Transcatheter embolization of complex pelvic vascular malformations: results and long-term follow-up

Double Microballoon-occluded Ethanol Embolization for Pelvic Arteriovenous Malformation: A Case Report

A 40-year-old man was incidentally found to have right-sided pelvic arteriovenous malformation (AVM) with an aneurysmal dominant outflow vein (DOV). The AVM had two main feeding arteries forming a cluster of fine vessels shunt to the DOV. As transvenous approach was impossible due to anatomical difficulty, transarterial ethanol embolization was performed under simultaneous double microballoon occlusion of the two feeding arteries in combination with protective coil embolization of the prostatic branches. Ethanol (13 mL) was intermittently injected from both microballoon catheters until the AV shunt was completely occluded. At 1-year follow-up, contrast-enhanced CT revealed shrinkage of the thrombosed DOV without any symptom. Our case demonstrated the usefulness of simultaneous double microballoon-occluded ethanol embolization for treating a localized pelvic AVM with a few feeding arteries.

Pelvic arteriovenous malformation causing per rectal haemorrhage - A case report

INTRODUCTION AND IMPORTANCE

We present the case of a 17 years old girl with per rectal haemorrhage secondary to pelvic arteriovenous malformations (AVM) and potentially haemorrhoids. Pelvic AVMs are rare and extremely variable in their clinical presentation, size and location and pose a therapeutic challenge. Focus has turned towards interventional radiological procedures with angioembolisation as the main treatment form for pelvic AVMs.

CASE PRESENTATION

A 17 years old girl presented to a rural hospital with significant per rectal bleeding requiring transfer to a tertiary centre with interventional radiology capabilities. Diagnostic imaging determined the presence of a pelvic AVM as well as haemorrhoid. She had no prior history of haemorrhoids, per rectal bleeding or per vaginal bleeding. Further diagnostic imaging including a digital subtraction angiography and MRI pelvis was performed and her case was discussed at a multidisciplinary meeting where the decision was made for angioembolisation of a large right rectal AVM as well as precautionary banding of haemorrhoids that had developed secondary to outflow obstruction. A repeat CT mesenteric angiogram a month later demonstrated diminished appearances of the rectal AVM.

CLINICAL DISCUSSION

Pelvic AVMs are a rare entity and are not a common cause for per rectal bleeding. There is currently no direct consensus on the optimum management of complex pelvic AVMs particularly those that present with a second pathology such as haemorrhoids. Surgical management often results in recurrence or rapid progression of the AVM lesion and recruitment of new blood supply further complicates the problem. Selective embolisation allows for control of haemorrhage and utilises chemical agents as well as detachable coils and balloons. However, postoperative pain and swelling can still be expected and multiple transcatheter embolisations may be required.

CONCLUSION

The treatment of symptomatic pelvic AVMs is complex and requires a multidisciplinary approach with careful radiological planning prior to embolisation. Angioembolisation is becoming increasingly prevalent and multiple embolisation procedures may be required to reach the desired therapeutic effect.

Pelvic AVM Embolization: A Tricky Affair-Multicenter Retrospective Experience

PURPOSE

Pelvic arteriovenous malformations (pAVMs) are congenital or acquired vascular anomalies, presenting with hematuria, menometrorrhagia, pelvic pain, and varices; they can be life-threatening in case of rupture. Surgical therapies have been proposed but endovascular embolization has been recognized as the primary modality. The aim of this article was to report a retrospective multicenter experience concerning embolization of pelvic AVMs and provide literature overview.

MATERIALS AND METHODS

We describe 18 patients (14 female and 4 male) diagnosed with pAVM and treated with minimally invasive methods. The pre-procedural imaging evaluation was based on transpelvic and/or transvaginal color Doppler ultrasound, contrast-enhanced computed tomography, and/or magnetic resonance. In 3 cases, the malformation was congenital and in other 15, acquired. Most common symptoms were menometrorrhagia, hematuria, pelvic pain and pressure, and heaviness in the lower abdominal region. In 10 cases (56%), only 1 procedure was required. Eight patients underwent multistage treatment.

RESULTS

Complete occlusion of the lesion in post-procedural angiography was observed in 12 patients (67%). No major periprocedural complications were observed. In 14 cases (78%), both satisfactory embolization and significant clinical improvement was achieved in long-term follow-up. Sixteen patients (88%) were at least satisfied with the clinical outcome. One patient reported subsequent successful pregnancy 5 years after the treatment.

