PERCUTANEOUS CLOSURE OF POST-TRAUMATIC PULMONARY ARTERIOVENOUS FISTULA
Mawri S, Fuller B, Szymanski T, Wang DD, and Alaswad K. PERCUTANEOUS CLOSURE OF POST-TRAUMATIC PULMONARY ARTERIOVENOUS FISTULA. J Am Coll Cardiol 2019; 73(9):2748.
J Am Coll Cardiol
Background: Acquired pulmonary arteriovenous fistulas (PAVF) are very rare and have been reported as complications of thoracic surgery, infections, and lung trauma. PAVFs can cause significant dyspnea and hypoxia from right-to-left shunting. Therapeutic options include surgical resection or percutaneous closure. Case: A 43-year-old man with history of gunshot wound to the chest requiring emergent thoracotomy at age 19 presented with progressive dyspnea and fatigue. He was profoundly hypoxic. CT chest demonstrated a fistula between the distal left main PA and superior left pulmonary vein (PV). Pulmonary angiogram confirmed a large AVF measuring 13mm x 14mm in diameter between left PA and left superior PV. Shunt run confirmed R to L shunting with Qp/Qs ratio of 0.75. Decision-making: The Heart Team evaluated the patient and felt that he was at prohibitive surgical risk given his prior surgical history, and thus he was scheduled for percutaneous intervention. CT with 3-D reconstruction of the heart provided accurate fistula dimensions and allowed for 3-D printed model used for septal occluder sizing. The procedure was performed under transesophageal echocardiographic guidance. Femoral access was obtained and through a PA catheter, an Amplatz super stiff wire was advanced to left PA. The PA catheter was exchanged for JR 4 catheter through which a Glidewire Advantage wire was used to cross the fistula. Trans-septal puncture into the LA was performed using a BRK XS needle and a 12Fr SL1 sheath was advanced into the left upper PV. An Amplatz wire was advanced across the fistula into the right ventricle over which the SL1 sheath was advanced through the fistula to the left PA and into the RV. A 30mm GORE CARDIOFORM septal occluder was advanced through the trans-septal access to the pulmonary A-V fistula and deployed. Pulmonary artery angiogram confirming cessation of flow through the fistula. Conclusion: Percutaneous closure of pulmonary AV fistula is a feasible alternative therapeutic option to surgery. Use of 3-D printed modeling ad 3-D reconstruction provided accurate fistula dimensions and customization of accurately sized occluder device, such as the one used in this case.
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