between 2005 and 2014. The burden of silent cerebral infarction approximates to twice that of clinical stroke. More than 80% of patients have underlying hereditary hemorrhagic telangiectasia. The predominant stroke mechanism is paradoxical embolization of platelet-rich emboli, with iron deficiency emerging as a modifiable risk factor. PAVM-related ischemic strokes may be cortical or subcortical, but very rarely cause proximal large vessel occlusions. Single antiplatelet therapy may be effective for secondary stroke prophylaxis, with dual antiplatelet or anticoagulation therapy requiring nuanced risk-benefit analysis given their risk of aggravating iron deficiency. This review summarizes the ischemic stroke burden from PAVMs, the implicative pathophysiology, and relevant diagnostic and treatment overviews to facilitate future incorporation into AHA/ASA guidelines.
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Affiliation(s)
- Karan K Topiwala
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK.
| | - Smit D Patel
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK
| | - Jeffrey L Saver
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK
| | - Christopher D Streib
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK
| | - Claire L Shovlin
- From the Department of Neurology (K.K.T., C.D.S.), University of Minnesota, Minneapolis; Department of Neurology (S.D.P., J.L.S.), Ronald Reagan UCLA Medical Center, Los Angeles, CA; and Department of Clinical and Molecular Medicine (C.L.S.), Imperial College London, UK
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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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Occult lung metastases of papillary thyroid cancer detected in a resected pulmonary arteriovenous malformation specimen. Respir Med Case Rep 2022; 35:101574. [PMID: 35036302 PMCID: PMC8743199 DOI: 10.1016/j.rmcr.2021.101574] [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: 08/24/2021] [Revised: 12/17/2021] [Accepted: 12/30/2021] [Indexed: 11/24/2022] Open
Abstract
A 41-year-old man with exertional dyspnea was referred to our hospital. Chest computed tomography (CT) showed a pulmonary arteriovenous malformation (PAVM) in the left lingular lobe, and magnetic resonance imaging showed a brain abscess. After antimicrobial therapy, the patient underwent thoracoscopic lingulectomy of the PAVM. Pathological examination revealed lung metastases of papillary thyroid cancer (PTC) that were undetectable by CT. The patient underwent total thyroidectomy and D2b lymphadenectomy for the PTC (the pathological stage was T1bN2M1, Stage II). After surgery, the patient received 100 mCi of 131Iodine; post-treatment scans revealed only neck (remnant) uptake and the patient continued with thyroid hormone replacement therapy. To the best of our knowledge, this is the first report of a case of combined PAVM and occult lung metastases of PTC. Clinicians should remember that they may detect micro lung metastases of any cancer when investigating resected lung specimens. Papillary thyroid cancer can cause occult lung metastases undetectable by thin-sliced computed tomography. In this case, occult metastatic papillary thyroid cancer was incidentally discovered in a lung specimen resected during the treatment of a pulmonary arteriovenous malformation. Clinicians should bear in mind the possible detection of micro lung metastases of all cancers when examining resected lung specimens.
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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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37
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Li T, Hao P, Lv X, Tian H. OUP accepted manuscript. J Surg Case Rep 2022; 2022:rjac006. [PMID: 35145623 PMCID: PMC8824442 DOI: 10.1093/jscr/rjac006] [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: 12/21/2021] [Accepted: 01/02/2021] [Indexed: 11/18/2022] Open
Abstract
Pulmonary arteriovenous malformations (PAVMs) are a rare pulmonary arteriovenous direct traffic vascular malformation, which directly connect the pulmonary artery to the pulmonary vein without pulmonary capillary bed. Currently, surgical resection and percutaneous transcatheter embolization are the main mode of treatment. Embolization is gradually becoming the preferred treatment for people with PAVMs, because it is less invasive and easy to repeat. We describe a case of PAVMs with hemoptysis that relapsed again after three times of embolization and then only presented new symptoms of transient ischemic attack. Finally, the patient was treated by Da Vinci robotic-assisted thoracoscopic surgery, and there were no obvious post-operative complications and recurrence. It is the first report of multiple recurrent complex PAVMs and we present our experience with the treatment of recurrent PAVMs.
