Percutaneous Interventional Closure of Large Pulmonary Arteriovenous Fistulas With the Amplatzer Duct Occluder Jacek Bialkowski, MD a, *, Carlos Zabal, MD c , Malgorzata Szkutnik, MD a , Jose Antonio Garcia Montes, MD c , Jacek Kusa, MD a , and Marian Zembala, MD b Large pulmonary arteriovenous fistulas (PAVFs) are difficult for transcatheter treatment. This report presents 5 patients aged 3 to 73 years with large PAVFs who underwent successful transcatheter closure with the Amplatzer duct occluder (ADO), designed for the occlusion of patent duct arteriosus. The procedures were performed without compli- cations and provided sustained improvement in arterial oxygen saturation and exercise tolerance on follow-up examination in all patients. The transcatheter closure of large PAVFs with the ADO is effective and can eliminate the need for surgical intervention. The newly designed Amplatzer vascular plug is undergoing clinical trials. © 2005 Elsevier Inc. All rights reserved. (Am J Cardiol 2005;96:127–129) Pulmonary arteriovenous fistulas (PAVFs) are a direct con- nection between arterial and venous circulation, with the exclusion of the capillary bed. These infrequent vascular anomalies are single or multiple. More than 500 cases have been described. 1 About half were congenital Rendu-Osler- Weber disease or hereditary generalized angiomatosis. Ac- quired fistulas are even less frequent, occurring after injuries and pulmonary operations, chronic inflammatory lung dis- ease, or metastases. Significant PAVFs cause clinical symp- toms and signs, such as easy fatigability, dyspnea on effort, cyanosis, stroke, and brain abscess. 2 Occasionally, a con- tinuous extracardiac murmur can be heard over the chest. Radiography of the lung reveals shadows of various forms, frequently cylindrical, pulsating on radioscopy, which fa- cilitates the correct diagnosis. 3 Angiography confirms the diagnosis. Computed tomography and magnetic resonance examinations are also of great diagnostic value. 4,5 The aim of treatment is the elimination of the right-to-left shunt. Surgical resection was the standard procedure before the introduction of interventional catheterization. 3,6 This tech- nique has been applied to small or medium-sized PAVFs only. It is the purpose of this communication to describe the closure of very large PAVFs with Amplatzer (AGA Medical Corporation, Golden Valley, Minnesota) devices. ••• Five patients with large PAVFs underwent device implan- tation (Table 1). All had easy fatigability and central cya- nosis, and 4 patients’ chest x-rays revealed masslike densi- ties in the lung (patients 1, 3, 4, and 5). In 3 patients, a continuous extracardiac murmur was heard (patients 1, 2, and 5). In all but 1 patient, PAVFs were congenital. In one 73-year-old patient with cyanosis, radiologic changes, and a murmur over the thorax, the PAVF was likely caused by a car accident 5 years earlier. The PAVF in this case was certainly post-traumatic. Pulmonary angiography revealed in all cases large PAVFs with a mean diameter of 10 mm (range 7.2 to 14). All congenital PAVFs were located in the basal part of the right lung (Figure 1). In the case of acquired PAVFs, the PAVFs were located at the left lower lobe pulmonary artery (Figure 2). In all cases, the interventional closure of PAVFs with the Amplatzer duct occluder (ADO) was performed. The details of this technique have been previously published. 7 This occluder is widely used to close large arterial ducts in our departments. In all cases, after the puncture of the femoral vein and catheterization of the afferent vessel, a long deliv- ery sheath (8Fr, angled 180°; AGA Medical Corporation) was introduced. In 1 tall patient (height 186 cm), the sheath proved too short (80 cm in length) and did not reach the fistula. The procedure was repeated through the right jugular vein. The mean follow-up period of our patients was 2 years (range 0.5 to 3.2). Nine ADOs with dimensions ranging from 8.6 to 16.14 mm were implanted (in 2 patients; 3 ADOs were used to close different feeders, see Figure 1). There were no com- Departments of a Congenital Heart Diseases and Pediatric Cardiology and b Transplantology and Cardiac Surgery, Silesian Center for Heart Dis- ease, Zabrze, Poland; and c Instituto Nacional de Cardiologia “Ignacio Chavez,” Mexico City, Mexico. Manuscript received November 29, 2004; revised manuscript received and accepted March 1, 2005. * Corresponding author: Tel.: 48-32-2713401; fax: 48-32-2713401. E-mail address: jabi_med@poczta.onet.pl (J. Bialkowski). Table Clinical data regarding patients with large PAVFs Patient Age (yr)/ Sex Saturation PAVF Device No. Before After Lung Diameter (mm) 1 3F 85% 98% Right 14 1 2 8M 88% 92% Right 8–9* 3 3 12 F 85% 95% Right 7–8* 3 4 23 M 85% 96% Right 8.5 1 5 73 M 80% 96% Left 10 1 * Presence of different afferent vessels. 0002-9149/05/$ – see front matter © 2005 Elsevier Inc. All rights reserved. www.AJConline.org doi:10.1016/j.amjcard.2005.03.033