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Pulmonary arteriovenous malformation

Pulmonary arteriovenous malformations (PAVM's) is rare vascular anomalies of the lung. They are generally considered direct high flow, low-resistance fistulous connections between the pulmonary arteries and veins.

Epidemiology

There is a recognised female predilection with F:M ratios ranging around 1.5 to 1.8:1. The estimated incidence is thought to be around 2-3 per 100,000 11.

Clinical presentation

Despite most patients being asymptomatic, the connection between the venous and arterial system can lead to dyspnoea (due to right-to-left shunting), as well as embolic events (due to paradoxical emboli). Although it is assumed that the vascular defects are present at birth, they are seldom manifested clinically until adult life until when the vessels have been subjected to pressure over several decades. Clinically a murmur or bruit may audible over the lesion (especially if peripheral). There are be an extremely variable age of presentation from infant to old age although most patient within the first three decades of life.

Pathology

In congenital cases they are considered to result from a defect in the terminal capillary loops which causes dilatation and the formation of thin-walled vascular sacs. They can be multiple in around one-third of cases.

Classification

They can be classified as simple, complex or diffuse 9.

  • simple type: commonest; has a single segmental artery feeding the malformation; the feeding segmental artery may have multiple subsegmental branches that feed the malformation, but must have only one single segmental level
  • complex type: have multiple segmental feeding arteries (~20% 7)
  • diffuse type: rare (~5% of lesions); the diffuse form of the disease is characterised by hundreds of malformations; some patients can have combination of simple and complex AVMs within a diffuse lesion

Another older embryological based classification proposed by Anatwabi et al in 1965 is as 11 

  • group I: multiple small arteriovenous fistulas without aneurysm
  • group II: large arteriovenous aneurysm
  • group III 
    • large arteriovenous aneurysm (central)
    • large arteriovenous aneurysm with anomalous venous drainage
    • multiple small arteriovenous fistulae with anomalous venous drainage
  • group IV
    • large venous aneurysm with systemic arterial communication
    • large venous aneurysm without fistula
  • group V: anomalous venous drainage with fistulae
Location

These are often unilateral. Although can potentially affect any part of the lung, there is a recognised predilection towards the lower lobes (50-70%) 7.

Associations

PAVMs have been described in association with a number of conditions.

In addition PAVMs have been found in:

Radiographic features

A number of modalities are available for the diagnosis of PAVMs, including contrast echocardiography, radionuclide perfusion lung scanning, computed tomography (CT), magnetic resonance imaging (MRI), and, the gold standard, pulmonary angiography 2.

CT / CT angiography

CT is often the diagnostic imaging modality of choice. The characteristic presentation of a PAVM on non-contrast CT is a homogeneous, well-circumscribed, non-calcified nodule up to several centimeters in diameter or the presence of a serpiginous mass connected with blood vessels 3. Occasionally associated phleboliths may be seen as calcifications. Contrast injection demonstrates enhancement of the feeding artery, the aneurysmal part, and the draining vein on early-phase sequences.

MR / MR angiography

Three-dimensional contrast–enhanced MR angiography has is considered the MR technique of choice for imaging vascular structures in the thorax 10. Most lesions within the lung have a relatively long relaxation time and produce medium to high intensity signals. Lesions with rapid blood flow within result in a signal void and produce low intensity signals.

Treatment and prognosis

Treatment options include:

  • trans-catheter coil embolisation 
  • surgery (historically treated with surgery)

Once successfully treated (embolotherapy, surgical resection), prognosis is generally good for an individual lesion.

Complications

History and etymology

The first description of pulmonary arteriovenous malformation was reported by T Churton in 1897.

Differential diagnosis

Possible imaging differential considerations include

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