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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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Lim KH, Kim SM, Park SJ, Kim EK, Chang SA, Lee SC, Park SW, Choe YH. Significance of transesophageal contrast echocardiography with the agitated saline test for diagnosing pulmonary arteriovenous malformations. Front Cardiovasc Med 2022; 9:975901. [PMID: 36158804 PMCID: PMC9497879 DOI: 10.3389/fcvm.2022.975901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/01/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives This study evaluated the diagnostic value of transesophageal contrast echocardiography (TECE) with the agitated saline test for diagnosing pulmonary arteriovenous malformations (PAVMs) in comparison with chest CT or pulmonary angiography. Background Although transthoracic contrast echocardiography (TTCE) is the recommended screening test for diagnosing PAVMs, it has low specificity and positive predictive value. TECE is expected to offer improved sensitivity and specificity compared with TTCE, but no studies have reported the diagnostic accuracy and clinical significance of TECE in detecting PAVMs. Methods and results In total, 1,809 patients underwent TECE with the agitated saline test to evaluate symptoms of a suspected right to left shunt. Patients with hereditary hemorrhagic telangiectasia (HHT) were excluded. A total of 387 patients showed transpulmonary bubble passage, indicating a PAVM. Among them, 182 patients had additional chest CT or pulmonary angiography. Those patients were divided into two groups according to the presence of a PAVM in the radiologic imaging. A total of 18 patients (9.8%) were confirmed for the PAVM group. Only 13 patients required embolization for their PAVMs. The TECE with saline test results were divided into four grades according to the number of bubbles: grade 1 (n = 91), grade 2 (n = 47), grade 3 (n = 35), and grade 4 (n = 9). None of the patients in the PAVM group had grade 1 shunts in their TECE results. The positive predictive values for the presence of a PAVM according to the TECE grade scale were 10.6% for grade 2, 22.8% for grade 3, and 55.6% for grade 4. Conclusion TECE with a grade scale is a useful method for initially diagnosing PAVMs in non-HHT patients with a suspected right to left shunt. The findings of this study also suggest that patients with a small grade (<10 bubbles) shunt in their TECE findings should be spared unnecessary radiation exposure from CT scans or pulmonary angiography.
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Affiliation(s)
- Kyung Hee Lim
- Division of Cardiology, Department of Internal Medicine, Dong-A University Hospital, Busan, South Korea
| | - Sung Mok Kim
- Department of Radiology, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- *Correspondence: Sung-Ji Park,
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung-A Chang
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung Woo Park
- Division of Cardiology, Department of Internal Medicine, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yeon Hyeon Choe
- Department of Radiology, Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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