Staged embolisation strategy for spinal epidural arteriovenous fistula with concomitant pulmonary arteriovenous malformation.

A woman in her 80s was referred for evaluation and treatment of progressive paraparesis due to a suspected spinal arteriovenous shunt. During hospitalisation at the referring institution, she developed multiterritory embolic stroke, prompting investigation.Bilateral deep venous thrombosis and a large pulmonary arteriovenous malformation (PAVM) with a high-grade extracardiac right-to-left shunt were identified, supporting paradoxical embolism as the most likely mechanism. Spinal angiography confirmed a spinal epidural arteriovenous fistula (SEDAVF) with venous drainage into intradural spinal veins and the inferior vena cava.Because liquid embolic material used for SEDAVF treatment could potentially migrate into the inferior vena cava and reach the systemic circulation through the PAVM, a staged approach was adopted. Coil embolisation of the PAVM was performed, followed by N-butyl-2-cyanoacrylate embolisation of the SEDAVF without clinically evident complications.This case highlights the importance of treatment planning based on vascular anatomy and haemodynamics in patients with coexisting arteriovenous shunt lesions.