Graded Transthoracic Contrast Echocardiography After Pulmonary Arteriovenous Malformation Embolization: Can Chest CT Be Avoided in Patients With a Low-Grade Shunt?
J Hessels, S Klompmaker, D A F van den Heuvel, S Boerman, J J Mager, M C Post
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Abstract
Background: 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.
Research question: Can TTCE predict the need for additional embolotherapy in the postembolization population as accurately as it does in the treatment-naive population?.
Study design and methods: 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 RLS grade. Additionally, the association between the RLS grade and indication for additional embolotherapy was investigated.
Results: 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.
Interpretation: This study shows chest CT scan might be forgone in patients with RLS grades 0 and 1 after PAVM embolization.
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