Case 1
A-52-year-old female with HHT. Saturation at rest was 96% and during exercise decreased to 92%. CE confirmed a shunt with grade I-II. CT without contrast confirmed a simple PAVM in the left lower lobe with a feeding artery of 3 mm. The left pulmonary artery was catheterised, and angiography depicted the PAVM (Fig. 1a, b). The PAVM was first embolised with a detachable coil of 4 mm diameter and 10 cm in length (Interlock, Boston Scientific Marlborough, MA, USA). After ten minutes waiting there was still flow thought the PAVM. It was decided to deploy an MVP-3Q (Reverse Medical Corporation, Irvine CA, USA) through a 2.4 Fr microcatheter (Renegade microcatheter, Boston ScientificMarlborough, MA, USA) with following immediate occlusion (Fig. 2a-c). No complications occurred during the intervention. The patient was discharged the following day, and follow-up consists of clinical and CE control which showed improved oxygenation and no shunt at CE control six months after embolization.
Case 2
A-19-year-old female with HHT and haemoptysis underwent three PAVM embolizations previously. The last embolization was performed in 2009, and the patient was without complaints. Recently she complained about shortness of breath and pain during mild exercise. Saturation at rest was 92% and during the exercise decreased to 89%. CE confirmed a shunt grade I-II. CT without contrast confirmed two new PAVMs. The right pulmonary artery was catheterized, and angiography depicted two PAVMs, one in a right upper lobe and one in the right lower lobe (Fig. 3a, b). Both PAVMs had feeding arteries with a diameter of 3.2 mm. The PAVM in the lower lobe was embolized with a detachable coil (Interlock, Boston ScientificMarlborough, MA, USA), 6 mm in diameter and 10 cm long. The PAVM located in the upper lobe was engaged coaxially with microcatheter 2.8 Fr (Renegade Hi-Flo; Boston ScientificMarlborough, MA, USA) and primarily embolized with MVP-5Q (Reverse Medical Corporation, Irvine CA, USA) with following immediate occlusion (Fig. 4 a, b). No complications occurred during the intervention. The patient was discharged the next day, and follow-up consisted of clinical and CE control showed improved oxygenation up to 96% and no shunt at six months CE control.
Case 3
A-32-year-old female with nasal bleeding during two years. A diagnosis of HHT was established. Oxygen saturation was 98% without significant changes during exercise. CE confirmed shunt grade II-III and non-contrast CT showed two PAVMs, one located in the right lower lobe with feeding artery of 5 mm and the other with feeding artery of 3.3 mm in diameter located in the right upper lobe (Fig. 5). The PAVM in the lower lobe was embolized with Amplatzer plug IV (St Jude Medical, Minnesota, USA), 8 mm in diameter. The PAVM in the upper lobe was embolized with MPV-5Q (Reverse Medical Corporation, Irvine CA, USA) delivered through a microcatheter 2.8 Fr (Renegade Hi-Flo; Boston ScientificMarlborough, MA, USA) with following immediate occlusion of both PAVMs (Fig. 6 a, b). No complications occurred during the deployment. The patient was discharged the next day, and clinical control and CE showed no shunt six months after embolization.
Case 4
20-year-old male patient with diagnosed HHT and multiple PAVMs in both lungs. Embolization of PAVMs in the left lung was performed in 2010 and 2011 with a good outcome. In 2017 CE control showed shunt grade II-III and CT confirmed two PAVMs in the right lung. The biggest had a feeding artery of 6 mm and was embolized with Amplatz plug IV (St Jude Medical, Minnesota, USA), 8 mm in diameter a few months before the actual intervention (Fig. 7). The smaller PAVM in the right lower lobe had two feeding arteries. One feeding artery with a diameter of 3 mm was embolized with a detachable coil 4 mm and 8 cm in length (Interlock, Boston ScientificMarlborough, MA, USA). The other feeding artery with a diameter of 3.4 mm was embolized with MVP-5Q delivered through a microcatheter 2.8 Fr (Renegade Hi-Flo; Boston ScientificMarlborough, MA, USA), but due to highly angulated feeding artery the MVP was displaced a little proximally and occluded the feeding artery a longer distance to the PAVM than intended (Fig. 8). No complications occurred, and the patient was discharged the following day without symptoms. The patient was asymptomatic at clinical control 12 months after the embolization, and no CE was performed during the follow-up. The patient did not experience any symptoms during the 12 months follow-up period.