Abstract Case Presentation A 64-year-old woman with Cowden syndrome (PTEN mutation), severe restrictive lung disease (FEV1 41%, FVC 38%), and chronic hypoxemic respiratory failure requiring 2L home oxygen presented following mechanical fall with left femoral neck fracture requiring urgent surgical fixation. Trauma imaging incidentally revealed three pulmonary arteriovenous malformations (PAVMs): two previously unknown upper lobe lesions with 4-5 mm feeding vessels and one stable lower lobe malformation. Transthoracic echocardiography with agitated saline confirmed significant right-to-left shunt.This created competing clinical imperatives: orthopedic literature emphasizes that delayed hip fracture repair beyond 48 hours increases mortality from thromboembolism and immobility complications, while cardiovascular literature documents stroke risk from paradoxical air embolism during general anesthesia in patients with persistent right-to-left shunts. Management and Outcome A multidisciplinary team comprising pulmonology, interventional radiology, orthopedics, anesthesiology, and critical care medicine performed coordinated risk stratification. Consensus determined that femoral neck fracture posed higher immediate mortality risk than proceeding with staged interventions under intensive monitoring.On hospital day 4, interventional radiology performed transcatheter embolization of four PAVM feeding vessels using microvascular plugs. Post-embolization echocardiography demonstrated reduced but persistent shunt. Following shared decision-making incorporating patient preferences and clinical urgency, orthopedic surgery was scheduled for hospital day 5.Perioperative management included rigorous intravenous line de-airing protocols with in-line filters, total intravenous anesthesia (propofol/remifentanil) avoiding volatile agents, continuous pulse oximetry maintaining SpO2 92%, invasive arterial monitoring, and post-operative ICU admission with continuous telemetry. The patient underwent uncomplicated left hip open reduction internal fixation (98 minutes) with stable hemodynamics and no desaturation or neurologic events. She was extubated in the operating room and transferred to ICU for 24-hour monitoring. Post-operative course was unremarkable with mobilization on post-operative day 1. She discharged on post-operative day 4 to acute Rehab. Discussion This case demonstrates the need for multidisciplainry approach when the surgical delay poses greater mortality risk than proceeding with intensive perioperative monitoring. While traditional practice delays elective surgery weeks to months post-embolization to allow shunt reduction, femoral neck fractures represent surgical emergencies where delayed fixation increases mortality. Our patient tolerated surgery without complications despite persistent post-embolization shunt using rigorous air-embolism precautions, suggesting that intensive monitoring protocols may sufficiently mitigate paradoxical embolism risk when clinical circumstances demand urgent intervention. The structured coordination framework employed—immediate team activation, explicit risk quantification, shared decision-making, and specialty-specific protocols—creates a reproducible model for managing patients requiring sequential high-risk interventions where evidence is absent. This abstract is funded by: none
Patel et al. (Fri,) studied this question.