Correct!
1. Coils
Pulmonary AVMs create an intrapulmonary right-to-left shunt, which can predispose patients to hypoxia (as in the case of this patient) and paradoxical systemic embolization, which can lead to complications such as stroke and brain abscess. Coils are the agent of choice for embolotherapy. Amplatzer vascular plugs have also been used to treat very large AVMs. The remaining answer choices are embolization agents that travel distally and would lead to systemic embolization and devastating consequences related to non-target embolization. Classically, feeding arteries 3 mm or larger in diameter are selectively embolized and the initial coil is oversized approximately 20% to minimize the risk of the coil passing through the AVM. For this patient, there were multiple tortuous feeding arteries feeding the pulmonary AVM, as seen in a representative pulmonary angiogram (Figure 4).
Figure 4. Catheter pulmonary angiography performed following selective injection of the left pulmonary arterial system shows opacification of the pulmonary arteriovenous malformation (arrow).
Post procedure chest radiographs (Figure 5) show that multiple coils were deployed for adequate treatment.
Figure 5. Frontal (A) and lateral (B) chest radiograph following embolotherapy for the left-sided pulmonary arteriovenous malformation shows endovascular placement of multiple metallic coils.
Patients typically receive a CTA at 1-3 months following embolization therapy, then at 6-12 months, and then every 3 years unless otherwise required. Treatment is considered successful at CTA when the draining vein decreases in size and the AVM nidus involutes. If this does not occur, then repeat angiography must be performed as this could indicate recanalization or incomplete embolization.
The patient has history of epistaxis, raising concern for hereditary hemorrhagic telangiectasia (HHT).
Which of the following is not part of the Curacao criteria (2000) for diagnosing HHT? (Click on the correct answer to proceed to the last of five panels)