Thoracoscopic Right Middle Lobectomy for a Centrally Located

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 O 2 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 Pa. O 2 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 Upon entering the chest the fistula was easily identifiable along the oblique fissure A right middle lobectomy was safely performed with the fistula being completely excised

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