Bilateral Multiple Pulmonary ArteriovenousMalformations: Endovascular Treatment withthe Amplatzer Vascular PlugBarbaros Cil, MD, Murat Canyigit, MD, Orhan S. Ozkan, MD, Gulsun A. Pamuk, MD, and Riza Dogan, MD

Pulmonary arteriovenous malformation (AVM) is a rare vascular malformation of the lung that carries a considerablerisk of serious complications such as cerebral embolism, brain abscess, and pulmonary hemorrhage. Embolizationwith coils or detachable balloons is currently the preferred treatment. Paradoxical embolization of coils and balloonsmay occur, especially in patients with large feeding arteries. This report describes an initial experience with the useof the Amplatzer Vascular Plug used for endovascular treatment of bilateral multiple pulmonary AVMs in an adultpatient.

J Vasc Interv Radiol 2006; 17:141–145

Abbreviations: AVM � arteriovenous malformation, AVP � Amplatzer Vascular Plug

PULMONARY arteriovenous malfor-mations (AVMs) are abnormal com-munications between the pulmonaryarteries and the pulmonary veins (1,2).In the past decade, endovascular ther-apy has made progress in the manage-ment of pulmonary AVMs and gainedacceptance because of its high successrate and low associated complicationrates (3,4). The Amplatzer VascularPlug (AVP; AGA Medical, GoldenValley, MN) is a new self-expandabledevice indicated for arterial and ve-nous embolizations in the peripheralvasculature and has been used re-cently for occlusion of abnormal vesselcommunications such as aortopulmo-nary collateral vessels (5).In this report, we describe our ini-

tial experience with the AVP used forendovascular treatment of multiplepulmonary AVMs in an adult patient

with hereditary hemorrhagic telangi-ectasia.

CASE REPORT

Institutional review board approvalis not required at our institution for acase report of this type. A 62-year-oldfemale patient with a diagnosis of he-reditary hemorrhagic telangiectasiawas referred to our department for en-dovascular treatment of her multiplepulmonary AVMs. Physical examina-tion was normal and she was noted tohave moderate desaturation (82% onroom air) on pulse oximetry. On chestradiography, there were bilateral mul-tiple nodular smooth-margined opaci-ties in the lower lung lobes. Chestcomputed tomography (CT) revealednodular structures in the lung paren-chyma bilaterally, continuing with en-larged vascular channels extending tothe right atrium, consistent with mul-tiple pulmonary AVMs.Under general anesthesia (request-

ed by the patient), diagnostic pul-monary angiograms were first ob-tained, which showed two pulmonaryAVMs at the left lower lobe, one at theright lower lobe, and another at theright upper lobe (Fig 1). We decidedto treat the pulmonary AVMs at the

left lower lobe first. Both were com-plex pulmonary AVMs with multiplefeeder vessels. Four different feedervessels were identified for the one lo-cated medially and two feeder vesselswere identified for the one locatedmore laterally. Then, over an exchangeguide wire, a 6-F angled guide cathe-ter (Envoy; Cordis, Miami, FL) wasplaced into the left lower-lobe artery.Short or exchange-length stiff guidewires were used whenever needed toadvance the guiding catheter. Thefeeding arteries of the medially lo-cated pulmonary AVM were selectedwith the help of a 0.035-inch, 180-cmangled guide wire (Radifocus; Terumo,Tokyo, Japan) and the guiding cath-eter was advanced into the feeding ar-tery of the pulmonary AVM as distallyas possible to achieve distal emboliza-tion (Fig 2a). The diameter of the firstfeeder vessel was 7 mm and a 12-mmAVP was deployed (Fig 2b,c). Theother three feeder vessels of the samepulmonary AVM were also selectedwith the same guiding catheter and6-mm, 8-mm, and 10-mm AVPs weredeployed. Each feeder vessel was to-tally occluded with only one AVP. To-tal occlusion was achieved in 6–10minutes from the time of deployment.Next, the other pulmonary AVM at the

From the Department of Radiology, HacettepeUniversity School of Medicine, Sihhiye 06100,Ankara, Turkey. Received July 6, 2005; acceptedAugust 28. Address correspondence to B.C.,E-mail: barbaros@hacettepe.edu.tr

None of the authors have identified a conflict ofinterest.

