1. To update current management of pulmonary arteriovenous malformations {PAVM}, by transcatheter embolotherapy. 2. To update current management of hemoptysis by bronchial embolotherapy using microcatheter technique and spherical embolics. 3. To review clinical and anatomical outeomes for thoracic vascular interventions. Pulmonary Arteriovenous Malformations {PAVM}: Since 1996, our HHT center (www.hhtavm.org/) has developed new techniques for treating PAVM, as well as confirming the importance of “aneurysmal sac involution” {Remy technique} as an anatomical outcome of successful treatment. Diagnosis of PAVM has been facilitated by contrast echocardiography which is becoming the standard for evaluation of patients with HHT for PAVM. Treatment of PAVM is now performed using guiding catheters and fibered high radial force stainless steel or Inconel coils and soft platinum fibered coils to achieve cross sectional occlusion of the feeding artery as close to the aneurysmal sac as is possible. Detachabable silicone balloons are no longer available and detachable coils are expensive and generally not required for closure of PAVM. Three new Approaches: “nesting”, anchoring and Scaffold techniques will be demonstrated. All patients should be evaluated 6 months after treatment by thin section, unenhanced spiral CT and pulse oximetry. Patients with persistent aneurysmal sacs {10-15%} should undergo pulmonary angiography and retreatment. Hemoptysis: Patients with life threatening hemoptysis {300ml/24 hours} are considered emergent and should be treated by bronchial embolotherapy. Since the original original description of bronchial embolotherapy by Professor Jacques Remy {1973} who achieved technical success of 64% and clinical success of 54%, improvements in catheter techniques and embolics have occurred. Our current technique includes a thoracic aortogram, followed by catheterization of the bronchial arteries, using a 5 Fr preshaped catheter. Once engaged, a standard microcatheter is advanced deep within the bronchial artery and embolization with tris acryl gelatin coated spheres {300 micron or greater} are utilized. With these technique improvements a 90% rate of completing the procedure is routine (technical success). A clinical rate of controlling bleeding for 30 days (clinical success) of 75% is achieved. Our approach has decreased spinal cord morbidity as well as other complications. Patients with hemoptysis due to diffuse PAVMS, a small subset of patient with PAVMs, should not be treated with spherical embolics. In these rare situations, spherical embolics may pass from the bronchial circulation through tiny PAVMs into the pulmonary venous circulation, resulting in myocardial infarction and /or stroke.

Treatment of patients with arteriovenous malformations {600 consecutive patients} and patients with hemoptysis of bronchial origin are reviewed. New techniques and outcomes are described.