Abstract Introduction Spontaneous pulmonary arteriovenous malformation (PAVM), particularly in patients without hereditary hemorrhagic telangiectasia (HHT), is a rare etiology of severe hypoxic respiratory failure.1 Treatment includes embolization, surgical excision, or lung transplantation; however, management is often complicated by difficulty maintaining oxygenation due to right-to-left intrapulmonary shunting. Description A 71-year-old man with a distant history of mitral valve stenosis, atrial fibrillation on warfarin, heart failure with preserved ejection fraction, cryptogenic cirrhosis, and chronic thrombocytopenia was admitted with hypoxic respiratory failure. Chest CT showed numerous new PAVMs absent on imaging three years earlier. He has no personal or familial history of HHT and genetic testing during admission for common HHT markers was unrevealing. He had no evidence of pulmonary hypertension or hepatopulmonary syndrome. Due to the size and amount of PAVMs, embolization was deferred as the risks outweighed potential benefits. During admission, his oxygen requirements continued to escalate, necessitating the use of inhaled nitric oxide (iNO) as a bridge to surgical intervention. He was placed on veno-venous (VV) ECMO to maintain oxygenation during right-sided video-assisted thoracoscopic surgery with resection of PAVMs in the right middle and lower lung lobes. He was extubated and decannulated immediately post-operatively. Recovery was complicated by development of a large hemothorax and subsequent hemorrhagic shock requiring multiple blood products, vasopressors, intubation, and reinitiation of iNO. He was recannulated for ECMO and returned to the operating room for right-sided thoracotomy and hematoma evacuation. A few days after surgery, he was again decannulated and extubated. He was then weaned to low dose oxygen by nasal canula and discharged to an inpatient rehabilitation facility. Discussion Perioperative VV ECMO can facilitate surgical treatment of PAVMs causing severe hypoxic respiratory failure refractory to supplemental oxygenation. Although ECMO-use has been reported in infants with congenital PAVMs,2,3 our experience describes, to our knowledge, the first recorded use of ECMO for resection of PAVMs causing hypoxic respiratory failure in an adult. References: 1. Nakayama M, Nawa T, Chonan T, et al. Prevalence of pulmonary arteriovenous malformations as estimated by low-dose thoracic CT screening. Intern Med Tokyo Jpn. 2012;51(13):1677-1681. doi:10.2169/internalmedicine.51.7305. 2. Aggarwal V, Khan DM, Rhodes JF. Pulmonary Arteriovenous Malformation Causing Systemic Hypoxemia in Early Infancy. Case Rep Pediatr. 2017;2017(1):2841720. doi:10.1155/2017/2841720. 3. Guvenc O, Odemis E, Saygi M, Onalan MA. Transcatheter management of life-threatening pulmonary arteriovenous fistula with extracorporeal membrane oxygenation support in an infant. Cardiol Young. 2023;33(3):498-501. doi:10.1017/S1047951122002724. This abstract is funded by: None
Smith et al. (2026) studied this question.