Transcatheter Embolotherapy of Maternal Pulmonary Arteriovenous Malformations During Pregnancy

Gershon, Andrea S.; Faughnan, Marie E.; Chon, Kenneth S.; Pugash, Robyn; Clark, John A.; Bohan, Michael J.; Henderson, Katherine J.; Hyland, Robert H.; White, Robert I.

doi:10.1378/chest.119.2.470

Cited by 89 publications

(67 citation statements)

References 21 publications

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“…The reason this question is important is that for individuals with pulmonary AVMs, embolisation is an effective means of reducing lifetime risks of paradoxical embolic stroke and brain abscess [1,2], improving oxygenation [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] and treating pulmonary AVM-related haemoptysis [18,19]. Conversely, embolisation may be expected to elevate pulmonary artery pressure (Ppa), since pulmonary AVMs are abnormal dilated vessels between pulmonary arteries and veins that provide low resistance pathways for pulmonary blood flow [20].…”

mentioning

confidence: 99%

Embolisation of pulmonary arteriovenous malformations: no consistent effect on pulmonary artery pressure

Shovlin¹,

Tighe²,

Davies³

et al. 2008

Eur Respir J

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Increasing evidence supports the use of embolisation to treat pulmonary arteriovenous malformations (AVMs). Most pulmonary AVM patients have hereditary haemorrhagic telangiectasia (HHT), a condition that may be associated with pulmonary hypertension.The current authors tested whether pulmonary AVM embolisation increases pulmonary artery pressure (Ppa) in patients without baseline severe pulmonary hypertension. Ppa was measured at the time of pulmonary AVM embolisation in 143 individuals, 131 (92%) of whom had underlying HHT. Angiography/embolisation was not performed in four individuals with severe pulmonary hypertension, whose systemic arterial oxygen saturation exceeded levels usually associated with dyspnoea in pulmonary AVM patients.In 143 patients undergoing pulmonary AVM embolisation, Ppa was significantly correlated with age, with the most significant increase occurring in the upper quartile (aged .58 yrs). In 43 patients with repeated measurements, there was no significant increase in Ppa as a result of embolisation. In half, embolisation led to a fall in Ppa. The maximum rise in mean Ppa was 8 mmHg: balloon test occlusion was performed in one of these individuals, and did not predict the subsequent rise in Ppa following definitive embolisation of the pulmonary AVMs.In the present series of patients, which excluded those with severe pulmonary hypertension, pulmonary artery pressure was not increased significantly by pulmonary arteriovenous malformation embolisation.KEYWORDS: Brain abscess, hypoxaemia, nosebleeds, oxygen saturation, right-to-left shunt, stroke D oes embolisation of pulmonary arteriovenous malformations (AVMs) precipitate pulmonary hypertension (PH)? The reason this question is important is that for individuals with pulmonary AVMs, embolisation is an effective means of reducing lifetime risks of paradoxical embolic stroke and brain abscess [1,2], improving oxygenation [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] and treating pulmonary AVM-related haemoptysis [18,19]. Conversely, embolisation may be expected to elevate pulmonary artery pressure (Ppa), since pulmonary AVMs are abnormal dilated vessels between pulmonary arteries and veins that provide low resistance pathways for pulmonary blood flow [20].The question of whether pulmonary AVM embolisation increases Ppa is particularly pertinent, since most individuals with pulmonary AVMs have underlying hereditary haemorrhagic telangiectasia (HHT). Typically recognised by nosebleeds, mucocutaneous telangiectasia and visceral AVMs [21], HHT may be associated with PH [9,[22][23][24][25][26][27][28][29][30]. The secondary causes of PH in HHT are diverse, as they are in the normal population [31], but PH particularly occurs either as a true pulmonary arterial hypertension (PAH) phenotype [9,22,[28][29][30] or in the context of high output cardiac failure secondary to hepatic AVMs, when PH may be reversible after hepatic AVM treatment [32]. The frequencies of PAH and hepatic AVMs differ with HHT genotype: HHT is caused by mutatio...