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Affiliation(s)
- Tong Li
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong, China
| | - Peng Hao
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong, China
| | - Xiaojing Lv
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong, China
| | - Hui Tian
- Correspondence address. Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China. Tel: +86-18560080016; E-mail:
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Shovlin CL, Buscarini E, Sabbà C, Mager HJ, Kjeldsen AD, Pagella F, Sure U, Ugolini S, Torring PM, Suppressa P, Rennie C, Post MC, Patel MC, Nielsen TH, Manfredi G, Lenato GM, Lefroy D, Kariholu U, Jones B, Fialla AD, Eker OF, Dupuis O, Droege F, Coote N, Boccardi E, Alsafi A, Alicante S, Dupuis-Girod S. The European Rare Disease Network for HHT Frameworks for management of hereditary haemorrhagic telangiectasia in general and speciality care. Eur J Med Genet 2022; 65:104370. [PMID: 34737116 DOI: 10.1016/j.ejmg.2021.104370] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/24/2021] [Accepted: 10/26/2021] [Indexed: 12/22/2022]
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a complex, multisystemic vascular dysplasia affecting approximately 85,000 European Citizens. In 2016, eight founding centres operating within 6 countries, set up a working group dedicated to HHT within what became the European Reference Network on Rare Multisystemic Vascular Diseases. By launch, combined experience exceeded 10,000 HHT patients, and Chairs representing 7 separate specialties provided a median of 24 years' experience in HHT. Integrated were expert patients who focused discussions on the patient experience. Following a 2016-2017 survey to capture priorities, and underpinned by more than 40 monthly meetings, and new data acquisitions, VASCERN HHT generated position statements that distinguish expert HHT care from non-expert HHT practice. Leadership was by specialists in the relevant sub-discipline(s), and 100% consensus was required amongst all clinicians before statements were published or disseminated. One major set of outputs targeted all healthcare professionals and their HHT patients, and include the new Orphanet definition; Do's and Don'ts for common situations; Outcome Measures suitable for all consultations; COVID-19; and anticoagulation. The second output set span aspects of vascular pathophysiology where greater understanding will assist organ-specific specialist clinicians to provide more informed care to HHT patients. These cover cerebral vascular malformations and screening; mucocutaneous telangiectasia and differential diagnosis; anti-angiogenic therapies; circulatory interplays between anaemia and arteriovenous malformations; and microbiological strategies to counteract loss of normal pulmonary capillary function. Overall, the integrated outputs, and documented current practices, provide frameworks for approaches that augment the health and safety of HHT patients in diverse health-care settings.
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Affiliation(s)
- C L Shovlin
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK; National Heart and Lung Institute, Imperial College London, UK.
| | - E Buscarini
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy.
| | - C Sabbà
- VASCERN HHT Reference Centre, Centro Sovraziendale Malattie Rare, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Italy.
| | - H J Mager
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands.
| | - A D Kjeldsen
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - F Pagella
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.
| | - U Sure
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany; Department of Neurosurgery and Spine Surgery, University Hospital Essen, Germany.
| | - S Ugolini
- VASCERN HHT Reference Centre, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.
| | - P M Torring
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - P Suppressa
- VASCERN HHT Reference Centre, Centro Sovraziendale Malattie Rare, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Italy.
| | - C Rennie
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - M C Post
- VASCERN HHT Reference Centre, St Antonius Ziekenhuis, Nieuwegein, Netherlands; Department of Cardiology, University Medical Center Utrecht, The Netherlands.
| | - M C Patel
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - T H Nielsen
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - G Manfredi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy.
| | - G M Lenato
- VASCERN HHT Reference Centre, Centro Sovraziendale Malattie Rare, "Frugoni" Internal Medicine Unit, University of Bari "A. Moro", Italy.
| | - D Lefroy
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - U Kariholu
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - B Jones
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - A D Fialla
- VASCERN HHT Reference Centre, Odense University Hospital, Syddansk Universitet, Odense, Denmark.
| | - O F Eker
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
| | - O Dupuis
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
| | - F Droege
- VASCERN HHT Reference Centre, Essen University Hospital, Essen, Germany; Department of ENT Surgery, University Hospital Essen, Germany.
| | - N Coote
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - E Boccardi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy; Niguarda Hospital, Milan, Italy.
| | - A Alsafi
- VASCERN HHT Reference Centre, Imperial College Healthcare National Health Service Trust, London, UK.
| | - S Alicante
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy.
| | - S Dupuis-Girod
- VASCERN HHT Reference Centre, Hospices Civils de Lyon, Lyon, France.
