Hessels Josefien, Klompmaker Sjors, van den Heuvel Daniel A F, Boerman Sanne, Mager Hans-Jurgen, Post Marco C
Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands.
Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands.
Chest. 2025 Mar;167(3):842-850. doi: 10.1016/j.chest.2024.09.029. Epub 2024 Oct 9.
Pulmonary arteriovenous malformations (PAVMs) are direct connections between the pulmonary artery and vein, creating a right-to-left shunt (RLS). Embolization is indicated to prevent complications. Guidelines recommend follow-up chest CT scans to confirm persistent occlusion and embolization of all treatable PAVMs. Graded transthoracic contrast echocardiography (TTCE) after PAVM embolization may offer a reliable alternative in a subgroup of patients while preventing radiation exposure.
Can TTCE predict the need for additional embolotherapy in the postembolization population as accurately as it does in the treatment-naive population?
Since 2018, follow-up after PAVM embolization at our study institution includes both TTCE and chest CT scan after 6 to 12 months and every 3 to 5 years thereafter. Patients who underwent at least 1 follow-up TTCE and chest CT scan were included. The indication for additional embolotherapy was discussed in a multidisciplinary team meeting. The primary outcome was the indication for additional embolotherapy in each right-to-left shunt (RLS) grade. Additionally, the association between the RLS grade and indication for additional embolotherapy was investigated.
A total of 339 patients with 412 embolization procedures were included; median time to follow-up TTCE was 7.5 months. An RLS was present in 399 postembolization TTCEs (97%): RLS grade 1 in 93 patients (23%), grade 2 in 149 patients (36%) and grade 3 in 157 patients (38%). In patients with RLS grades 0 and 1, no treatable PAVMs were found on CT scan. In patients with RLS grades 2 and 3, 22 (15%) and 72 (46%) underwent additional embolization.
This study shows chest CT scan might be withheld in patients with RLS grades 0 and 1 after PAVM embolization.
肺动静脉畸形（PAVM）是肺动脉与肺静脉之间的直接连接，形成右向左分流（RLS）。栓塞治疗可预防并发症。指南建议进行胸部CT随访扫描，以确认所有可治疗的PAVM持续闭塞及栓塞情况。PAVM栓塞术后的分级经胸对比超声心动图（TTCE）可能为部分患者提供可靠的替代方法，同时避免辐射暴露。
TTCE对栓塞术后患者预测再次栓塞治疗需求的准确性是否与对初治患者一样？
自2018年起，我们研究机构对PAVM栓塞术后的随访包括6至12个月后的TTCE和胸部CT扫描，此后每3至5年进行一次。纳入至少接受过1次随访TTCE和胸部CT扫描的患者。在多学科团队会议上讨论再次栓塞治疗的指征。主要结局是每个右向左分流（RLS）分级中再次栓塞治疗的指征。此外，研究RLS分级与再次栓塞治疗指征之间的关联。
共纳入339例患者，进行了412次栓塞手术；随访TTCE的中位时间为7.5个月。399次栓塞术后TTCE检查发现存在RLS（97%）：93例患者（23%）为RLS 1级，149例患者（36%）为2级，157例患者（38%）为3级。RLS 0级和1级的患者在CT扫描中未发现可治疗的PAVM。RLS 2级和3级的患者中，分别有22例（15%）和72例（46%）接受了再次栓塞治疗。
本研究表明，PAVM栓塞术后RLS 0级和1级的患者可能无需进行胸部CT扫描。