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mentioning

confidence: 99%

Embolisation of pulmonary arteriovenous malformations: no consistent effect on pulmonary artery pressure

Shovlin¹,

Tighe²,

Davies³

et al. 2008

Eur Respir J

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“…Progression of PAVMs is often noted during pregnancy [8]. A progressive increase in cyanosis is often noted because of the opening of new or enlargement of the existing fistula, and development of polycythemia.…”

Section: Discussionmentioning

confidence: 99%

Congenital pulmonary arteriovenous malformation: a rare cause of cyanosis in childhood

Mottaghi¹,

Kahrom²,

Nezafati³

et al. 2010

Pan Afr Med Jrnl

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“…1,[9][10][11][12] The effect of pregnancy on vascular malformations is thought to be due to increased circulating blood volume, cardiac output, venous congestion secondary to the gravid uterus, and/or hormonal effects on the vasculature, with most changes occurring in the second and third trimesters. 9,11,[13][14][15] It has been hypothesized that the increased estrogen and progesterone levels of pregnancy increase TGF-b, accentuating the abnormal growth and enlargement of the vasculature. 14 …”

Section: Hht: Etiology and Diagnosismentioning

confidence: 99%

“…The dose of radiation is estimated as being less than half the maximum recommended occupational exposure for a pregnant worker. 15,18 Due to the potentially fatal complications occurring during pregnancy, any woman of reproductive age diagnosed with a PAVM should be offered treatment. 12 It may be appropriate to attempt closure of the PAVM either with surgery or, more commonly, with angiographic embolization techniques, which have been undertaken in pregnant patients in their second and third trimesters when interventional radiology carries a lower teratogenic risk.…”

Section: Pulmonary Features Of Hhtmentioning

confidence: 99%

“…12 It may be appropriate to attempt closure of the PAVM either with surgery or, more commonly, with angiographic embolization techniques, which have been undertaken in pregnant patients in their second and third trimesters when interventional radiology carries a lower teratogenic risk. 15,21 Nevertheless, more disease may be identified than can be treated. In such cases, management aims to minimize the risk of cerebral embolic events 1 by including the administration of prophylactic antibiotics during delivery and paying meticulous attention to avoiding air bubbles and, thus, paradoxical air embolism during intravenous injection.…”

Section: Pulmonary Features Of Hhtmentioning

confidence: 99%

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Anesthetic implications for the parturient with hereditary hemorrhagic telangiectasia

Lomax

Edgcombe

2009

Can J Anesth/J Can Anesth

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Purpose To review the effects of hereditary hemorrhagic telangiectasia (HHT) in the parturient and the anesthetic management of such patients during pregnancy and delivery. Source A literature search was performed using Medline and EMBASE databases. Bibliographies of retrieved articles were searched for additional sources. Principal findings Hereditary hemorrhagic telangiectasia affects 1 in 5000-8000 people. It is a genetic condition in which vascular dysplasia affects many organs particularly the pulmonary, cerebral, gastrointestinal, and spinal vasculature. A large proportion of women with HHT have uneventful pregnancies. However, women can present in pregnancy with clinically silent but potentially life-threatening features of the disorder including fatal hemorrhage from ruptured arteriovenous malformations (AVMs), systemic emboli, and high output cardiac failure secondary to arteriovenous shunting. Literature on the anesthetic management of HHT in pregnancy is limited. Both general and regional anesthetic techniques have been successfully performed in these patients, but are reliant on identifying the presence of specific AVMs; avoidance of cardiovascular instability; and prophylaxis against systemic emboli secondary to pulmonary AVM shunting. The presence of spinal AVMs is considered a relative contraindication to regional techniques. As with other systemic AVMs, these can develop and increase in size during pregnancy with implications for the timing of screening and surveillance. Conclusions An understanding of the presence and potential development of life-threatening AVMs during pregnancy is imperative for anesthesiologists caring for parturients with HHT. Even in the asymptomatic patient, a high index of suspicion should be maintained, screening performed where possible and anesthetic technique adapted accordingly. RésuméObjectif Passer en revue les effets de la te´langiectasie he´morragique he´re´ditaire (THH) chez les parturientes et la prise en charge de telles patientes pendant leur grossesse et l'accouchement. Source Une recherche de la litte´rature

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Transcatheter Embolotherapy of Maternal Pulmonary Arteriovenous Malformations During Pregnancy

Cited by 89 publications

References 21 publications

Embolisation of pulmonary arteriovenous malformations: no consistent effect on pulmonary artery pressure

Embolisation of pulmonary arteriovenous malformations: no consistent effect on pulmonary artery pressure

Congenital pulmonary arteriovenous malformation: a rare cause of cyanosis in childhood

Anesthetic implications for the parturient with hereditary hemorrhagic telangiectasia

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