A Rare Case of Pulmonary Arteriovenous Malformation - A Diagnostic Dilemma

Pulmonary arteriovenous malformations (PAVM) are rare anomalies of pulmonary vascular system which may be incidentally detected or can have manifestations resulting from right to left shunt. PAVM can cause various systemic implications including central nervous system complications like stroke, brain abscess due to paradoxical emboli which mostly seen in previously undiagnosed PAVMs indicating importance of early diagnosis and timely intervention in PAVM. Computed Tomography Pulmonary Angiography (CTPA) is the diagnostic method of choice in PAVM. We present here a unique case of complex multiple PAVM presented with refractory hypoxemia in a middle aged patient diagnosed in our centre initially evaluated for malignancy based on chest radiography & High Resolution Computed tomography(HRCT)thorax findings and symptoms, later on after CTPA was diagnosed to have complex PAVM which showed clinicoradiological improvement following pulmonary vascular plugging. This case shows clinical scenario, diagnostic & management methods and differential diagnosis to be discussed in similar clinicoradiological pattern and peculiarity of PAVM despite advanced age.

The pivotal role of PFO in paradoxical embolism following venous sclerotherapy: a unique case report with pathological correlations

Background Vein sclerosing therapy for varicose veins remains an extremely popular procedure. Cerebrovascular accidents can be a serious complication. A patent foramen ovale (PFO) can act as a conduit to the arterial circulation, which could explain the adverse neurologic consequence of this procedure. This case provides pathologic evidence of this concept. Case summary A 66-year-old female presented with syncope after undergoing varicose vein sclerotherapy. A computed tomography angiography of the head and neck in the emergency room revealed an occluded right distal M1 middle cerebral artery. Clot retrieval was performed with final pathology revealing amorphous material consistent with an exogenous agent, polidocanol foam, which was used for the patient’s vein sclerotherapy. A transthoracic echocardiogram and transoesophageal echocardiogram showed a PFO, which was ultimately closed percutaneously. Discussion In a quarter of the population, lack of closure of the intrauterine interatrial shunt leads to the existence of a PFO. This direct communication between the atria provides an anatomical conduit for paradoxical emboli and eventually infarction of affected tissues. While a paradoxical embolism is an uncommon cause of acute arterial occlusion, it can have catastrophic sequelae. Historically, the presence of an arterial thrombus from the venous circulation has been difficult to establish unless the thrombus is visualized in transit through a PFO. Complications from vein sclerotherapy have been reported in the literature and include transient ischaemic attacks and strokes, however, this is the first case to provide pathological proof of a paradoxical embolism, which ultimately resulted in percutaneous closure of the PFO.

Diagnosis and endovascular management of pulmonary arteriovenous malformations

Pulmonary arteriovenous malformations (PAVM) are abnormal communication of a branch of the pulmonary artery and pulmonary vein circumventing the intervening pulmonary capillaries. This results in a right-to-left (R-L) shunt and its related manifestations, which include hampered gas exchange leading to hypoxaemia, dyspnoea, paradoxical emboli leading to stroke, cerebral abscess, myocardial infarction and pulmonary haemorrhage due to rupture of the PAVM. Endovascular transcatheter embolization of the feeding vessels with coils or occlusion devices is the current standard care of treatment and preferred treatment modality. The articles aim to provide insights into the current trends in diagnosis, the current recommendations, approach and management options for patients with PAVM.

Variable Presentations in Pulmonary Arteriovenous Malformation

Pulmonary arteriovenous malformations (PAVM) are a group of vascular anomalies of lung which present with variable clinical symptoms. Most patients with PAVM are asymptomatic but it can cause dyspnea on exertion, paradoxical emboli to brain causing various central nervous system complications like stroke and brain abscess, hemoptysis and rupture. The age at the presentation can range from 1st to 7th decade but the majority of patients present before the age of 30 years. PAVM is strongly associated with hereditary haemorrhagic telangiectasis which presents with epistaxis, mucocutaneous telangiectasias and AV malformations of various organs. In our case series, we have patients ranging from 3 yrs to 75 years with presentation ranging from asymptomatic to exertional dyspnea, hemoptysis and neurological complications.

Morphological study of patent foramen ovale in Sudanese population

The aim of this study is to establish anatomical reference regarding PFO among Sudanese as increasing evidence was found that PFO is culprit in paradoxical emboli events; this led to the reevaluation of this relatively important anomaly. We included 60 apparently normal hearts available in Dissection Rooms in five faculties of medicine in Sudan. The rate of PFO was 7 (11.7%) and the diameter was ranging between 5 mm and 21 mm, with average of 0.87 mm. We conclude that PFO is common among Sudanese and was seen in seven cadavers (11.7%).