SESSION TYPE: Miscellaneous Global Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Pulmonary arterio-venous malformation (PAVM) is an anomalous communication between arteries and veins of a portion of the pulmonary vascular bed. The PAVM may manifest itself in later life if certain conditions are fulfilled.The usual presentation of PAVMs is with haemoptysis or cyanosis With the increased use of angiography, PAVMs are recognized more readily than before.
CASE PRESENTATION: A 40 years old gentleman, who was a known case of chronic glomerulonephritis for 5 years and end stage renal disease (ESRD) for 3 years presented with history of hemoptysis and breathlessness for one day. The chest X-ray showed complete collapse of the right lung. As he was de-saturating rapidly , he was intubated and ventilated. An urgent bronchoscopy was performed. The left main bronchus was cleared of blood clots, but the right main bronchus was occluded with soft clots that could not be cleared. A CT pulmonary angiography revealed an enhancing endobronchial lesion causing complete occlusion of right main bronchus. Bronchial artery angiography showed an AVM to be the cause of hemoptysis. Bronchial artery embolization stopped the life threatening bleeding. At this stage, pneumonectomy was considered as the only option to save the life of patient. There was swelling of right upper limb due an arterio-venous fistula (AVF) used for hemodialysis. A color doppler was performed which revealed gross dilatation of the vascular bed of this limb and hyperdynamic systemic circulation. A possible link between hyperdynamic AVF in the limb and opening up of pulmonary AVM was considered. The AVF in the upper limb was closed. There was a dramatic response with decrease in swelling of upper limb, no recurrence of bleeding from the bronchus and re-expansion of the right lung. The endobronchial occlusion regressed completely. An AVM surrounded by mucosa was masquerading as an endobronchial lesion occluding the right main bronchus leading to collapse of the right lung.
DISCUSSION: In this unusual case there was opening up of a latent PAVM that was predominatly submucosal in the right main bronchus caused by the peripheral AVF created for dialysing the patient. This AVF progressively created a hyperdynamic circulation in the systemic bed thet caused the pressure to be transmitted through the bronchial arteries thus opening up the PAVM and leading to lung collapse.
CONCLUSIONS: Arterio venous fistulae in the limb leading to opening of vascular communications between the pulmonary and bronchial circulation leading to collapse of the lung due to endobronchial mucosal protrusion is reported. To the best of our knowledge this is the first case of its kind described.
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2) Esplin MS,Varner MW,Progression of pulmonary arterio venous malformations during pregnancy,Obstet Gynae surv 1997;52:248-253 Esplin MS,Varner MW, Progression of pulmonary arteriovenous malfformations during pregnancy, Obstet Gynaecol Surv 1997;52:248-253
DISCLOSURE: The following authors have nothing to disclose: Deepak Rosha, Viny Kantroo
No Product/Research Disclosure InformationIndraprastha Apollo Hospitals, New Delhi, India