34 year old woman presented with significant chest pain over the sternal area and shortness of breath. Previous diagnostic work-up including Doppler studies and noninvasive arteriograms - CTA (not shown here) revealed an arteriovenous malformation in the retrosternal area. The patient states that she have had this chect pain for the last several years, changing in intensity and does not respond well to pain meds. 

A decision was made to proceed with conventional arteriogram with possible transcatheter embolization if feasible. See the angiographic pictures below. 


First image is a subclavian arteriography demonstrating a prominent internal mammary artery with multiple arterial substernal feeders centrally with opacification of the right pulmonary arteries, revealing an intramammary to pulmonary artery shunt.  This shunt is better demonstrated on the second selective contrast injection in one of the arterial feeder. 

This is a left to right shunt requiring an embolization procedure or surgical excision or ligation of the abnormal intramammary to pulmonary artery shunts. Our decision was proceed with embolization. See the pictures and discussion below.  

  First image is after embolization of the largest arterial feeder with coils. The internal mammary artery is patient, but there are multiple small remaining arterial feeders resulting in persistent peripheral to pulmonary artery shunt. Attempts to embolize remaining small arterial feeders were not satisfactory. Therefore, a decision was made to embolize the entire internal mammary artery segmentally where it gives arterial feeders to the nidus of the arteriovenous malformation. The 2nd image is after the embolization procedure, revealing no remaining arterial feeders.  

The patient had significant discomfort in the area following embolization for several days, which responded well to pain medications. The pain gradually improved. The patient's shortness of breath improved significantly immediately after the procedure. 





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