Percutaneous Closure of Pulmonary Arteriovenous Malformation and Concomitant Patent Foramen Ovale for Cryptogenic Stroke

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J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00268. Epub November 4, 2024.

A 64-year-old woman presented with acute onset left-sided facial droop, left upper extremity paresis, and aphasia. Magnetic resonance imaging demonstrated acute infarction of the right thalamus. A chest x-ray revealed a 1.7-cm nodular opacity at the right lung base (Figure A). A contrast-enhanced computed tomography (CT) revealed a right lower lobe (RLL) pulmonary arteriovenous malformation (AVM) (Figure B), and a transthoracic echocardiogram (TTE) with agitated saline showed bubbles in the left atrium.

The patient underwent pulmonary angiography, which demonstrated a simple AVM arising from a branch of the RLL pulmonary artery (Figure C), with subsequent embolization. Via a 10-French (Fr) femoral venous sheath, the pulmonary arterial system was catheterized using a 7-Fr guide catheter and 4-Fr Glidecath (Terumo). A 12-mm Amplatzer AVP II plug (Abbott) was inserted for embolization (Figure D). Repeat TTE continued to show bubbles in the left atrium. A transesophageal echocardiogram revealed a patent foramen ovale (PFO) with atrial septal aneurysm (Figure E). The patient was referred for concomitant PFO closure. A 6-Fr multipurpose guide catheter was advanced across the PFO into the pulmonary vein. An 8-Fr Amplatzer Intravascular Delivery system was subsequently advanced across the inter-atrial septum over a stiff wire, and a 30-mm Amplatzer PFO Occluder (Abbott) was deployed and released (Figure F) utilizing intracardiac echocardiography guidance. Repeat TTE (Figure G) and CT demonstrated the absence of bubbles in the left atrium and complete occlusion of the pulmonary AVM, respectively.

This case illustrates that pulmonary AVM can often co-exist with PFO in patients with cryptogenic stroke. Consideration for closure may need to be considered, especially if the culprit of the stroke event is unclear.

Affiliations and Disclosures

Manasa Dondapati, MD¹; Chad Gier, MD¹; Daniel Ohngemach, MD²; Smadar Kort, MD¹; On Chen, MD¹; Puja B. Parikh, MD¹

From the Departments of ¹Medicine and ²Radiology, Stony Brook University Hospital, Stony Brook, New York.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement: The authors confirm that informed consent was obtained from the patient for the interventions described in the manuscript and to the publication of their data.

Address for correspondence: Puja B. Parikh, MD, MPH, FACC, FAHA, FSCAI, Stony Brook University Medical Center, Health Sciences Center T16-080, Stony Brook, NY 11794-8160, USA. Email: puja.parikh@stonybrookmedicine.edu