Treatment of Recurrent Pulmonary Arteriovenous Malformations: Comparison of Proximal Versus Distal Embolization Technique

  • Lucas R. Cusumano
  • Gary R. Duckwiler
  • Dustin G. Roberts
  • Justin P. McWilliamsEmail author
Clinical Investigation Arterial Interventions
Part of the following topical collections:
  1. Arterial Interventions



To examine the characteristics of recurrent pulmonary arteriovenous malformations (PAVMs) and compare the success of proximal versus distal embolization technique for treatment of recanalized PAVMs.


Between July 2007 and October 2018, 26 consecutive patients underwent embolization of 64 previously treated recurrent PAVMs at a single center with imaging follow-up. PAVM angioarchitecture was classified as either simple (1 feeding artery) or complex (≥ 2 feeding arteries). The mechanism of recurrence was characterized as recanalization (flow through previously placed embolic material) or reperfusion (flow through accessory arteries). For recanalized PAVMs, we compared embolizing proximal to or within the existing embolic (proximal embolization technique) versus embolizing distal to the existing embolic (distal embolization technique). Follow-up imaging was reviewed to determine treatment success, defined as decrease of the draining vein or sac size by at least 70%.


Mean patient age was 47.6 years (range 22–72 years), and 61.5% were female. Twenty-four patients (92.3%) had hereditary hemorrhagic telangiectasia, a disorder associated with PAVM formation. 31/64 (48.4%) PAVMs were simple, and 33/64 (51.6%) PAVMs were complex. Recanalization was the most common pattern of recurrence, occurring in 54/64 (84.4%) PAVMs. Treatment success following repeat embolization was 54.7% at a mean follow-up time of 1.6 years. For recanalized PAVMs, treatment success was significantly more likely with distal embolization technique (14/15, 93.3%) than with proximal embolization technique (19/33, 57.6%) (P = 0.0180).


Recurrent PAVMs are difficult to treat, with high rates of recurrence following repeat embolization. Distal embolization technique is more likely to produce durable occlusion than proximal embolization.


Pulmonary arteriovenous malformations Recanalization Reperfusion Embolization Hereditary hemorrhagic telangiectasia 



This study was not supported by any funding.

Compliance with Ethical Standards

Conflict of interest

Gary R Duckwiler, MD, is a scientific advisor for Sequent Medical, pipeline proctor for Medtronic, and scientific advisor for Neurvana. Justin P. McWilliams, MD, is a scientific advisor for Boston Scientific, Penumbra, and Merit Medical.

Ethical Approval

For this type of study, formal consent is not required.

Informed Consent

This study has obtained IRB approval from the UCLA IRB, and the need for informed consent was waived.

Consent for Publication

For this type of study, consent for publication is not required.