CONCLUSION

Hemodynamics of pAVM are variable and thorough understanding of the vessel anatomy is crucial in planning and choosing proper treatment. Both transarterial and percutaneous direct puncture embolization strategies appear safe, technically feasible, and clinically effective.

CLINICAL IMPACT

In this manuscript, we discuss the role of interventional radiology methods in the treatment of pelvic arteriovenous malformations along with its advantages, limitations and possible complications. In addition to this, we review the current literature and confront our findings with those made by other authors. We believe that modern endovascular methods offer safe and reliable alternative for traditional surgical therapy and should be therefore considered during multidisciplinary treatment of these patients.

A male congenital pelvic arteriovenous malformation diagnosed by abdominal ultrasound: A case report and literature review

Congenital pelvic arteriovenous malformation (AVM) is a rare vascular abnormality whereby arteries and veins are directly connected with malformed vascular plexus. Owing to its low incidence and nonspecific symptoms, the ultrasonographic characteristics of congenital pelvic AVM in males have been infrequently studied. A 30-year-old man visited our hospital complaining of progressive pain in the right lower abdomen and lumbar area since 2 months previously. Abdominal ultrasound (US) was performed at the initial examination and pelvic AVM was diagnosed, which was then confirmed by computed tomographic angiography. After right internal iliac artery embolization, the patient recovered uneventfully and remained asymptomatic during the 12-month follow-up period. Congenital pelvic AVM should thus be included in the differential diagnosis of pelvic cystic masses in males despite its low incidence, with US also being of great diagnostic value. We describe the ultrasonic features of AVM in detail and hope that this study may contribute to the ultrasonic diagnosis of congenital pelvic AVM in males.

Case Report: A Rare Abdominopelvic Arteriovenous Malformation: Originating From Splenic Artery and Draining Into Portal Vein

Background

Abdominopelvic arteriovenous malformation is an uncommon congenital vascular lesion, for which the diagnosis and treatment are usually difficult. Though embolization and sclerotherapy are the primary treatment strategies, traditional surgical resection remains a valuable option.

Case Presentation

Herein, we present a 32-year-old female diagnosed with a massive abdominopelvic arteriovenous malformation that originates from the splenic artery and drains into the portal vein. The vascular lesion was evaluated with multiple imaging modalities and then surgically resected successfully. The patient was discharged post-operatively on day 6 and free of symptoms during the 12-month follow-up.

Conclusion

To our knowledge, the presented abdominopelvic arteriovenous malformation is the first to be reported in the literature, with such a rare condition originating from the splenic artery and draining into the portal vein.

Our Experience in Using the Endovascular Therapy in the Management of Hemorrhages in Obstetrics and Gynecology

(1) Background: A quarter of maternal deaths are caused by post-partum hemorrhage; hence obstetric bleeding is a significant cause of morbidity and mortality among women. Pelvic artery embolization (PAE) represents a minimally invasive interventional procedure which plays an important role in conservative management of significant bleeding in Obstetrics and Gynecology. The aim of this study was to evaluate the effect and the complications of PAE in patients with significant vaginal bleeding with different obstetrical and gynecological pathologies. (2) Methods: We conducted an observational, retrospective study on 1135 patients who presented to the University Emergency Hospital of Bucharest with vaginal bleeding of various etiology treated with endovascular therapy. All the patients included in the study presented vaginal hemorrhage that was caused by: uterine leiomyomas, genital tract malignancies, ectopic pregnancy, arterio-venous mal-formations and other obstetrical causes. We excluded patients with uncontrolled high blood pressure, severe hepatic impairment, congestive heart failure, renal failure or ventricular arrhythmias. (3) Results: Bleeding was caused in 88.19% of cases by uterine leiomyomas (n = 1001), 7.84% (n = 89) by cervical cancer, 2.29% by ectopic pregnancy (n = 26), 1.23% by arteriovenous malformation (n = 14) and 0.52% by major hemorrhage of obstetrical causes. Endovascular procedures were used in all the cases. In patients with uterine leiomyomas, supra-selective uterine arteries embolization was used. In 97% (n = 1101) of patients, bleeding was stopped after the first attempt of PAE. 3% (n = 34) needed a second embolization. In 12 of 14 cases of AVM, PAE was successful, two other cases needed reintervention; (4) Conclusions: Endovascular procedures represent a major therapy method for both acute and chronic hemorrhage in Obstetrics and Gynecology. It can be used in post-partum or post-traumatic causes of vaginal bleeding, but also in patients with chronic hemorrhage from uterine leiomyomas or inoperable genital malignancies or even as a preoperative adjuvant in cases of voluminous uterine fibroids or invasive malignant tumors, aiming to reduce intraoperative hemorrhage.

