CONQUERING A GIANT HIGH-FLOW PULMONARY ARTERIOVENOUS MALFORMATION UNDER REAL-WORLD CONSTRAINTS USING COMBINED AMPLATZER VASCULAR PLUG I AND COIL EMBOLIZATION

Abstract

Background: Pulmonary arteriovenous malformations (PAVMs) are uncommon pulmonary vascular abnormalities characterized by direct arteriovenous communications, resulting in intrapulmonary right-to-left shunting. Although often asymptomatic until early adulthood, PAVMs may cause serious complications, including hypoxemia and neurological events such as cerebral abscess and ischemic stroke. Giant high-flow PAVMs pose additional therapeutic challenges due to their complex hemodynamics.

Objective: To demonstrate the feasibility and effectiveness of a combined vascular plug I and coil embolization strategy for treating a giant high-flow pulmonary arteriovenous malformation under real-world device availability and cost constraints.

Case Report: A 34-year-old male presented with severe headache, chronic exertional dyspnea, and difficulty gaining weight. Brain imaging revealed a cerebral abscess with associated chronic cerebral infarction. Contrast-enhanced thoracic CT demonstrated a giant high-flow PAVM in the apical segment of the right upper lobe supplied by a markedly dilated feeding artery, along with pneumonia in the same segment suspected to represent pulmonary tuberculosis. Although Amplatzer Vascular Plug II (AVP II) was initially recommended, embolization was performed using Amplatzer Vascular Plug I (AVP I) combined with adjunctive coils due to financial limitations, achieving complete occlusion.

Discussion: True PAVMs are inherently high-flow vascular malformations due to direct arteriovenous shunting and loss of pulmonary capillary filtration, explaining the neurological presentation. Concomitant pneumonia likely exacerbated hypoxemia through ventilation–perfusion mismatch. In giant high-flow lesions, combined plug-and-coil embolization provides effective flow control and durable occlusion, while normalization of pulmonary hemodynamics may contribute to improvement of coexisting pulmonary infection.

Conclusion: Giant high-flow PAVMs represent a complex endovascular challenge. In this case, combined AVP I and coil embolization resulted in favorable clinical and radiological outcomes, supporting individualized, multimodal endovascular strategies under real-world constraints.
Keyword: Pulmonary arteriovenous malformation, High-flow vascular malformation, Combined embolization, Amplatzer vascular plug, Coil embolization, Cerebral abscess.