Ann Thorac Surg 1996;61:1821-1823
© 1996 The Society of Thoracic Surgeons
Case Report
Usefulness of Ultrasonography in Operation for Pulmonary Arteriovenous Fistula
Makoto Sugita, MD,
Hirokazu Aikawa, MD,
Shigefumi Fujimura, MD,
Takashi Kondo, MD,
Gunji Okaniwa, MD
Department of Surgery, Sendai Kosei Hospital, Sendai, Japan
Accepted for publication November 10, 1995.
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Abstract
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A 54-year-old woman presented with nonhereditary, bilateral pulmonary arteriovenous fistulas. One of them was small (10 x 10 mm) and embedded in the parenchyma; it was neither visible nor palpable from the pleural surface. We therefore used intraoperative ultrasonography and succeeded in detecting and enucleating the small fistula with minimal resection of the normal lung tissue.
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Introduction
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Since Churton [1] described the first case of pulmonary arteriovenous fistula (PAVF) in 1897, many such cases have been reported in the literature [2, 3]. Embolization of PAVF has been reported recently [4]; however, this procedure is still controversial. Today, the preferred treatment for PAVF is still minimal resection to remove the entire fistula [5, 6]. In some cases of PAVF, it is difficult to locate the fistula during operation because it is small or embedded in the parenchyma. In the present case, before the operation, one of the PAVFs was considered too small and too far away from the pleura to be recognized during the operation using angiography and dynamic computed tomography. To solve the problem, we used ultrasonography intraoperatively and succeeded in locating and enucleating the fistula.
A 54-year-old woman was referred to our institution and admitted to our affiliated hospital, Sendai Kosei Hospital, for abnormal shadows on her chest roentgenogram. No abnormalities had been suggested on her yearly physical examinations until the year before the admittance. The chest dynamic computed tomographic study revealed three intrapulmonary masses, which were enhanced at the same density as the major vessels. A pulmonary arteriographic study confirmed the diagnosis of PAVFs (Fig 1
). On the basis of the results of preoperative examinations, we concluded that there were three PAVFs: one in the right posterior basal segment (30 x 35 mm), one in the right medial segment (10 x 10 mm), and one in the left apicoposterior segment (25 x 22 mm). We excluded the possibility of Rendu-Osler-Weber disease from the patient's past and family history of illness and the results of her brain and abdominal computed tomographic studies.
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Fig 1. . Preoperative pulmonary arteriographic study confirming three arteriovenous fistulas: one in the right posterior basal segment (A), one in the right medial segment (B), and one in the left apicoposterior segment (C).
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To minimize the reduction of postoperative pulmonary function and to achieve complete removal of all three fistulas in both lungs with one operation, we planned a sequential bilateral muscle-sparing thoracotomy through the triangle of auscultation for enucleation of the three PAVFs. We preferred this approach over median sternotomy for this case because exposure and removal of the PAVF in the posterior basal segment were expected to be difficult by the median approach. The fistula in the right medial segment was small and embedded in the parenchyma, about 1 cm from the most proximal pleura, so that difficulty in finding this fistula was also expected. To facilitate treatment of the small fistula, we decided to use ultrasonography intraoperatively. We employed a rigid laparoscopic ultrasound probe (UST-5522-7.5; Aloka Inc, Tokyo, Japan) that was 12 mm in maximum diameter and 405 mm in length. The probe was equipped with a 7.5-MHz side linear transducer and had a 38-mm scanning width.
A right thoracotomy was performed as planned. As expected, the fistula in the basal segment was found easily by visual observation of the pleural surface. The fistula itself and vessels running through the fistula were visualized (Fig 2A) by ultrasonography, and it was enucleated without any trouble. The fistula in the medial segment could not be located despite both observation and squeezing of the lung around the segment. No thrill was palpable. We inserted the ultrasonographic probe and started searching for the fistula from the surface of the collapsed lung. Because a left-sided double-lumen endotracheal tube had been placed, we were able to collapse the operated lung. The fistula was easily depicted by ultrasonography (Fig 2B); therefore, it was successfully enucleated with minimal dissection of the surrounding normal lung tissue. Subsequently, a left thoracotomy was performed as planned. The fistula in the apicoposterior segment was detected and enucleation was attempted. Because the oxygen saturation dropped to 93% during the attempt, we performed a partial resection to reduce the operative time.
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Fig 2. . Intraoperative ultrasonographic studies. (A) The fistula in the right basal segment (arrow). (B) The fistula in the right medial segment (arrow).
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The patient had an uneventful postoperative course and was discharged 2 weeks after the procedure. Postoperatively, pulmonary function tests, arterial blood gas analyses, and a pulmonary arteriography study were performed. A reduction of the rate of right-to-left shunt (Table 1) was observed, and no remaining PAVF was found on the pulmonary arteriography study. Histologic examination confirmed the diagnosis of PAVF.
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Comment
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For removing intrapulmonary nonmalignant soft masses, the operative procedure should allow complete resection of the masses, minimal resection of the normal lung tissue, and maximum sparing of respiratory muscles. In the present case, bilateral PAVFs were apparent before the operation, and one of the nodules was expected to be small, soft, and embedded in the parenchyma. To minimize the effort to localize the PAVF, we prepared for ultrasonography. As expected, the PAVF could not be found despite both visual examination of the pleural surface and squeezing of the lung. By using intraoperative ultrasonography on the surface of the collapsed lung, we located the PAVF easily and successfully enucleated the fistula with minimal resection of normal lung tissue. In conclusion, intraoperative ultrasonography is valuable for searching for intrapulmonary masses that are neither visible nor palpable on the surface of the lung.
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Footnotes
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Address reprint requests to Dr Sugita, Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryomachi, Aoba-ku, Sendai, 980-77 Japan.
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References
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- Churton T. Multiple aneurysms of pulmonary artery. BMJ 1897;1:1223.
- Dines DE, Seward JB, Bernatz PE. Pulmonary arteriovenous fistulas. Mayo Clin Proc 1983;58:176–81.[Medline]
- Prager RL, Laws KH, Bender HW. Arteriovenous fistula of the lung. Ann Thorac Surg 1983;36:231–9.[Abstract/Free Full Text]
- Nogimura H, Imaizumi T, Tomii M, et al. Surgery versus detachable balloon embolization of pulmonary arteriovenous fistula: clinical experience. Kyobu Geka 1992;45:595–7.[Medline]
- Parker EF, Stallworth JM, Charleston SC. Arteriovenous fistula of the lung treated by dissection and excision without pulmonary excision. Surgery 1951;32:31–8.
- Bamba J, Tomoyasu H, Tanimura S, Masaki M, Nishiyama S, Matsushita H. Pulmonary arteriovenous fistula. Kyobu Geka 1984;37:370–5.[Medline]
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Abstract
Introduction
