Evaluating Pulmonary Arteriovenous Malformations (PAVMs)
A pulmonary arteriovenous malformation (PAVM) is an abnormal connection between one or more arteries — an arteriovenous malformation (AVM) — in the lung with one or more veins.
In a normal lung, the capillary is not only the site where oxygen enters the bloodstream, it is also a filter for small blood clots and bacteria that occur in our bloodstream.
In a PAVM, this filtering function is lost, and a clot or bacterium can pass through to the pulmonary veins and from there to the heart, where it is pumped throughout the body.
Depending upon where the clot or bacterium goes, it can produce a variety of symptoms, most commonly stroke. In a simple PAVM there is one feeding artery, and in a complex PAVM there are two or more. A rarer form of PAVM called diffuse type has innumerable abnormal connections.
Treating PAVMs With Embolization by Interventional Radiologists
The standard treatment for PAVMs is a minimally invasive, image-guided procedure called embolization. These procedures are performed by interventional radiologists. Dr. Scott O. Trerotola does embolizations to treat HHT at Penn Medicine’s Hereditary Hemorrhagic Telangiectasia Center of Excellence.
In this procedure, the abnormal connection between the artery and vein is blocked with a variety of devices, most commonly vascular plugs with or without platinum coils. These devices cause the feeding artery to clot and become a scar, and the abnormal connection shrinks over time.
The embolization procedure is done on an outpatient basis under moderate sedation and local anesthesia. Depending upon the number of PAVMs, the procedure can take up to four hours and the recovery is two hours. Patients can return to normal activities the next day.
How Successful Is PAVM Embolization?
In experienced hands such as in an HHT Center of Excellence, PAVM embolization is virtually 100 percent successful. Depending upon the type of embolization device used, there is up to a 20 percent chance that the treated PAVM will need further treatment in the future. However, based on research done at Penn, if the combination of a plug and coils is used, this risk is far lower, approaching zero percent. Newer plugs may achieve this rate even without coils.
Can PAVMs Recur After Embolization?
When plugs are used, the risk of a treated PAVM needing to be retreated is low. However, PAVMs treated in other fashions may persist or recur and these can be retreated. Also, PAVMs too small to treat initially may grow (although very slowly) over time. This is why lifelong surveillance with CT scans and/or echocardiogram (ultrasound of the heart) every five years is necessary.
Selected Publications About PAVMs from Penn
- Woodward CS, Pyeritz RE, Chittams JL, Trerotola SO, Treated Pulmonary Arteriovenous Malformations: Patterns of Persistence and Associated Retreatment Success. Radiology. 2013;269:919-926
- Trerotola SO and Pyeritz RE. PAVM embolization: an update. AJR 2010;195:837-45.
Trerotola SO and Pyeritz RE. Does use of coils in addition to Amplatzer vascular plugs prevent recanalization? AJR 2010; 195:766-771.
- Trerotola SO, Bernhardt B, Pyeritz R, Outpatient single-session pulmonary arteriovenous malformation embolization. JVIR 2009;20:1287-1291.
- DePietro DM, Curnes NR, Chittams J, Ferrari VA, Pyeritz RE, Trerotola SO: Postembolotherapy Pulmonary Arteriovenous Malformation Follow-Up: A Role for Graded Transthoracic Contrast Echocardiography Prior to High-Resolution Chest CT Scan. Chest 2020; 157(5): 1278-1286
- Curnes NR, Desjardins B, Pyeritz R, Chittams J, Sienko D, Trerotola SO: Lack of Growth of Small (u88042 mm Feeding Artery) Untreated PulmonaryArteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia. J Vasc Interv Radiol 2019;30: 1259-1264
- Ehrie JE, Sammarco TE, Chittams JL, Trerotola SO: Unmasking of Previously Asymptomatic Central Venous Stenosis following Percutaneous Transluminal Angioplasty of Hemodialysis Access. JVIR 2017;28: 1409-1414
- Stein EJ, Chittams JL, Miller M, Trerotola SO: Persistence in Coil-Embolized Pulmonary Arteriovenous Malformations with Feeding Artery Diameters of 3mm or Less: A Retrospective Single-Center Observational Study. JVIR 2017 28(3): 442-449
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