Reperfusion of Pulmonary Arteriovenous Malformations after Embolotherapy

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PURPOSE

To describe the mechanisms and risk factors associated with reperfusion of successfully treated pulmonary arteriovenous malformations (PAVMs) after embolotherapy.

MATERIALS AND METHODS

Among 112 consecutive patients with PAVMs treated by embolotherapy, 19 patients were identified who had 33 angiographically confirmed reperfused PAVMs. A retrospective analysis of computed tomography (CT) and angiography was performed in patients with documented reperfused PAVMs in which reperfused PAVMs were compared with nonreperfused PAVMs. CT images were examined for persistence of the aneurysm and/or draining vein after initial embolotherapy and correlated with angiography to determine the mechanism of reperfusion. PAVM and embolic agent characteristics (eg, feeding artery size and number; PAVM location; coil size, number, and location) were evaluated for association with reperfusion. The outcomes of repeat embolotherapy for reperfused PAVMs were evaluated.

RESULTS

The PAVM aneurysm and/or draining vein persisted on CT after initial embolotherapy in all reperfused PAVMs and resolved in all nonreperfused PAVMs (in patients with nondiffuse PAVMs). Recanalization was the mechanism of reperfusion in 88%. Reperfusion was associated with the use of a single coil (P < .0001), oversized coils (P < .0001), coil placement more than 1 cm from the aneurysm (P < .0001), and increased feeding artery size (P < .001). Repeat embolotherapy for reperfused PAVMs was technically successful in 94% of cases. In the remaining 6% of cases, insufficient feeding artery length prevented safe repeat treatment. After a mean follow-up of 41 months, 42% of reperfused PAVMs in our series have been successfully treated again and occluded.

CONCLUSIONS

Recanalization is the most common mechanism of PAVM reperfusion. Increased feeding artery diameter, low number of coils, use of oversized coils, and proximal coil placement within the feeding artery are associated with reperfusion. Distal coil placement facilitates repeat embolization if reperfusion occurs.

Section snippets

Patient Population

From a database of 112 patients with PAVMs treated consecutively with embolotherapy at our tertiarycare institution between September 1996 and January 2004, 19 patients with 33 angiographically confirmed reperfused PAVMs were identified based on review of imaging studies and reports as well as clinical notes. The 11 male and eight female patients ranged in age from 21 to 62 years (mean, 41 y). Eighteen patients (95%) had hereditary hemorrhagic telangiectasia and five patients (26%) had diffuse

PAVM Morphology before Embolization and Embolic Material Characteristics

Total follow-up from the time of suspected PAVM reperfusion on CT to the end of the study ranged from 12 to 84 months (mean, 40.8 mo). Three patients (one with diffuse disease and two with nondiffuse disease) had transient neurologic deficits during the period of known PAVM reperfusion. The angioarchitectural features in 14 patients (with 18 reperfused PAVMs) before initial embolotherapy are presented in Table 1. The data are presented descriptively with no statistical analysis. The feeding

DISCUSSION

To our knowledge, risk factors for reperfusion of PAVMs have not previously been studied comprehensively, although several authors have suggested based on anecdotal evidence that coil number, size, and location relative to the aneurysm may be factors that predict reperfusion. This study attempts to examine an association between these coil characteristics and PAVM reperfusion by comparison of reperfused PAVMs with nonreperfused PAVMs. Our findings corroborate previous observations that the use

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      Citation Excerpt :

      Results from previous studies recommend the use of two or more coils, which are at maximum 2 mm larger than the feeding artery, for adequate embolization (11,33). It has been emphasized by many studies that the initial distal coiling (<1cm from the sac) prevents reperfusion due to new accessory pulmonary artery feeders (11,44-46). It also keeps the option of repeat embolization open in case of reperfusion.

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    M.E.F. has received grant support from the Nelson Arthur Hyland Foundation and St. Michael's Hospital Research Institute. None of the authors have identified a conflict of interest.

    From the 2004 SIR Annual Meeting.

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