Transcatheter device occlusion of a large pulmonary arteriovenous fistula by exit closure: the road less travelled

Large pulmonary arteriovenous fistula (PAVF) manifests as cyanosis and predisposes to serious complications of right-to-left shunt, and therefore necessitates early treatment. The emergence of antegrade transcatheter closure of feeding arteries as treatment of choice is limited by inherent risk of either recanalization or reappearance of new feeders and potential risk of systemic embolization. Additional closure of the draining vessel by transcatheter device occlusion should overcome the limitations of conventional antegrade technique. We describe two cases of successful transcatheter closure of a large PAVF by antegrade device closure of feeders as well as transseptal retrograde closure of the exiting channel.