Clinical presentation of simple and combined or syndromic arteriovenous malformations

OBJECTIVE

Arteriovenous malformations of the lower extremities (AVM^LE) can present as simple or complex combined or syndromic forms (eg, Parkes Weber Syndrome). We aimed to characterize the differences in clinical presentation and natural history of these potentially life- and limb-threatening congenital vascular malformations.

METHODS

We conducted a retrospective analysis of a consecutive series of patients with AVM^LE who presented to a tertiary referral center in Switzerland between 2008 and 2018. Clinical baseline characteristics, D-dimer level, and course were summarized and differences between simple, non-syndromic and combined or syndromic AVM^LE determined. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression models.

RESULTS

Overall, 506 patients were prospectively enrolled in the Bernese Congenital Vascular Malformation Registry, 31 (6%) with AVM^LE. There were 16 women and 15 men, with a mean age of 18 years at first diagnosis (range, 1 month to 72 years). Simple AVM^LE was present in 22 (71%) and combined or syndromic AVM^LE with limb overgrowth in 9 patients (29%), respectively. Common symptoms and signs were pain (n = 25; 81%), swelling (n = 21; 68%), and soft tissue hypertrophy (n = 13; 42%). Among combined or syndromic patients, three patients died from wound infection with sepsis or disseminated intravascular coagulation with bleeding complications (intracranial hemorrhage and bleeding from extensive leg ulcers). Combined or syndromic patients presented more often with bleeding (67% vs 5%; P < .001), malformation-related infection (44% vs 5%; P = .017) and leg length difference (56% vs 14%; P = .049). D-dimer levels were elevated (mean, 17,256 μg/L; range, 1557-80,000 μg/L) and angiographic appearance showed complex, mixed type of AVMs, including interstitial type IV, in all patients with combined or syndromic AVM^LE.

CONCLUSIONS

Patients with congenital simple AVM^LE most often present with benign clinical features and rarely with complications related to hemodynamic changes. Patients with combined or syndromic AVM^LE often face serious outcomes dominated by complications other than direct high-flow-related heart failure.

Sonographic Evaluation of Pelvic Venous Disorders

ABSTRACT

Pelvic venous disorders are a group of interrelated conditions characterized by venous incompetence. These conditions often manifest with nonspecific symptoms that overlap with many gynecological, gastrointestinal, and urologic diseases. Clinical diagnosis can be difficult, and imaging can play a vital role in differentiating etiology. Sonographic evaluation is often the first step in evaluating these symptoms. Special attention to possible underlying pelvic venous disorders can reveal characteristic findings, support diagnosis, and guide treatment. Here we review pelvic congestion syndrome, nutcracker syndrome, May-Thurner syndrome, and other venous disorders, with a specific focus on sonographic findings and considerations.

Location of embolization affects patency after coil embolization for pulmonary arteriovenous malformations: importance of time-resolved magnetic resonance angiography for diagnosis of patency

OBJECTIVES

This study aimed to assess the diagnostic accuracy of computed tomography (CT) and time-resolved magnetic resonance angiography (TR-MRA) for patency after coil embolization of pulmonary arteriovenous malformations (PAVMs) and identify factors affecting patency.

METHODS

Data from the records of 205 patients with 378 untreated PAVMs were retrospectively analyzed. Differences in proportional reduction of the sac or draining vein on CT between occluded and patent PAVMs were examined, and receiver operating characteristic analysis was performed to assess the accuracy of CT using digital subtraction angiography (DSA) as the definitive diagnostic modality. The accuracy of TR-MRA was also assessed in comparison to DSA. Potential factors affecting patency, including sex, age, number of PAVMs, location of PAVMs, type of PAVM, and location of embolization, were evaluated.

