Usefulness of dynamic volume scanning with 320-row CT in detecting recanalization of pulmonary arteriovenous fistula after coil embolization

Ryoichi Tanaka, Kunihiro Yoshioka, Masayuki Takeda, Kenta Muranaka, Miyuki Sone, Michiko Suzuki, Shigeru Ehara

Pulmonary arteriovenous fistula is a congenital and rarely acquired anomalous direct communications between pulmonary arteries and veins. Transcatheter embolization using metallic coil or detachable balloon is one of the common treatment procedure. However, recanalization after the embolization is one of the concern and its differentiation from the retrograde filling via pulmonary vein is difficult except using invasive angiography. We report a case with recanalized pulmonary arteriovenous fistula non-invasively detected by dynamic CT angiography with 320-rows multi detector CT. A 45-year-old women who had underwent coil embolization for pulmonary arteriovenous fistula was examined with dynamic CT angiography and antegrade contrast enhancement of the fistula was noted. The recanalization through the embolized artery was confirmed by digital subtraction angiography, and the second coil embolization was performed. The follow-up dynamic CT angiography at three months after the second procedure found the retrograde enhancement of aneurysmal sac and no antegrade shunt. The dynamic CT angiography was useful for the detect the recanalization of pulmonary arteriovenous fistula. Delayed pulmonary artery recanalization was reported to be observed in 5- 10% of cases as a complication after the successful occlusion of segmental pulmonary artery. Lack of change in aneurysmal diameter of pulmonary arteriovenous fistula demonstrated by CT was reported as the result of persistent aneurysmal perfusion or aneurysmal thrombosis. However, the retrograde filling of aneurysmal sac via pulmonary vein or remnant collateral pathway to the pulmonary arteriovenous fistula were also considered. Therefore, before the invasive procedure, we performed dynamic CT angiography to detect the flow direction and pathway to the pulmonary arteriovenous fistula. Using dynamic CT angiography, we could obtain hemodynamic information through the aneurysmal sac of pulmonary arteriovenous fistula and decide to proceed to the invasive embolotherapy. Prospective perfusion CT scan could be an alternative to invasive angiography in the initial follow-up after the embolotherapy or in the cases with the recanalization of pulmonary arteriovenous fistula.