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Monaco S, Tagliapietra M, Turri G, Bortolotti F, Mansueto G. Ischemic stroke due to sporadic and genetic pulmonary arteriovenous malformations: Case report. Brain Circ 2022; 8:57-60. [PMID: 35372731 PMCID: PMC8973452 DOI: 10.4103/bc.bc_66_21] [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: 09/13/2021] [Revised: 11/28/2021] [Accepted: 12/16/2021] [Indexed: 11/04/2022] Open
Abstract
Pulmonary arteriovenous malformations (PAVMs) encompass congenital and genetic vascular anomalies characterized by complex interlacing of arteries and veins connected by fistulas, which allow rapid and continuous extracardiac right-to-left shunting (RLS). Presenting neurologic manifestations of PAVM include brain abscess and stroke, as the consequence of paradoxical embolism. Although rare, PAVM represents an overlooked cause of cryptogenic ischemic stroke in young adults, being misdiagnosed as patent foramen ovale and a preventable trigger of silent cerebral ischemic changes. In the emergency clinical setting, the recommended ischemic stroke workup in patients with RLS should include the influence of postural changes and the effect of Valsalva maneuver on the entity of the RLS on contrast-enhanced transcranial color Doppler ultrasound and the delay in the right inferior pulmonary vein and left heart opacification on contrast-enhanced transthoracic echocardiography. This is in addition to the evaluation of chest X-rays or thoracic computed tomography. We here describe two patients with ischemic stroke due to sporadic and genetic PAVM-associated paradoxical embolism.
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40
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Roberts JI, Woodward K, Kirton A, Esser MJ. Pearls & Oy-sters: Cerebral Abscess Secondary to Pulmonary Arteriovenous Malformation in Hereditary Hemorrhagic Telangiectasia. Neurology 2021; 98:292-295. [PMID: 34880085 DOI: 10.1212/wnl.0000000000013181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal-dominant condition which is linked to a myriad of neurological complications arising from vascular malformations of the brain, spinal cord, and lungs. Our case describes a previously healthy 3-year-old male who presented to hospital with fever of unknown origin and was found to have a brain abscess stemming from a pulmonary arteriovenous malformation (PAVM). This etiology was identified after a period of diagnostic delay; the medical team was suspicious for a proximal embolic source due to the presence of multiple tiny infarcts seen on MRI brain, but transthoracic echocardiogram and head and neck angiogram were unremarkable. Fortunately, an enhanced CT chest was performed, identifying a moderately-sized PAVM. PAVMs are associated with intracranial abscesses due to shunting and loss of the normal filtering effects of the lung capillary bed. Impaired pulmonary filtration can permit paradoxical thromboemboli and septic microemboli to enter systemic circulation, predisposing patients with PAVMs to cerebral abscess and ischemic stroke. Screening for PAVMs with contrast enhanced echocardiogram or enhanced CT chest may be considered in patients with cryptogenic brain abscess or recurrent embolic stroke of unknown origin. PAVMs are often associated with hereditary hemorrhagic telangiectasia (HHT). As many features of HHT have delayed clinical manifestation, genetic testing for HHT should be considered in patients with PAVM, even in the absence of other clinical features. In our case, genetic testing returned positive, confirming a new diagnosis of HHT type 1.
