Pulmonary arteriovenous malformations (PAVMs) cause cerebral abscess and ischemic stroke due to paradoxical emboli, risks that are increasingly recognized. We report the evolving placement of thoracic surgery in multi-disciplinary team management of PAVMs that were sporadic or associated with hereditary hemorrhagic telangiectasia. From 1983 to 2006, all patients receiving elective treatment had embolization. Between January 2006 and July 2022, 24 of 714 (3%) patients reviewed at our institution underwent elective surgical resection of one or more PAVMs. Initially, the bar for elective surgery had been set very high, and only patients with persistent symptoms of cerebral ischemia after maximal embolization and medical therapy were referred. As PAVM natural history, follow-up radiation exposures for residual PAVMs, and good surgical outcomes were appreciated, PAVM resection became part of the discussion for highly localized, very complex PAVMs which we consider are best treated surgically. Elective surgical intervention may be considered for other selected patients.