© SIR, 2006

DOI: 10.1097/01.RVI.0000186954.74462.CE

141

lateral segment with two feeder ves-sels was targeted. Feeding vessel di-ameters were 2 mm and 5 mm. Thesmall feeding vessel was not emboli-zed. The larger feeder vessel was oc-cluded with an 8-mm AVP. The leftpulmonary arteriogram after emboli-zation showed total occlusion of theembolized feeding vessels (Fig 3a).The patient’s oxygen saturation in-creased from 82% to 87% after the firstsession of embolization. Three dayslater, a second session of embolizationwas performed for the pulmonaryAVMs at the right upper and lowerlobes. Initially, the feeding artery ofthe lower-lobe pulmonary AVM wascatheterized with an 8-F guiding cath-eter (Envoy; Cordis). The vessel diam-eter was 10.4 mm and a 16-mm AVPwas deployed, which resulted in totalocclusion in 8 minutes. Next, the 8-Fguiding catheter was exchanged witha 6-F guiding catheter and the larger ofthe two feeder vessels of the upper-lobe pulmonary AVM was occluded

with a 10-mm AVP. The other feedingvessel was small (�3 mm) and notembolized. Right pulmonary arterio-gram after embolization showed totalocclusion of the embolized feedingvessels (Fig 3b). A thoracic CT imagewas obtained 3 days after the secondsession of embolization, which con-firmed thrombosis of the embolizedvessels and pulmonary AVMs. Thepatient was discharged without com-plications and with normal arterial ox-ygen saturation (95% on room air). Shewas without symptoms at 1-monthfollow-up examination, and 6-monthand 12-month follow-up chest CT im-ages are planned.

DISCUSSION

The AVP is a self-expandable cylin-drical device made from a nitinol wiremesh that allows the device to com-press inside a catheter and then returnto its intended shape to occlude thetarget vessel (Fig 4). It uses the same

technology used in other preshapedAmplatzer occluders that are used toclose atrial septal defects, ventricularseptal defects, or patent foramenovale. The device has platinum mark-ers on both ends. A stainless-steel mi-croscrew is welded to one of the plat-inum marker bands, which allowsattachment to the 135-cm-long deliv-ery cable. The AVP is available in sizesranging from 4 mm to 16 mm in 2-mmincrements. It is preloaded in a loaderand delivered through currently avail-able 5-F, 6-F, or 8-F guiding catheters.When positioned, it is released by ro-tating the delivery cable in counter-clockwise fashion. It is recommendedto select a device approximately 30%–50% larger than the vessel diameter. Inthis case, we generally oversize thedevice 50% or slightly more. The AVPis a flexible nitinol wire mesh that ad-justs to the shape of the vessel, andoversizing prevents device migrationafter deployment.Pulmonary AVMs are uncommon

Figure 1. Selective left (a) and right (b) pulmonary arteriograms show bilateral complex pulmonary AVMs located at the left lower lobeand right upper and lower lobes with multiple feeder vessels.

142 • Endovascular Treatment of Bilateral Pulmonary AVMs January 2006 JVIR

and usually congenital. The indica-tions for treatment include stroke andbrain abscess caused by paradoxicalembolization, hemorrhage, desatura-tion, or a combination of these. Pulmo-nary AVMs with afferent arterieslarger than 3 mm in diameter have

been documented to cause seriousneurologic symptoms, and treatmentof pulmonary AVMs with feeding ves-sels 3 mm or larger has been recom-mended to prevent paradoxical embo-lization during the lifetimes of patientswho have them (3,4,6).

By virtue of their less invasive na-ture, transcatheter techniques have be-come increasingly used during the pastdecade to treat abnormal vessel commu-nications like pulmonary AVMs. De-pending on the size, flow characteristics,and localization of the abnormal com-

Figure 2. Catheterization of one of the feeder vessels of the pulmonary AVM located at the left lower-lobe medial segment (a). Contrastmaterial injection from the guiding catheter after a 12-mm AVP has been placed but not deployed shows good distal position of thedevice (b). Contrast material injection performed 8 minutes after deployment shows total occlusion of the segmental artery (c).

