A 42-year-old Indian woman with a 20-year history of recurrent epistaxis and mucocutaneous telangiectasias on her lips and fingers presents with progressive dyspnea and orthodeoxia. Contrast bubble echocardiography confirms an intrapulmonary shunt. CT pulmonary angiography (marked **A** in the diagram) reveals a 4 mm feeding artery with direct communication to a draining pulmonary vein. Which of the following is the most appropriate next step in management?
A. Long-term anticoagulation with warfarin
B. Transcatheter coil embolization of the feeding artery
C. Surgical lobectomy of the affected lobe
D. Beta-blockers and clinical observation
Explanation
Why Transcatheter coil embolization of the feeding artery is right
According to the Second International HHT Guidelines (Faughnan et al., Ann Intern Med 2020), transcatheter coil or vascular plug embolization of feeding arteries ≥2–3 mm is the first-line, definitive, and minimally invasive treatment for pulmonary AVMs in HHT. The CT pulmonary angiography (marked A) provides the gold-standard anatomical definition of the feeding artery and draining vein, which is essential for planning embolization. In this case, the 4 mm feeding artery is well above the threshold for intervention and represents a significant risk for paradoxical embolism and stroke. Embolization is preferred over anticoagulation, observation, or surgery as the initial therapeutic approach.
Why each distractor is wrong
Long-term anticoagulation with warfarin: Anticoagulation does not address the underlying anatomic right-to-left shunt and does not reduce the risk of paradoxical thromboembolism as effectively as obliterating the AVM. It is not recommended as first-line therapy for pulmonary AVMs in HHT.
Surgical lobectomy of the affected lobe: Surgery is reserved only for cases where transcatheter embolization has failed or is technically impossible. It is not first-line and carries higher morbidity than percutaneous embolization.
Beta-blockers and clinical observation: Observation alone is inappropriate for a 4 mm AVM with symptomatic hypoxemia and orthodeoxia. Beta-blockers do not treat the underlying vascular lesion and leave the patient at risk for stroke and hemoptysis.
High-YieldNEET PG
Pulmonary AVMs in HHT with feeding arteries ≥2–3 mm require transcatheter embolization first; CT angiography defines anatomy for intervention.
Faughnan ME et al. Second International HHT Guidelines, Ann Intern Med 2020
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