PMC3253396_01
50-year-old man with giant, complex-type pulmonary arteriovenous malformation in right thorax.. A. Multiplanar reformatted coronal CT image showing high-flow type giant pulmonary arteriovenous malformation with two feeding arteries. One measured 10.5 mm in maximum diameter (arrow) and originated from lateral basal segment branch of right pulmonary artery (A9), while other measured 9.5 mm and originated from posterior basal segment branch (A10). Note giant nidus (asterisk), which measured 6 cm in maximum diameter in right cardiophrenic angle. B. Right pulmonary arteriogram shows entire structure of giant pulmonary arteriovenous malformation. One feeding artery originated from lateral basal segment branch of right pulmonary artery (A9) (arrow) and another from posterior basal segment branch (A10) (arrowhead). C. Fluoroscopic image of inflated balloon (arrow), second microcatheter (arrowhead) advanced beyond balloon, and multiple platinum microcoils (open arrow) to embolize feeding artery from lateral basal segment branch of right pulmonary artery (A9). D-G. Schemes showing microcoil embolization procedure. First anchored detachable coil (arrow in D) was placed under flow control achieved using balloon (arrowhead in D) without detaching it from delivery wire; multiple microcoils were packed proximally adjacent to first anchored detachable coil using other types of multi-purpose and coaxial catheters (curved arrow in E) by passing balloon. Balloon was then carefully deflated, confirming that no coil migration occurred (F), and finally first anchored detachable coil was detached from delivery wire (G). H. Right pulmonary arteriogram obtained after coil embolization. Note multiple platinum microcoils (arrows) in A9 and A10 feeders. Feeding arteries, nidus, and drainage vein are not visualized. At one year postoperatively, diameter of nidus was reduced to 15 mm.
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A9 and A10 feeding arteries to be 10.5 and 9.2 mm, respectively (Fig. 1A). A thick drainage vein, with a maximum diameter measuring 18 mm, was found to originate from the lateral portion of the nidus, run posteriorly and superiorly, and to drain into the left atrium. To ensure tight impaction of embolization coils in the A9 feeder, we placed a total of 6 platinum microcoils (0.018 inch, 4- to 8-mm diameter, 14-cm length) (Nester; Cook Medical Inc., Bloomington, IN) via the second microcatheter (Fig. 1C). Right pulmonary arteriography after embolization did not visualize the feeding arteries, nidus, or the drainage vein (Fig. 1H).