Percutaneous embolotherapy was carried out successfully in a 79 year old woman with a 56% shunt through a single pulmonary arteriovenuos malformation.With appreciable shunting pulmonary arteriovenous malformations produce disabling symptoms; and neurological complications, although less common, may complicate shunts of all sizes. Surgical resection has been the only definitive treatment and where pulmonary arteriovenous malformations are progressive and multiple, as in patients with hereditary haemorrhagic telangiectasia, multiple staged thoracotomies have been necessary. Embolotherapy is now a recognised alternative.We report a 79 year old patient with a large (56%) right to left shunt through a single pulmonary arteriovenous malformation. Closure was effected by means of percutaneous transcatheter balloon embolisation without complications.
Case reportA 79 year old woman was transferred from a district hospital, where she had presented with dyspnoea, cyanosis, and clubbing. A left lower lobe opacity was first noted on the chest radiograph in 1962, and although it enlarged she remained symptomless until late 1985. Since then she had developed increasing dyspnoea on exertion and had become bedridden. Clubbing had been present for at least a year and peripheral cyanosis for several months. She had a smoking history of 40 pack years, having stopped eight years previously, but no other relevant history.Despite central cyanosis there was no respiratory distress at rest. The fingers and toes were clubbed and the conjunctivae plethoric. Examination of the chest showed nothing abnormal and there were no thrills or bruits. The heart rate and blood pressure were normal. Cardiac examination disclosed no abnormalities apart from a grade 2/6 ejection systolic murmur at the base. There were no telangiectases of the skin or mucous membranes and no signs of chronic liver disease.The chest radiograph showed a single 6 x 3 cm rounded opacity behind the heart shadow in the left lung field. The haemoglobin concentration was 17 7 g/dl. Arterial oxygen tension (Pao2) while she was seated was 5 5 kPa in room air Address for reprint requests: Dr P C Pigott, Department of Thoracic Medicine, Royal North Shore Hospital, St Leonards, NSW 2065, Australia. Accepted 19 August 1988 and 5 9 kPa with 100% oxygen. Pulmonary function tests showed mild hyperinflation and airflow obstruction. Intracardiac and pulmonary artery pressures were normal and there was no evidence of an intracardiac shunt. On the basis of the modified Fick equation the calculated right to left pulmonary shunt was 56%.At pulmonary angiography a solitary pulmonary arteriovenous malformation (6 x 5 cm) was identified in the left lower lobe (fig 1). There was a single feeding artery (12 mm diameter) and venous drainage was by three veins into a left pulmonary vein. Two 15 mm stainless steel spiders (Amplatz vascular obstructing device, Cook Inc, Bloomington, Indiana) were placed in the feeding artery proximal to the fistula. Two 12 mm detachable balloons were place...