RESULTS

The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of CT were 82%, 81%, 77%, 85%, and 82%, respectively, when the reduction rate threshold was set to 55%, which led to the highest diagnostic accuracy. The sensitivity, specificity, PPV, NPV, and accuracy of TR-MRA were 89%, 95%, 89%, 95%, and 93%, respectively. On both univariable and multivariable analyses, embolization of the distal position to the last normal branch of the pulmonary artery was a factor that significantly affected the prevention of patency.

CONCLUSIONS

TR-MRA appears to be an appropriate method for follow-up examinations due to its high accuracy for the diagnosis of patency after coil embolization of PAVMs. The location of embolization is a factor affecting patency.

KEY POINTS

• Diagnosis of patency after coil embolization for pulmonary arteriovenous malformations (PAVMs) is important because a patent PAVM can lead to neurologic complications. • The diagnostic accuracies of CT with a cutoff value of 55% and TR-MRA were 82% and 93%, respectively. • The positioning of the coils relative to the sac and the last normal branch of the artery was significant for preventing PAVM patency.

Preoperative embolization of high-flow peripheral AVMs using plug and push technique with low-density NBCA/Lipiodol

Arteriovenous malformations (AVMs) embolization is considered as a promising option either its single treatment or in combination with surgery, and the use of low-density N-butyl cyanoacrylate (NBCA)/Lipiodol is acceptable mixture agents but its application should be performed by experienced endovascular teams. We describe a successful case preoperative embolization of high-flow AVMs with low-density NBCA/Lipiodol. A 26-year-old male patient was hospitalized with a big pulsatile mass at the right thigh. Doppler ultrasound showed a mass with high systolic, and diastolic velocities coming from the right superficial femoral artery. Angiogram showed a large and high-flow AVM type IV, according to Yakes classification. Low-density NBCA/Lipiodol 12.5% were performed to obstruct all the nidus and feeding arteries. Extirpation surgery was implemented 4 days after the complete embolization procedure.

Case report of a successful multidisciplinary approach to a giant scrotal malformation

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Giant arterio-venous malformations in the pelvic region are rare.

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Selective angiography is mandatory for diagnosis and treatment to define the extent and limits of the malformation.

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Skin necrosis can by managed jointly by vascular and plastic surgeons.

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Azoospermia is frequent in the postoperative period.

Introduction

Congenital pelvic malformations are rare and represent a difficult therapeutic challenge. Scrotal arteriovenous malformations are quite unusual, with only a few such cases reported in the literature. Only one case of scrotal malformation? due to an arteriovenous fistula resulting in azoospermia has been described.

Presentation of case

The two-phase strategy adopted in that case permitted complete treatment of a large-sized malformation that was served by 4 main blood confluences.

Discussion

Angio-CT performed using reconstructions with MIP and SSD algorithms provided more detailed data about the extension of the afferents and efferents of the arteriovenous malformation, thus enabling us to plan the endovascular treatment of the lesion.

Conclusion

A multidisciplinary approach is mandatory to achieve good results in these cases.

Paravesical space arteriovenous malformation as a specific subgroup of pelvic vascular anomaly: a case series and review of literature

Treatment of pelvic arteriovenous malformations (AVMs) is frequently challenging because of the complex structures and anatomical diversity among cases. We present a case series of six patients with pelvic AVMs. All patients had a similar anatomical structure consisting of multiple feeders from the unilateral internal iliac artery, collecting into a dilated venous sac in the unilateral paravesical space and draining into a single outflow, eventually joining the pre-prostatic vein or internal iliac vein. Five among these patients were successfully treated by catheter-directed embolo-sclerotherapy. In addition to our six cases, we identified six previous case reports of pelvic AVM with similar anatomical characteristics. Herein, we summarize the clinical and anatomical features of these 12 paravesical AVM cases. In all cases, the patients were men; the AVM was predominantly located at the right paravesical space and demonstrated good therapeutic effect of catheter-directed embolosclerotherapy. These paravesical AVMs may constitute a new subgroup of pelvic vascular anomalies with the same etiology that are treatable by adequate catheter intervention.

Localized prostate cancer with pelvic arteriovenous malformation treated with low-dose-rate brachytherapy after transcatheter embolization: Two case reports

Background

We describe two patients who underwent low‐dose‐rate prostate brachytherapy after embolization for pelvic arteriovenous malformation.

