Severe Refractory Hypoxemia 16 Years After a Gunshot Injury

A 53-year-old man presented with a history of depressant syndrome. He had been hospitalized 16 years previously because of penetrating traumatic injury of the left hemithorax by bullet secondary to a suicide attempt. Recently, he came to the emergency department for an illness leading to the discovery of severe hypoxemia refractory to nasal oxygen therapy. The arterial blood gas measurements revealed a pH of 7.41, a Paco2 of 41 mm Hg, a Pao2 of 45 mm Hg, and O2 saturation of 83% on ambient air; the Pao2 increased to 85 mm Hg on inspired oxygen of 100%. resulting in a shunt of 30%. Multidetector computed tomography–angiography of the chest showed clearly a giant proximal pulmonary arteriovenous fistula (Figure 1A and B and …