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A
19
Pulmonary Arteriovenous Fistulas
Mary E. Meek • James C. Meek
pulmonary arteriovenous fistula (PAVF) is a direct connection
between a pulmonary artery and pulmonary vein. These high-flow,
low pressure, thin-walled fistulae are commonly called pulmonary
arteriovenous malformations (PAVMs). Complications of untreated PAVFs
are related to the right-to-left shunt. Patients may present with hypoxia,
exercise intolerance (59%), stroke/transient ischemic attack (TIA) (30%),
brain abscess (9%), or hemoptysis (3%).1 Massive hemoptysis and/or
hemothorax occurs in fewer than 8% of patients.2 Enlargement and rupture of
the PAVF occurs more commonly in times of increased cardiac output and
hormonal surges such as pregnancy.
3,4
Migraines are present in up to 46% of
patients with PAVFs.
1
Acquired PAVFs occur in hepatopulmonary syndrome and in patients
with Glenn or Fontan shunts, malignancy, trauma, amyloidosis, and erosion
from Rasmussen aneurysms. Most (>90%) congenital PAVFs are associated
with hereditary hemorrhagic telangiectasia (HHT) or an HHT-like disorder.
1
PAVFs are commonly seen in HHT, previously known as Rendu-Osler-
Weber syndrome. HHT is an autosomal dominant disorder characterized by
epistaxis, telangiectasias (commonly on the lips, nose, and fingers), and
AVMs (PAVFs, brain, gastrointestinal [GI] tract). A diagnosis of HHT is
made based on the Curacao criteria (Table 19.1) or by genetic testing.
5
Genetic defects associated with HHT and HHT-like syndromes are
related to the transforming growth factor beta (TGF-β) pathway. Three
mutations have been identified: endoglin (ENG), activin A receptor type II
like 1 (ACVRL1 or ALK1), and SMAD4. The ENG mutation is associated
with a higher incidence of PAVF and cerebral AVM than the ALK1
mutation.6 A new genetic mutation in BMP9 has recently been identified in
patients with an HHT-like syndrome.
7
Workup for PAVF is required in all patients with HHT, hypoxia of
unknown origin, or evidence of a right-to-left shunt such as a young patient
with a brain abscess. Patients may experience orthodeoxia, which is a
decrease in oxygen saturation when standing. The workup starts with an
Echo–bubble study. Delayed appearance of bubbles in the left heart indicates
an extracardiac shunt. If the Echo–bubble study is positive, we proceed with
a noncontrast chest computed tomography (CT). Contrast is not necessary for
the chest CT. It increases the radiation dose and serves as a risk for
intravenous air embolus. The 1-mm axial images should be carefully
reviewed to identify any abnormal connection between a pulmonary artery
and pulmonary vein. Coronal and sagittal reconstructions can also be helpful.
Due to the need for continuous long-term follow-up, not only of PAVFs
but also of the other vascular malformations associated with HHT, we and
many other experienced interventionalists believe that these patients should
be treated at an HHT Center of Excellence. However, patients will present
outside of HHT Centers of Excellence with emergent indications for
embolization of their PAVF such as hemoptysis, hemothorax, or brain
abscess. It is beyond the scope of this text to discuss the entire workup and
management of an HHT patient.8 Our goal is to provide a basic guide to
performing PAVF embolization with the current embolic technology
available.
DEVICE/MATERIAL DESCRIPTION
TECHNIQUE
Embolization for PAVF was first described by Porstmann9 in 1977 and
Taylor et al.10 in 1978. Dr. White and colleagues11 further refined the
techniques, which led to the development of the White LuMax catheter
system (Cook Medical, Inc., Bloomington, Indiana). Early on, coils and
detachable balloons were used to close PAVFs. Detachable balloons are no
longer available in the United States due to deflation and systemic
embolization concerns. The techniques used today are not much different
than those described by Dr. White, with the exception of improved embolic
devices.
1,11,12
Our goal with adult patients is to embolize as many PAVFs in
one outpatient setting as possible within the constraints of contrast load and
radiation exposure.13 In children, we embolize the PAVFs greater than 3 mm
in size with the concern that embolization of smaller vessels in the
developing lung will result in a “blocked path” to a PAVF that has recruited
smaller feeders, making subsequent embolization more difficult.
Right heart and pulmonary artery pressures should be measured to
evaluate cardiac physiology. Large right-to-left shunts can cause increased
cardiac output and may lead to heart failure. Rarely, pulmonary hypertension
(even with PAVFs) may be present. This is felt to be related to the TGF-β
family of receptors.14 If pulmonary hypertension is present, evaluation for a
left-to-right shunt, such as in the liver, should be performed.
PAVFs represent a right-to-left shunt; therefore, careful attention to
technique is critical. Setup should be similar to neuroangiography cases with
in-line air filters, continuous flush lines, a closed system for contrast, and
double flush technique (Fig. 19.8).
We use a standard right femoral vein approach using a 7-Fr introducer
sheath. A diagnostic pulmonary arteriogram is performed with a 7-Fr MONT1 catheter (Cook Medical, Inc., Bloomington, Indiana). Alternatively, a
pigtail catheter over the back end of a shaped Bentson wire (Allwin Medical
Devices, Anaheim, California) or a tip-deflecting wire (Cook Medical, Inc.,
Bloomington, Indiana) may be used. Pulmonary artery pressure
measurements are obtained. Diagnostic angiography is performed in full
inspiration in the anteroposterior view and the ipsilateral oblique (40 to 60
degrees; we generally use 40 degrees). This projection may seem
counterintuitive as it projects the heart over the lung, but this view is best for
spreading out the basilar segments where most PAVFs occur. Contrast
injection rates range from 20 to 50 mL at 10 to 25 mL per second depending
on the size of the pulmonary arteries, size of PAVFs, and presence of
pulmonary hypertension. A frame rate of at least six frames per second
should be used. It is important to include deep into the lung bases in the field
of view as most PAVFs occur in the bases. Each segmental artery should be
carefully followed to evaluate for the fistulous connection. A PAVF looks
like a long continuation of the pulmonary artery into the pulmonary vein (Fig.
19.9). Frequently, there is an aneurysmal component at the site of the fistula
(Fig. 19.10). The feeding vessel is measured. The standard teaching is that
anything larger than 3 mm should be embolized. However, typically, the
HHT Centers of Excellence use the technique that embolizes as many PAVFs
in one setting as possible in the adult patient even sizes smaller than 3 mm as