Management of pulmonary arteriovenous malformation with pulmonary hypertension

Introduction. - Pulmonary arteriovenous malformations (PAVM) are abnormal communications between arteries and pulmonary veins without interposition of capillaries. Embolization is effective both in reducing lifetime complications associated with PAVM and in improving arterial oxygenation. Embolization is however not recommended in patients with pulmonary hypertension (PH) as it abolishes low resistance pathways for pulmonary blood flow and therefore might be expected to elevate pulmonary arterial pressure (PAP). Case report. - We report the case of a 70-year-old patient with a large PAVM as well as group 3 PH [mean PAP = 21 mmHg, pulmonary vascular resistance (PVR) at 3.4 Wood units] secondary to stage 2 chronic obstructive pulmonary disease (COPD) with emphysema. According to the measured shunt flow (26% of cardiac output), predicted post-embolization PVR was estimated at 4.6 Wood units. These values were considered compatible with embolization of the PAVM. Dyspnea and gas exchange improved after PAVM embolization, without worsening PH. Conclusion. - Embolization of a PAVM can be considered in patients with stable PH but requires careful prior hemodynamic assessment. The estimation of the shunt flow and predicted post-embolization PVR may guide the therapeutic decision. (C) 2020 SPLF. Published by Elsevier Masson SAS. All rights reserved.