Hemoptysis due to Pulmonary Arteriovenous Malformation after Coil Embolization during Long-Term Follow-Up

Case Reports in Radiology
08 Nov, 2019 ,

A 28-year-old man with a history of coil embolization of multiple pulmonary arteriovenous malformations presented with hemoptysis 11 years after initial embolization. A cavity lesion in the left upper lobe, which was accompanied by deformed coils and ground-glass opacity, was considered responsible for hemoptysis. Embolization of the bronchial artery was performed.

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A 28-year-old man presented with hemoptysis. Eleven years earlier, he was diagnosed with HHT because he had multiple PAVMs, epistaxis, and positive family history. The genetic test for HHT was not performed, because it was not covered with medical insurance in our country. He underwent coil embolization of multiple PAVMs. During the follow-up, chest radiograph images showed that the coils in the left upper lobe became deformed.

To evaluate the reason for hemoptysis, he underwent chest CT. We observed a cavity lesion at the left upper lobe, which also showed deformed coils and ground-glass opacity around the cavity lesion. In a previous CT, which was performed 10 years earlier, the cavity lesion and ground-glass opacity were not observed. We suspected that the ground-glass opacity represented the cause of the bleeding.

Thereafter, angiography of both the left bronchial artery and pulmonary artery was performed to confirm which vessel was responsible for the symptoms. An 8-Fr. sheath was introduced into the right femoral vein, and a 4-Fr. sheath was placed at the right femoral artery. An 8-Fr. catheter (Optimo; Tokai Medical Products, Kasugai, Japan) was introduced into the pulmonary artery. Pulmonary angiography showed no extravasation or hypervascular inflammatory parenchymal lesions around the coils of the cavity lesion. Then, a 4-Fr. catheter (Broncho; Medikit, Tokyo, Japan) was placed into the left bronchial artery. Angiography showed hypervascular inflammatory parenchymal lesions around the coils of the cavity lesion. We concluded that the left bronchial artery was the vessel responsible for the hemoptysis.

A microcatheter (Sniper 2 high-flow; Terumo, Tokyo, Japan) was advanced to the target branch of the left bronchial artery and embolization was performed using gelatin sponge. The reason for choosing gelatin sponge was as follows. We thought coils could only make proximal embolization, which might more readily allow recurrence of hemoptysis due to the development of other systemic arteries.

In addition, polyvinyl alcohol and microspheres were not covered with medical insurance for hemoptysis in our country. Subsequent angiography of the left bronchial artery showed a complete occlusion of the target branch. After the procedure, hemoptysis markedly decreased, but a small amount of hemosputa remained. To complete the treatment, lobectomy of the left upper lobe was performed. Thereafter, hemoptysis disappeared during the two years of follow-up.