Pulmonary AV fistula in bilateral pulmonary embolism with pulmonary hypertension
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* G Shalima
* B K Goyal
* D K Mishra
* A Sharma

*   PAVF
*   pulmonary embolism
*   PAH
*   pulmonary hypertension
*   thromboembolism

A 40-year male presented with complaints of dyspnoea on exertion of 6 months duration. Physical examination was unremarkable, and arterial oxygen saturation was 95%. ECG revealed sinus tachycardia with RV strain. Doppler lower-limb study showed significant thrombus burden in bilateral femoral veins and also in the right iliac vein.

x-Ray chest pulmonary artery view showed prominent main pulmonary artery with abrupt cut-off. Pulmonary angiogram showed dilated right pulmonary artery and left pulmonary artery with intraluminal lucency of both the arteries with abrupt narrowing of distal pulmonary arteries consistent with pulmonary artery hypertension (figure 1 ). An arteo venous malformation is seen in the medial portion of upper lobe of left lung, filling promptly from left upper lobe pulmonary artery and emptying prior to the venous phase in left atrium (figure 2 ). The mean pulmonary artery pressure was 62 mm Hg.

![Figure 1](http://heartasia.bmj.com/https://heartasia.bmj.com/content/heartasia/2/1/5/F1.medium.gif)

[Figure 1](http://heartasia.bmj.com/content/2/1/5/F1)

Figure 1 
Selective RPA angiogram in antero posterior view revealing intraluminal filling defects with abrupt narrowing of the distal vessel.

![Figure 2](http://heartasia.bmj.com/https://heartasia.bmj.com/content/heartasia/2/1/5/F2.medium.gif)

[Figure 2](http://heartasia.bmj.com/content/2/1/5/F2)

Figure 2 
Selective left pulmonary artery angiogram revealing pulmonary artero-venous malformation in the upper lobe of the left lung draining in left atrium prior to the venous phase.

## Footnotes

*   Competing interests None.

*   Patient consent Obtained.

*   Provenance and peer review Not commissioned; externally peer reviewed.