Pulmonary AVM Embolization
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Procedure Outline
Table of Contents
- Informed consent
- Sterilely prep and drape patient’s groin
- Timeout
- General anesthesia (patient is a minor)
- Right common femoral vein is punctured under ultrasound guidance
- Use great saphenous vein as landmark in place of fluoroscopy
- Advance wire to IVC
- Identified as placement of the wire directly to the right of the spine on imaging
- A 5-French pigtail catheter was threaded over a Bentson wire into the right atrium
- EKG monitor used to check for ectopic beats upon entry into the heart
- Positioning was considered accurate based on the pressure readings
- Pressure was recorded in the right atrium (11/8 with a mean of 9)
- Using the curved stiff back end of the Bentson wire, the catheter was then advanced into the right ventricle
- Pressure was recorded in the right ventricle (23/6 with a mean of 11)
- Distal end of the catheter was manipulated into the pulmonary artery
- Pressure was recorded in the pulmonary artery (22/13 with a mean of 17)
- Heparin 3000 units were administered intravenously
- Contrast injections with digital imaging over the left lung
- Right anterior oblique projection
- The left lung’s two simple pulmonary arteriovenous malformations were visualized
- The left lower lobe contained one small PAVM previously discovered by CT (feeding artery 2 mm in diameter)
- Second lesion in the middle of the lower lobe (not suitable for embolization due to size)
- Based on size and location, feeding arteries determined to arise from the left lower lobe anterior branch
- No other PAVMs were appreciated in left lung
- Curved stiff back end of the Bentson wire used to return to the right pulmonary artery for angiography
- Left and right anterior oblique projections
- The right lung’s PAVMs were visualized
- One simple lesion was appreciated at the right lung apex (feeding artery 2.5 mm in diameter)
- A small lesion at the right lung base (not suitable for embolization due to size)
- No other PAVMs were appreciated in right lung
- Pigtail catheter was exchanged over a Rosen wire
- 90-cm long 6-French sheath with a coaxial 125-cm long Berenstein catheter
- Allows access to the right upper lobe PAVM
- Catheter advanced and placed distally to feeding artery, adjacent to sac
- PAVM embolized with 5-mm Amplatzer Vascular Plug version 4 (AVP4)
- Consists of a Nitinol mesh
- Occlusion confirmed via angiography
- Catheters manipulated into left pulmonary artery
- Coaxial catheter system advanced into first feeding artery within anterior lower lobe (diameter 1.7 mm), and eventually, the sac
- Location confirmed with contrast injection
- PAVM embolized with 4-mm AVP4
- Occlusion confirmed via angiography
- Cathers and sheath are removed
- Hemostasis is achieved at puncture site with manual compression 5–10 minutes
- 6–12 months, classically for repeat CT scan
- Because patient is a minor and AVMS are relatively small, may be less agressive getting CT scans
- 3–5 years (unless planning on getting pregnant)
