Asian Cardiovasc Thorac Ann 2006;14:412-415
© 2006 Asia Publishing EXchange Ltd
Thoracoscopic Surgery for Pulmonary Arteriovenous Malformation
Jun Nakajima, MD,
Shinichi Takamoto, MD,
Eriho Takeuchi, MD,
Takeshi Fukami, MD,
Atsushi Sano, MD
Department of Cardiothoracic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
For reprint information contact: Jun Nakajima, MD Tel: 81 33 815 5411 Ext. 33321 Fax: 81 35 684 3989 Email: nakajima-tho{at}h.u-tokyo.ac.jp, Department of Cardiothoracic Surgery, Faculty of Medicine, The University of Tokyo 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
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ABSTRACT
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We report 6 consecutive cases of pulmonary arteriovenous malformation in the periphery of the lung, which were treated successfully by thoracoscopy. Pulmonary wedge resection was performed with a linear cutting stapler to divide the feeding artery, drainage vein, and aneurysmal lesion of the arteriovenous malformation. Operative time ranged from 30 to 95 min (mean, 50 min). Bleeding was minimal in all cases. No major surgery-related complications were observed. Postoperative hospital stay was limited to one week except for one patient who had experienced a brain infarction preoperatively, caused by migration of an embolization coil. Histological examination confirmed that the arteriovenous malformation foci were completely removed. Pulmonary wedge resection through thoracoscopy is feasible as an alternative treatment for arteriovenous malformation located in the periphery of the lung parenchyma when pulmonary embolization therapy is difficult or unsuccessful.
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INTRODUCTION
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Pulmonary arteriovenous malformation (PAVM) is a relatively rare disease. Patients may experience rupture of the aneurysmal section or systemic thromboembolism. Coil embolization has recently been used to treat PAVM, but it has several serious complications including inadequate obliteration of the lesion and migration of the coil, resulting in systemic thromboembolism. We describe the techniques and results of thoracoscopic surgery for PAVM.
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PATIENTS AND METHODS
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Six cases of PAVM have been treated by thoracoscopic surgery in our institute since 1998. The indications for surgical resection in these patients were: solitary or multiple PAVM nodules located in the periphery of the lung, which were not obliterated by coil embolization; and reasonably good general physical condition for pulmonary resection. The thoracoscopic surgery procedure has been described elsewhere.1 Briefly, under general anesthesia and separated ventilation with a double-lumen tube, the patient was placed in the recumbent position. Three small skin incisions, approximately 1 cm, 1 cm, and 2 cm long were made for the access ports. The PAVM focus was identified by observing the surface of the visceral pleura. The PAVM focus was easily identified as a black spot or protrusion of the visceral pleura (Figure 1
). The lesion was captured with ring-shaped forceps to clamp the feeding artery and draining vein, to avoid the migration of any clot in the PAVM. Video-assisted pulmonary wedge resection with a linear cutting stapler with a staple leg of 2.0 mm was performed around the forceps to occlude the afferent and efferent vessels. After resection, the PAVM was completely removed. The feeding artery and draining vein were divided at the stapling line. Thin staples were used to obliterate these vessels completely (Figure 2). The specimen was removed through the trocar access port, and a chest tube drain was inserted.
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Figure 1. Computed tomographic findings (left) and thoracoscopic findings (right) of a pulmonary arteriovenous malformation in patient #6. The malformation in the periphery of the right middle lobe of the lung was easily identified by thoracoscopy as a dark protruding subpleural mass.
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Figure 2. Thoracoscopic procedure for treatment of a pulmonary arteriovenous malformation in patient #3. A malformation located in the periphery of the right lower lobe of the lung was easily identified by thoracoscopy (A). The malformation was captured with ring-shaped forceps (B). Pulmonary wedge resection with a linear cutting stapler was performed to remove the malformation (C). The resected specimen included the arteriovenous lesion (D).
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RESULTS
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Pulmonary wedge resections through thoracoscopy were performed successfully in all 6 patients (Table 1). None of them had hereditary or systemic arteriovenous malformations. Four patients had evidence of cerebral infarction on preoperative brain computed tomography or magnetic resonance imaging. One had an episode of left hemiparesis because of brain infarction due to migration of an embolization coil during catheter treatment for PAVM. Five patients had one PAVM focus each, while one had 2 foci. The PAVM was located in the periphery of the lung in all cases. The diameters of the PAVM were rather small, ranging from 10 to 28 mm. Mean operative time was 50 min (range, 30–95 min). No more than 20 mL of blood loss was observed during surgery. No major postsurgical complications were detected. Postoperative hospital stay was limited to one week, except for patient #1 who had a brain infarction preoperatively. Pathological examination of the resected specimens confirmed that the arteriovenous malformation foci were completely removed.
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DISCUSSION
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Patients with untreated PAVM are expected to suffer considerable morbidity and mortality. Neurological complications have been observed in more than 10% of such patients.2–4 Furthermore, when patients are followed over time, approximately 25% of these malformations gradually enlarge, usually at a rate of 0.3 to 2 mm per year.5 Most deaths from PAVM result from stroke, cerebral abscess, hemoptysis, or hemothorax.2–6
Indications for treatment of PAVM include aneurysmal enlargement, symptomatic hypoxemia due to right-to-left shunting, and systemic embolization.7 All patients with PAVM are advised to undergo treatment to decrease the risk of future neurological complications.8 Since its first description in 1978, embolization therapy for PAVM has been used in several series.9 The largest of these involved the successful occlusion of 276 lesions in 76 patients, with a success rate of 100%.10 The success rate was over 98% in cumulative series, with no procedure-related mortality.11 Serious procedural complications have been infrequent and typically self-limiting: transient air embolization in 5% of patients; radiographic pulmonary infarction in 3%; distal migration of the detachable balloon in 1%; and stroke in < 1%. In our series, one patient experienced brain infarction because of migration of an embolization coil.
Conventional thoracotomy using vascular ligation, pulmonary wedge excision, and lobectomy was the first modality for treatment of PAVM. In general, surgical morbidity and mortality for this disease have been similar to those found in other thoracic operations, including a prolonged hospital stay and its associated cost. Thoracoscopic surgery is a less invasive surgical method that results in less postoperative pain, less respiratory dysfunction, and a shorter hospital stay. There have been several case reports of PAVM successfully treated by thoracoscopy.12–15 This series supports the use of thoracoscopy accompanied by pulmonary wedge resection with a linear cutting stapler as an alternative treatment for PAVM located in the periphery of the lung parenchyma. Thoracoscopy should be considered when pulmonary embolization therapy is difficult or unsuccessful in patients with PAVM.
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REFERENCES
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ABSTRACT
INTRODUCTION