  1. 1.
    Cartin-Ceba R, Swanson KL, Krowka MJ. Pulmonary arteriovenous malformations. Chest. 2013;144(3):1033–44.CrossRefPubMedGoogle Scholar
  2. 2.
    Lacombe P, Lacout A, Marcy PY, et al. Diagnosis and treatment of pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: an overview. Diagn Interv Imaging. 2013;94(9):835–48.CrossRefPubMedGoogle Scholar
  3. 3.
    Garg N, Khunger M, Gupta A, Kumar N. Optimal management of hereditary hemorrhagic telangiectasia. J Blood Med. 2014;5:191–206.PubMedPubMedCentralGoogle Scholar
  4. 4.
    Abdalla SA, Letarte M. Hereditary haemorrhagic telangiectasia: current views on genetics and mechanisms of disease. J Med Genet. 2006;43(2):97–110.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Faughnan ME, Palda VA, Garcia-Tsao G, et al. International guidelines for the diagnosis and management of hereditary haemorrhagic telangiectasia. J Med Genet. 2011;48(2):73–87.CrossRefPubMedGoogle Scholar
  6. 6.
    Pollak JS, Saluja S, Thabet A, Henderson KJ, Denbow N, White RI Jr. Clinical and anatomic outcomes after embolotherapy of pulmonary arteriovenous malformations. J Vasc Interv Radiol. 2006;17(1):35–44 (quiz 45).CrossRefPubMedGoogle Scholar
  7. 7.
    Swanson KL, Prakash UB, Stanson AW. Pulmonary arteriovenous fistulas: Mayo Clinic experience, 1982–1997. Mayo Clin Proc. 1999;74(7):671–80.CrossRefPubMedGoogle Scholar
  8. 8.
    Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med. 1998;158(2):643–61.CrossRefPubMedGoogle Scholar
  9. 9.
    White RI Jr. Pulmonary arteriovenous malformations: how do I embolize? Tech Vasc Interv Radiol. 2007;10(4):283–90.CrossRefPubMedGoogle Scholar
  10. 10.
    Remy-Jardin M, Dumont P, Brillet PY, Dupuis P, Duhamel A, Remy J. Pulmonary arteriovenous malformations treated with embolotherapy: helical CT evaluation of long-term effectiveness after 2 to 21-year follow-up. Radiology. 2006;239(2):576–85.CrossRefPubMedGoogle Scholar
  11. 11.
    Mager JJ, Overtoom TT, Blauw H, Lammers JW, Westermann CJ. Embolotherapy of pulmonary arteriovenous malformations: long-term results in 112 patients. J Vasc Interv Radiol. 2004;15(5):451–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Narsinh KH, Ramaswamy R, Kinney TB. Management of pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia patients. Semin Interv Radiol. 2013;30(4):408–12.CrossRefGoogle Scholar
  13. 13.
    Shimohira M, Kawai T, Hashizume T, et al. Reperfusion rates of pulmonary arteriovenous malformations after coil embolization: evaluation with time-resolved MR angiography or pulmonary angiography. J Vasc Interv Radiol JVIR. 2015;26(6):856.e851–864.e851.CrossRefGoogle Scholar
  14. 14.
    Makimoto S, Hiraki T, Gobara H, et al. Association between reperfusion and shrinkage percentage of the aneurysmal sac after embolization of pulmonary arteriovenous malformation: evaluation based on contrast-enhanced thin-section CT images. Jpn J Radiol. 2014;32(5):266–73.CrossRefPubMedGoogle Scholar
  15. 15.
    Saluja S, Henderson KJ, White RI Jr. Embolotherapy in the bronchial and pulmonary circulations. Radiol Clin N Am. 2000;38(2):425–48.CrossRefPubMedGoogle Scholar
  16. 16.
    Milic A, Chan RP, Cohen JH, Faughnan ME. Reperfusion of pulmonary arteriovenous malformations after embolotherapy. J Vasc Interv Radiol. 2005;16(12):1675–83.CrossRefPubMedGoogle Scholar
  17. 17.
    Lee DW, White RI Jr, Egglin TK, et al. Embolotherapy of large pulmonary arteriovenous malformations: long-term results. Ann Thorac Surg. 1997;64(4):930–9 (discussion 939-940).CrossRefPubMedGoogle Scholar
  18. 18.
    Woodward CS, Pyeritz RE, Chittams JL, Trerotola SO. Treated pulmonary arteriovenous malformations: patterns of persistence and associated retreatment success. Radiology. 2013;269(3):919–26.CrossRefPubMedGoogle Scholar
  19. 19.
    Faughnan ME, Lui YW, Wirth JA, et al. Diffuse pulmonary arteriovenous malformations: characteristics and prognosis. Chest. 2000;117(1):31–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Pierucci P, Murphy J, Henderson KJ, Chyun DA, White RI Jr. New definition and natural history of patients with diffuse pulmonary arteriovenous malformations: twenty-seven-year experience. Chest. 2008;133(3):653–61.CrossRefPubMedGoogle Scholar
  21. 21.
    Remy J, Remy-Jardin M, Giraud F, Wattinne L. Angioarchitecture of pulmonary arteriovenous malformations: clinical utility of three-dimensional helical CT. Radiology. 1994;191(3):657–64.CrossRefPubMedGoogle Scholar
  22. 22.
    Greben CR, Setton A, Putterman D, Caplin D, Lenner R, Gandras EJ. Pulmonary arteriovenous malformation embolization: how we do it. Tech Vasc Interv Radiol. 2013;16(1):39–44.CrossRefPubMedGoogle Scholar
  23. 23.
    Chamarthy MR, Park H, Sutphin P, et al. Pulmonary arteriovenous malformations: endovascular therapy. Cardiovasc Diagn Ther. 2018;8(3):338–49.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Trerotola SO, Pyeritz RE, Bernhardt BA. Outpatient single-session pulmonary arteriovenous malformation embolization. J Vasc Interv Radiol. 2009;20(10):1287–91.CrossRefPubMedGoogle Scholar
  25. 25.
    Letourneau-Guillon L, Faughnan ME, Soulez G, et al. Embolization of pulmonary arteriovenous malformations with amplatzer vascular plugs: safety and midterm effectiveness. J Vasc Interv Radiol. 2010;21(5):649–56.CrossRefPubMedGoogle Scholar
  26. 26.
    Shovlin CL, Guttmacher AE, Buscarini E, et al. Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Am J Med Genet. 2000;91(1):66–7.CrossRefPubMedGoogle Scholar
  27. 27.
    Filippiadis DK, Binkert C, Pellerin O, Hoffmann RT, Krajina A, Pereira PL. Cirse quality assurance document and standards for classification of complications: the cirse classification system. Cardiovasc Interv Radiol. 2017;40(8):1141–6.CrossRefGoogle Scholar
  28. 28.
    Nawaz A, Litt HI, Stavropoulos SW, et al. Digital subtraction pulmonary arteriography versus multidetector CT in the detection of pulmonary arteriovenous malformations. J Vasc Interv Radiol. 2008;19(11):1582–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Saboo SS, Chamarthy M, Bhalla S, et al. Pulmonary arteriovenous malformations: diagnosis. Cardiovasc Diagn Ther. 2018;8(3):325–37.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Kawai T, Shimohira M, Kan H, et al. Feasibility of time-resolved MR angiography for detecting recanalization of pulmonary arteriovenous malformations treated with embolization with platinum coils. J Vasc Interv Radiol JVIR. 2014;25(9):1339–47.CrossRefPubMedGoogle Scholar
  31. 31.
    Komiyama M, Ishiguro T, Umaba R, Suzuki T. Transcardiac retrograde transvenous embolization of proximally occluded pulmonary arteriovenous malformation. Cardiovasc Interv Radiol. 2014;37(3):791–4.CrossRefGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2019

Authors and Affiliations

  1. 1.Division of Interventional Radiology, Department of RadiologyDavid Geffen School of Medicine at UCLALos AngelesUSA

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