Cil et al • 143Volume 17 Number 1

munication, various devices can beused. Although stainless-steel or plati-num coils are the most commonly used

devices, it may not be possible to safelyplace coils, especially when the commu-nication is large and has a high degreeof flow. Even in experienced hands andwith state-of-the-art techniques, coil em-bolization is associated with a risk ofcoil migration (5,6). AVP is a new alter-native device used to occlude fistulas(7–9). It allows for targeted delivery, en-abling more precise placement withinthe artery. The position of the device canbe easily verified with a test injectionthrough the guiding catheter. If deviceposition is unsatisfactory, it can be repo-sitioned or removed. The additional ad-vantages of this device compared withcoil embolization are less risk of devicemigration, easy deployment with theneed for only a single device, ability toreposition the device, and magnetic res-onance imaging compatibility. Weachieved total occlusion with only oneAVP in each of the feeding vessels em-bolized. We did not embolize small

feeding vessels (�3 mm) because therisks resulting from the presence offeeder vessels of such small diameters(eg, paradoxical embolization, stroke,brain abscess) is very low (10). In thiscase, compared with coils, the use ofAVP decreased the duration and cost ofthe procedure, especially in patientswith multiple pulmonary AVMs andfeeder vessels to be treated. The onlylimitation of the device is that it requiresdistal placement of a 5–8-F guidingcatheter depending on the diameter ofthe vessel to be occluded. After theguiding catheter has been placed to thesite of embolization, the device can beadvanced through the catheter withoutdifficulty.In conclusion, the new vessel oc-

cluder described herein is a simpleand effective device for the endovas-cular treatment of pulmonary AVMsand similar abnormal vascular com-munications. We believe that, in se-

Figure 3. Selective left (a) and right (b) pulmonary arteriograms after embolization show total occlusion of the embolized feedingarteries. A total of five AVPs were deployed on the left side and two AVPs were deployed on the right side (arrows).

Figure 4. Photograph of the AVP.

144 • Endovascular Treatment of Bilateral Pulmonary AVMs January 2006 JVIR

lected cases, its use can reduce the du-ration and increase the safety of theembolization procedure.

References1. Gossage JR, Kanj G. Pulmonary arte-riovenous malformations. Am J RespirCrit Care Med 1998; 158:643–661.

2. Swanson KL, Prakash UBS, StansonAW. Pulmonary arteriovenous fistu-las: Mayo Clinic experience, 1982–1997.Mayo Clin Proc 1999; 74:671–680.

3. Clark JA, Pugash RA, Faughnan ME, etal. Multidisciplinary team interestedin the treatment of pulmonary arterio-venous fistulas or malformations

(PAVFs). World J Surg 2001; 25:254–255.

4. Cil BE, Erdogan C, Akmangit I, et al.Use of the TriSpan coil to facilitate thetranscatheter occlusion of pulmonaryarteriovenous malformation. Cardio-vasc Intervent Radiol 2004; 27:655–658.

5. Magger JJ, Overtoom TT, Blauw H, etal. Embolotherapy of pulmonary ar-teriovenous malformations: long-termresults in 112 patients. J Vasc IntervRadiol 2004; 15:451–456.

6. Prasad V, Chan RP, Faughnan ME.Embolotherapy of pulmonary arterio-venous malformations: efficacy of plat-inum versus stainless steel coils. J VascInterv Radiol 2004; 15:153–160.

7. Hijazi ZM. New device for percuta-neous closure of aortopulmonary col-laterals. Catheter Cardiovasc Intervent2004; 63:482–485.

8. Lee DW, White RI Jr, Egglin TK, et al.Embolotherapy of large pulmonary ar-teriovenous malformations: long-termresults. Ann Thorac Surg 1997; 64:630–640.

9. Hoyer MH. Novel use of the Am-platzer plug for closure of a patentductus arteriosus. Catheter CardiovascIntervent 2005; 56:570–580.

10. Lee DW, White RI Jr, Egglin TK, et al.Embolotherapy of large pulmonary arte-riovenous malformations: long term re-sults. Ann Thorac Surg 1997; 64:930–939.

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