A 62 year old woman was admitted to our outpatient department because of an unusual precordial murmur detected during a physical examination performed by her general practitioner after an upper airway infection.

Physical examination confirmed a continuous murmur (crescendo-decrescendo) maximal at the left second intercostal space along the midclavicular line. ECG sinus rhythm, chest x ray, and transthoracic and transoesophageal ultrasounds were normal.

A contrast enhanced 16 slice spiral CT (MSCT) of the entire thorax (panels A and B) showed an arteriovenous malformation (AVM) originating from the left subclavian artery (panel B, arrow) and draining into the subclavian vein (arrowhead). Three dimensional reconstruction with volume rendering shows the anatomy, location, and configuration of the vascular anomaly (panels A and B). The patient referred to a chest trauma more than 20 years ago with specific details. At three months follow up she was still asymptomatic.

The therapeutic decision was that only after symptoms or evidence of progression of the arteriovenous malformation should a percutaneous coiling procedure be performed.