A female patient in her 30s presented with a history of hypoxia, syncope, and headaches for 5 years. Physical examination revealed cyanotic lips, clubbed fingers, and no heart murmur. A shrinking cerebellar abscess was treated with antibiotics and followed up by brain magnetic resonance imaging for 5 years. The initial diagnosis was anomalous pulmonary venous connection or patent foramen ovale. An agitated saline study showed a late passage of bubbles after 5 heartbeats. Computed tomography pulmonary angiography (CTPA) demonstrated bilateral and multiple pulmonary arteriovenous fistulas (PAVFs) (Figure, A).¹

A, Preprocedural 3-dimensional (3-D) reconstruction of a computed tomography angiography (CTA) image. This image shows bilateral and multiple pulmonary arteriovenous fistulas. B, Postprocedural CTA image. Satisfactory occlusion of pulmonary arteriovenous fistulas was achieved with different-sized Amplatzer Duct Occluder II devices (Abbott Cardiovascular; yellow arrowheads) and embolization coils (white arrowheads) at 1-month follow-up.

The patient underwent transcatheter embolization of the PAVFs. Two large saccular pouches in both lungs shrank after being occluded with 2 Amplatzer Duct Occluder II devices (Abbott Medical) and 11 MReye embolization coils (Cook Medical). Three other small PAVFs were sealed with 5 different-sized coils (Figure, B).² The patient had an uneventful recovery, and her oxygen saturation level increased from 71% to 93%. At 1-month follow-up, CTPA documented satisfactory results, and the headache had resolved.