Thoracoscopic Right Middle Lobectomy for a Centrally Located Pulmonary AV Fistula M. R. Reidy, D. Kwazneski, R. J. Landreneau, O. Awais

Background  Pulmonary AV fistulas are an abnormal connection between the pulmonary arteries and veins  This connection allows shunting of unoxygenated blood and possible right to left embolization.  These lesions are typically managed by angiographic coil embolization. As the lesions become larger or more central, embolization therapy become limited as coils can enter the heart  Our patient underwent a successful thoracoscopic right middle lobectomy with resulting decreased shunt, and no longer required oxygen utilization

History  A 76 year old female seen in clinic presented with a history of new onset dyspnea requiring 2 L home oxygen and recent recurrent Transient Ischemic Attacks and migraines.  Her oxygen saturation without supplemental O2 was in the low 80’s. She was known to have a pulmonary arteriovenous fistula seen radiographically as early as 1995, but only recently had she become symptomatic  Labarotory workup was significant for a PaO2 of 70 on room air, and a calculated shunt fraction of 19.9%.

CT  Chest computed tomography (CT) with contrast enhancement showed a large fistulous connection involving the right middle pulmonary arteries and vein measuring 4.5 X 3.8 X 2.6 cm.

Operative Findings A right middle lobectomy was safely performed with the fistula being completely excised Upon entering the chest the fistula was easily identifiable along the oblique fissure

Conclusions  In this case, the fistula was both large and central, this precluded coil embolization  Complications of embolization include coil or balloon migration as well as recannalization of the tract  Open surgical treatments as well as video assisted thoracoscopic methods are available and effective  Limitations to a less invasive closure of the AVM by coils include a centrally located, large malformation where coil migration to the left atrium is possible  In these cases a lobectomy is still the preferred treatment option