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J Thorac Cardiovasc Surg 1996;112:1395-1397
© 1996 Mosby, Inc.
BRIEF COMMUNICATIONS |
Osaka, Japan
From the First Department of Sugery, Osaka University Medical School, Suita, Osaka, Japan.
Received for publication April, 8, 1996 Accepted for publication April 17, 1996.
Recent advances in therapeutic embolization have made nonsurgical treatment of pulmonary arteriovenous malformation preferred over conventional surgical excision.
1,2 In embolization therapy there is a possibility of incomplete treatment and a risk of accidental systemic embolization, 3 however, so surgical excision is considered appropriate for at least some patients. In such cases, conservative operation, such as wedge resection and local excision, is desirable if possible. In this report, video-assisted thoracoscopic surgical technique, which has recently been applied to a variety of thoracic lesions, was adopted as a less invasive modality to excise a pulmonary arteriovenous fistula (PAVF).
A 35-year-old man was referred for a nodule in the right middle field that was found on a chest roentgenogram. He had no symptoms but had a continuous murmur on the right side of the anterior chest. A computed tomogram showed a 2 cm PAVF just beneath the visceral pleura in subsegment 3b of the right upper lobe, which was fed from the dilated A. lobi sup. vent. medialis and drained to V. ventralis superior. There were no other lesions. Pulmonary arteriography revealed a noncavernous, well-demarcated PAVF with single feeder and drainage vessels (Fig. 1).
Blood hemoglobin content was 16.4 gm/dl. Arterial blood gas analysis showed an arterial oxygen tension of 84 mm Hg, an arterial carbon dioxide tension of 38 mm Hg, and an arterial oxygen saturation of 95%. Shunt fraction was estimated at 19%.
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A dark blue 2 to 3 cm pulsatile lesion that protruded from the lung was easily visible on the anterolateral surface of the right upper lobe. Intraoperative intrathoracic ultrasonography showed a clearly smooth-surfaced cystic lesion connected to a pair of distinct echogeneic tubular architectures, which were judged to be the feeder and drainage vessels (Fig. 2).
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The postoperative course was uncomplicated, and the chest drain was extubated on the second postoperative day. The patient was able to leave the hospital on the fourth postoperative day. Three months after the operation, a pulmonary arteriogram showed no residual PAVF in the area operated on. A small, previously unidentified PAVF was found in the left lower lobe, however, and the patient is now being closely followed up.
It is usually not difficult to locate a PAVF through an open thoracotomy, if it is close below the visceral pleura, by finding a protrusion from the pleural surface and palpating a thrill. In the thoracoscopic approach, however, digital examination is not always easy to apply. In this case, ultrasonographic guidance proved useful not only in detection of the lesion but in evaluation of its size, shape, and above all relationship with vessels for appropriate positioning of the clamp. In fact, it was possible to occlude blood flow of the PAVF exactly, expose the fistula safely, and ligate both the artery and vein independently. The merit of intraoperative intrathoracic ultrasonography, which has been reported for localization of lung tumors, 4 may be greater for vascular lesions. Color Doppler ultrasonography would be more informative, although we could not use it.
Although in this case we did not use an endosurgical stapler for fear of sudden massive bleeding in case of incomplete stapling or tear of the pleura along the staple line, the lesion may have been resectable by stapling. Also, permanent occlusion of the blood flow of a PAVF by an endosurgical stapler without a knife may be possible if the lesion is small enough. Three ports and utility thoracotomy taken together are not much smaller than a conventional axillary thoracotomy, but we considered it important to avoid rib spreading. Furthermore, with more experience, we could use an endosurgical clamp to occlude the pulmonary blood flow without utility thoracotomy. In our case, at least, all the goals of the conventional approach of surgical excision of PAVF by thoracotomy were accomplished with the video-assisted thoracoscopic surgical approach. Because PAVFs are usually close to the visceral pleura, 5 video-assisted thoracoscopic surgical intervention may become the treatment of choice.
Footnotes
J THORAC CARDIOVASC SURG 1996;112:1395-7 
References
This article has been cited by other articles:
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  J. Nakajima, S. Takamoto, E. Takeuchi, T. Fukami, and A. Sano Thoracoscopic Surgery for Pulmonary Arteriovenous Malformation Asian Cardiovascular and Thoracic Annals, October 1, 2006; 14(5): 412 - 415. [Abstract] [Full Text] [PDF]
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 I Khurshid and G H Downie Pulmonary arteriovenous malformation Postgrad. Med. J., April 1, 2002; 78(918): 191 - 197. [Abstract] [Full Text] [PDF]
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