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Affiliation(s)
- Jodie I Roberts
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kristine Woodward
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Ali Mohamed D, Waiss A, Onka B, Mohamed W, Allali N, Chat L, El Haddad S. Pulmonary Arteriovenous Malformations Incidentalloma in a 10-Years-Old Child. Glob Pediatr Health 2021; 8:2333794X211051186. [PMID: 34869794 PMCID: PMC8641107 DOI: 10.1177/2333794x211051186] [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: 07/25/2021] [Accepted: 09/17/2021] [Indexed: 11/17/2022] Open
Abstract
Pulmonary Arteriovenous Malformations (PAVMs) are structurally abnormal vascular communications between pulmonary arteries and pulmonary veins, which bypass the normal capillary bed and cause a low resistance right-to-left shunt with refractory hypoxemia. Generally, PAVMs were congenital, most commonly associated with (Hereditary hemorrhagic teleangiectasia (HHT). The age of diagnosis is very variable, range neonatal to adulthood, mostly diagnosed in the first 3 decades of life and clinical manifestations occur later in life generally. Here, we report PAVMs discovered incidentally in a 10-years-old child without any known risk factor.
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Affiliation(s)
| | - Amarkak Waiss
- University Hospital of Ibn Sina Rabat, Rabat, Morroco
| | - Behyamet Onka
- University Hospital of Ibn Sina Rabat, Rabat, Morroco
| | - Walid Mohamed
- University Hospital of Ibn Sina Rabat, Rabat, Morroco
| | - Nazik Allali
- University Hospital of Ibn Sina Rabat, Rabat, Morroco
| | - Latifa Chat
- University Hospital of Ibn Sina Rabat, Rabat, Morroco
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Toolis M. A massive pulmonary arteriovenous malformation with platypnoea-orthodeoxia: an important and reversible cause of refractory hypoxaemia. Med J Aust 2021; 216:19. [PMID: 34847614 DOI: 10.5694/mja2.51356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/27/2021] [Accepted: 06/02/2021] [Indexed: 11/17/2022]
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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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Marrone M, Marrone L, Cazzato G, Baldassarra SL, Ingravallo G, Stellacci A. Death Related to a Congenital Vascular Anomaly of Pulmonary Hamartoma Type: Malpractice or Tragic Fatality? MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57111231. [PMID: 34833450 PMCID: PMC8623422 DOI: 10.3390/medicina57111231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 02/05/2023]
Abstract
In forensic pathology, apparently straightforward cases can often hide rarities that, if not correctly interpreted, can alter the results of the entire investigation, leading to misinterpretations. This occurs when the investigation is conducted to assess medical malpractice. An unexpected death, with no known apparent cause, is often linked to an underlying disease process of unclear etiological origin whose nature can, unfortunately, be properly investigated only post-mortem. This presentation shows a case study, in which it was possible to reconduct the death of a patient to a natural pathology and not to medical treatment. Here, the authors illustrate a case with a hamartoma developed in chronic inflammatory conditions (bronchiectasis) that was difficult to differentiate from lung cancer due to the inability to perform specific instrumental examinations. The hamartoma, usually benign and identifiable by standard instrumental investigations, in this case, led to the patient's death precisely during the execution of a bronchoscopy. However, in the absence of a certain cause of death, public opinion unanimously attributes a patient's disease to medical error. Indeed, a routine practice such as bronchoscopy should not cause death and consequently, the doctor must have made a mistake. Fortunately, the autopsy not only demonstrated the origin of the bleeding but also unveiled the reason for this, as rare congenital lung disease. Fate, one might say.
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Affiliation(s)
- Maricla Marrone
- Legal Medicine Section, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (M.M.); (S.L.B.); (A.S.)
| | - Laura Marrone
- Military Court Judge of Verona, 37100 Verona, Italy;
| | - Gerardo Cazzato
- Pathology Section, Department of Emergency and Organ Transplantation DETO, University of Bari “Aldo Moro”, 70124 Bari, Italy;
- Correspondence:
| | - Stefania Lonero Baldassarra
- Legal Medicine Section, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (M.M.); (S.L.B.); (A.S.)
| | - Giuseppe Ingravallo
- Pathology Section, Department of Emergency and Organ Transplantation DETO, University of Bari “Aldo Moro”, 70124 Bari, Italy;
| | - Alessandra Stellacci
- Legal Medicine Section, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, 70124 Bari, Italy; (M.M.); (S.L.B.); (A.S.)
