Criteria for PAVM Reintervention

Wednesday, April 2, 2025

10:39 AM – 10:48 AM CT

Location: Music City Center, 201 AB

Presenting Author(s)

Adam Fish, MD

Interventional Radiology Resident
Yale University School of Medicine, United States

Author/Co-author(s)

EK

Elizabeth Knight, MS

Medical student
Yale School of Medicine, United States
JP

Jeffrey Pollak, MD

Professor of Radiology and Biomedical Imaging
Yale University School of Medicine, United States
Todd Schlachter, MD

Professor of Radiology and Biomedical Imaging
Yale University, United States

Purpose: To propose criteria for retreating previously embolized PAVMs and determining the effectiveness of the criteria to prevent paradoxical embolization.

Materials and Methods: A retrospective review of patients with PAVMs treated at a single HHT center of excellence between January 1, 2013, and September 10, 2023, was performed. Patients with PAVM recurrence were either retreated or observed based on the following criteria for PAVM reintervention: 1. Embolic device(s) not creating a sufficiently dense matrix, such that a channel through them may be >/ 2mm; 2. Accessory feeding artery or pulmonary collateral >/ 2mm; 3. Hemoptysis in a patient with no other explanation.

Results: 438 PAVMs were treated in 151 patients including 106 patients with definite, 14 possible, and 31 doubtful HHT. Post-embolization PAVM recurrence occurred in 36 patients (36/151, 23.8%), including 15 patients (15/151, 9.9%) with 22 PAVMs (22/438, 5.0%) meeting criteria for reintervention. 21 patients (21/151, 13.9%) with recurrence did not meet reintervention criteria and were therefore observed. Pre-treatment paradoxical embolization occurred in 36 patients (36/151) for a lifetime prevalence rate of 23.7%. Post-treatment paradoxical embolization did not occur in any patients following PAVM embolization (0/151). There was one case of iatrogenic paradoxical embolization in a patient being treated for systemic collateral reperfusion and hemoptysis. However, this was not included given that it was not a spontaneous event.

Conclusion: Utilizing modern embolization techniques and devices, the proposed reintervention criteria, and screening intervals, paradoxical embolizations can be effectively prevented in patients with PAVMs.