Atraumatic Pulmonary Valve Crossing to Enable Successful Embolization of Multiple Pulmonary Arteriovenous Malformations after Failed Attempts

Abstract

Pulmonary arteriovenous malformations (PAVMs) are an important cause of right-to-left shunting and paradoxical embolic events, particularly in patients with hereditary hemorrhagic telangiectasia (HHT). Endovascular embolization is the treatment of choice, but prior unsuccessful attempts may complicate subsequent management. We report a 48-year-old woman with genetically confirmed HHT and progressive hypoxemia, in whom two earlier embolization procedures were aborted due to ventricular ectopy and transient tachyarrhythmia. Under general anesthesia, atraumatic pulmonary valve crossing was achieved using a 4 Fr angled pigtail catheter, enabling successful embolization of five PAVMs in a single session with microvascular plugs and detachable coils. No arrhythmias occurred, and oxygen saturation improved from 92% to 98%. This case highlights the value of tailored procedural planning—including catheter selection and anesthesia—in preventing arrhythmia-related complications and achieving complete treatment in technically challenging or previously failed PAVM interventions.