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Anderson E, Green R, Swift A, Semple MG. Hereditary haemorrhagic telangiectasia: development of a regional life-course collaborative clinical care pathway. Br J Hosp Med (Lond) 2021; 82:1-9. [PMID: 34817258 DOI: 10.12968/hmed.2020.0537] [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: 11/11/2022]
Abstract
Hereditary haemorrhagic telangiectasia is a rare, genetic disorder that can present at any age. It is characterised by epistaxis, mucocutaneous telangiectasia and visceral arteriovenous malformations, which can affect multiple organs. Early diagnosis and management reduces the morbidity and mortality associated with the disease. There is a well-established hereditary haemorrhagic telangiectasia clinic in London, and excellent links across Europe via the European Reference Network. However, local coordinated care for patients with hereditary haemorrhagic telangiectasia across the UK can be variable and often absent for children and young people. Some patients travel long distances to receive care in London, while others are referred to local clinicians or lost to follow up entirely. This article presents the experience to date from two regional UK centres (Liverpool and Dundee) where care for patients with hereditary haemorrhagic telangiectasia is being coordinated and streamlined. While there is still a lot to learn, this article highlights some of the successes and challenges identified so far, with suggestions for how these could be addressed. Collaborative regional networks such as these can facilitate the sharing of best practice and ensure that all patients with hereditary haemorrhagic telangiectasia are able to access safe, high-quality care.
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Affiliation(s)
- Emily Anderson
- Liverpool Centre for Genomic Medicine, Liverpool Women's Hospital, Liverpool, UK
| | - Richard Green
- Department of Ear, Nose and Throat Surgery, Ninewells Hospital, Dundee, UK
| | - Andrew Swift
- Liverpool Head and Neck Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Malcolm G Semple
- Department of Paediatric Respiratory Medicine, Alder Hey Children's Hospital, Liverpool, UK.,NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
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Luís H, Machado B, Barros C, Gomes M. Pulmonary arteriovenous malformation as a cause of ischaemic stroke in the elderly. BMJ Case Rep 2021; 14:e245529. [PMID: 34598969 PMCID: PMC8488706 DOI: 10.1136/bcr-2021-245529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 12/15/2022] Open
Abstract
Pulmonary arteriovenous malformation (PAVM) is well recognised as a cause of paradoxical brain embolism. The authors report the case of an older woman with a medical history of arterial hypertension who was found unconscious and was discovered to have pulmonary thromboembolism and ischaemic stroke related to a PAVM.
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Affiliation(s)
- Helena Luís
- Internal Medicine, SESARAM, Funchal, Portugal
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Ochi T, Chiyo M, Ito T, Furumoto H, Sugiura T, Saitoh Y. Successful treatment of bilateral multiple pulmonary arteriovenous malformations in a patient with brain abscess and severe hypoxemia using a combination of transcatheter embolotherapy and surgical resection: a case report. J Cardiothorac Surg 2021; 16:258. [PMID: 34496897 PMCID: PMC8424910 DOI: 10.1186/s13019-021-01644-2] [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: 12/17/2020] [Accepted: 08/30/2021] [Indexed: 11/15/2022] Open
Abstract
Background A pulmonary arteriovenous malformation is an abnormal dilated blood vessel that makes direct communication between a pulmonary artery and pulmonary vein and can be associated with hypoxemia or neurological complications, including brain abscess and cerebral infarction. Treatment of pulmonary arteriovenous malformation includes surgical resection and transcatheter embolotherapy, however the adaptation of therapies should be considered when a patient is in bad condition. Case presentation A 51-year-old man was admitted after developing fever, consciousness disorder, and hypoxemia. Magnetic resonance imaging of the brain showed a brain abscess. Bilateral pulmonary arteriovenous malformations were found by contrast computed tomography. Because of a family history of pulmonary arteriovenous malformation, a history of epistaxis, and the existence of oral mucosa telangiectasia, he was diagnosed with hereditary hemorrhagic telangiectasia and brain abscess caused by intrapulmonary right-to-left shunt. The brain abscess improved with antibiotic treatment; however, the administration of oxygen did not ameliorate his hypoxemia. His hypoxemia was exacerbated by positive pressure ventilation. Considering his systemic and respiratory condition, we considered surgery to involve a high degree of risk. After controlling his brain abscess and pneumonia, transcatheter embolotherapy was performed. This improved his systemic condition, enabling surgical treatment. Conclusions This middle-aged patient suffering from brain abscess and severe hypoxemia with multiple pulmonary arteriovenous malformations was successfully treated by a combination of transcatheter embolotherapy and surgery. The adaptation and combination of therapies, as well as the sequence of treatments, should be considered depending on the patient status and lesions.
