0
Original Research: PULMONARY ARTERIOVENOUS MALFORMATION |

Embolization for Pulmonary Arteriovenous Malformation in Hereditary Hemorrhagic Telangiectasia: A Decision Analysis

Samir Gupta, MD, MSc; Marie E. Faughnan, MD, MSc; Ahmed M. Bayoumi, MD, MSc
Author and Funding Information

Affiliations: From the Departments of Medicine (Drs. Gupta, Faughnan, and Bayoumi), and Health Policy, Management, and Evaluation (Dr. Bayoumi), University of Toronto, Toronto, ON, Canada; and the Division of Respirology (Drs. Gupta and Faughnan), Department of Medicine, the Centre for Research on Inner City Health, Keenan Research Centre (Dr. Bayoumi), Li Ka Shing Knowledge Institute (Drs. Gupta, Faughnan, and Bayoumi), and the Division of General Internal Medicine (Dr. Bayoumi), St. Michael's Hospital, Toronto, ON, Canada.

Correspondence to: Samir Gupta, MD, MSc, 30 Bond St, Suite 6045, Bond Wing, Toronto, ON, Canada, M5B 1W8; e-mail guptas@smh.toronto.on.ca


This research was supported by the Li Ka Shing Knowledge Institute of St. Michael's Hospital and the St. Michael's Hospital Research Institute (Dr. Gupta). During this research, Dr. Gupta was also supported by the Canadian Lung Association and the University of Toronto Clinician Scientist Program. Dr. Faughnan is supported by the Nelson Arthur Hyland Foundation and the Li Ka Shing Knowledge Institute of St. Michael's Hospital. Dr. Bayoumi is supported by Canadian Institutes of Health Research/Ministry of Health and Long Term Care Applied Chair in Health Services Research. The Centre for Research on Inner City Health is supported in part by a grant from the Ontario Ministry of Health and Long-Term Care.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(3):849-858. doi:10.1378/chest.09-0334
Text Size: A A A
Published online

Background:  Although experts recommend presymptomatic coil embolotherapy for patients with hereditary hemorrhagic telangiectasia (HHT) who have pulmonary arteriovenous malformations (PAVMs), this approach has not been studied prospectively and is not applied universally. We used decision analysis to evaluate the optimal treatment strategy for HHT patients with asymptomatic PAVMs.

Methods:  We developed a Markov model to evaluate the following three strategies: no embolotherapy; embolotherapy only in the event of a PAVM complication; and immediate embolotherapy. Our model incorporated PAVM complications, embolotherapy effectiveness and complications, and the possibility of PAVM growth or reperfusion of successfully embolized PAVMs. The base case was a 40-year-old man with HHT and an asymptomatic PAVM with a 3-mm feeding artery. We modeled the natural history of HHT and the clinical course of embolotherapy based on review of the medical literature. We incorporated quality-of-life weights derived from the direct assessment of patient preferences (n = 45) and a literature review.

Results:  No embolotherapy, embolotherapy only in the event of a PAVM complication, and immediate embolotherapy were associated with expected survival times of 37.2, 37.6, and 39.0 years, respectively. After adjusting for quality of life, the corresponding estimates were 32.6, 34.1, and 37.2 quality-adjusted life-years. The outcome of the model was robust to changing model parameters within plausible ranges.

Conclusions:  Patients with HHT and a PAVM with a feeding artery of ≥ 3 mm have improved life expectancy and quality-adjusted survival with immediate embolotherapy. Embolotherapy should be the standard of care in such circumstances.

Figures in this Article

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Figures

Tables

References

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543