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Affiliation(s)
- Takahiro Ochi
- Department of Thoracic Surgery, National Hospital Organization Chiba Medical Center, 4-1-2, Tsubakimori, Chuo-ku, Chiba, 260-8606, Japan
| | - Masako Chiyo
- Department of Thoracic Surgery, National Hospital Organization Chiba Medical Center, 4-1-2, Tsubakimori, Chuo-ku, Chiba, 260-8606, Japan.
| | - Takamasa Ito
- Department of Thoracic Surgery, National Hospital Organization Chiba Medical Center, 4-1-2, Tsubakimori, Chuo-ku, Chiba, 260-8606, Japan
| | - Hideharu Furumoto
- Department of Neurology, National Hospital Organization Chiba Medical Center, 4-1-2, Tsubakimori, Chuo-ku, Chiba, 260-8606, Japan
| | - Toshihiko Sugiura
- Department of Respirology Medicine, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Yukio Saitoh
- Department of Thoracic Surgery, National Hospital Organization Chiba Medical Center, 4-1-2, Tsubakimori, Chuo-ku, Chiba, 260-8606, Japan
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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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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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50
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Topiwala KK, Patel SD, Pervez M, Shovlin CL, Alberts MJ. Ischemic Stroke in Patients With Pulmonary Arteriovenous Fistulas. Stroke 2021; 52:e311-e315. [PMID: 34082575 DOI: 10.1161/strokeaha.120.032073] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Pulmonary arteriovenous fistulas (PAVFs) are a treatable cause of acute ischemic stroke (AIS), not mentioned in current American Heart/Stroke Association guidelines. PAVFs are recognized as an important complication of hereditary hemorrhagic telangiectasia. METHODS The prevalence of PAVF and hereditary hemorrhagic telangiectasia among patients admitted with AIS in the United States (2005-2014) was retrospectively studied, utilizing the Nationwide Inpatient Sample database. Clinical factors, morbidity, mortality, and management were compared in AIS patients with and without PAVF/hereditary hemorrhagic telangiectasia. RESULTS Of 4 271 910 patients admitted with AIS, 822 (0.02%) were diagnosed with PAVF. Among them, 106 of 822 (12.9%) were diagnosed with hereditary hemorrhagic telangiectasia. The prevalence of PAVF per million AIS admissions rose from 197 in 2005 to 368 in 2014 (Ptrend, 0.026). Patients with PAVF were younger than AIS patients without PAVF (median age, 57.5 versus 72.5 years), had lower age-adjusted inpatient morbidity (defined as any discharge other than home; 39.6% versus 46.9%), and had lower in-hospital case fatality rates (1.8% versus 5.1%). Multivariate analyses identified the following as independent risk markers (odds ratio [95% CI]) for AIS in patients with PAVF: hypoxemia (8.4 [6.3-11.2]), pulmonary hemorrhage (7.9 [4.1-15.1]), pulmonary hypertension (4.3 [4.1-15.1]), patent foramen ovale (4.2 [3.5-5.1]), epistaxis (3.7 [2.1-6.8]), venous thrombosis (2.6 [1.9-3.6]), and iron deficiency anemia (2 [1.5-2.7]). Patients with and without PAVF received intravenous thrombolytics at a similar rate (5.9% versus 5.8%), but those with PAVF did not receive mechanical thrombectomy (0% versus 0.7%). CONCLUSIONS Pulmonary arteriovenous fistula-related ischemic stroke represents an important younger demographic with a unique set of stroke risk markers, including treatable conditions such as causal PAVFs and iron deficiency anemia.
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Affiliation(s)
| | - Smit D Patel
- University of Connecticut, Storrs (S.D.P., M.J.A.)
| | | | | | - Mark J Alberts
- University of Connecticut, Storrs (S.D.P., M.J.A.).,Hartford Hospital, CT (M.P., M.J.A.)
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