Case presentation

Case 1: A 76‐year‐old man was referred for definitive treatment of intermediate‐risk prostate cancer (prostate‐specific antigen 8.667 ng/mL, cT2aN0M0, Gleason score 3 + 4 = 7). We planned low‐dose‐rate brachytherapy. However, magnetic resonance imaging and computed tomography demonstrated a large pelvic arteriovenous malformation. We performed embolization of the arteriovenous malformation before initiating treatment to lower the risk of rupture of the arteriovenous malformation during low‐dose‐rate brachytherapy. Case 2: A 69‐year‐old man was referred for the definitive treatment of high‐risk prostate cancer (prostate‐specific antigen 5.81 ng/mL, cT2aN0M0, Gleason score 4 + 4 = 8) with a pelvic arteriovenous malformation. Similar to Case 1, we performed embolization of the arteriovenous malformation before initiating treatment. In both cases, low‐dose‐rate brachytherapy could be performed without complications.

Conclusions

Low‐dose‐rate brachytherapy after transcatheter embolization of pelvic arteriovenous malformations can safely and effectively treat localized prostate cancer with pelvic arteriovenous malformations.

New Alcohol and Onyx Mixture for Embolization: Feasibility and Proof of Concept in Both In Vitro and In Vivo Models

INTRODUCTION

Onyx and ethanol are well-known embolic and sclerotic agents that are frequently used in embolization. These agents present advantages and disadvantages regarding visibility, injection control and penetration depth. Mixing both products might yield a new product with different characteristics. The aim of this study is to evaluate the injectability, radiopacity, and mechanical and occlusive properties of different mixtures of Onyx 18 and ethanol in vitro and in vivo (in a swine model).

MATERIALS AND METHODS

Various Onyx 18 and ethanol formulations were prepared and tested in vitro for their injectability, solidification rate and shrinkage, cohesion and occlusive properties. In vivo tests were performed using 3 swine. Ease of injection, radiopacity, cohesiveness and penetration were analyzed using fluoroscopy and high-resolution CT.

RESULTS

All mixtures were easy to inject through a microcatheter with no resistance or blockage in vitro and in vivo. The 50%-ethanol mixture showed delayed copolymerization with fragmentation and proximal occlusion. The 75%-ethanol mixture showed poor radiopacity in vivo and was not tested in vitro. The 25%-ethanol mixture showed good occlusive properties and accepted penetration and radiopacity.

CONCLUSION

Mixing Onyx and ethanol is feasible. The mixture of 25% of ethanol and 75% of Onyx 18 could be a new sclero-embolic agent. Further research is needed to study the chemical changes of the mixture, to confirm the significance of the added sclerotic effect and to find out the ideal mixture percentages.

Parkes Weber syndrome-Diagnostic and management paradigms: A systematic review

Objectives Parkes Weber syndrome is a congenital vascular malformation which consists of capillary malformation, venous malformation, lymphatic malformation, and arteriovenous malformation. Although Parkes Weber syndrome is a clinically distinctive entity with serious complications, it is still frequently misdiagnosed as Klippel-Trenaunay syndrome that consists of the triad capillary malformation, venous malformation, and lymphatic malformation. Methods We performed a systematic review investigating clinical, diagnostic, and treatment modalities of Parkes Weber syndrome (PubMed/MEDLINE, Embase, and Cochrane databases). Thirty-six publications (48 patients) fulfilled the eligibility criteria. Results The median age of patients was 23 years (IQR, 8-32), and 24 (50.0%) were males. Lower extremity was affected in 42 (87.5%) and upper extremity in 6 (12.5%) patients; 15 (31.3%) patients developed high-output heart failure; 12 (25.0%) patients had chronic venous ulcerations, whereas 4 (8.3%) manifested distal arterial ischemia. The spinal arteriovenous malformations were reported in six (12.5%) patients and coexistence of aneurysmatic disease in five (10.4%) patients. The most frequently utilized invasive treatments were embotherapy followed by amputation and surgical arteriovenous malformation resection, and occasionally stent-graft implantation. All modalities showed clinical improvement. However, long follow-up and outcome remained unclear. Conclusion A diagnosis of Parkes Weber syndrome should be made on the presence of capillary malformation, venous malformation, lymphatic malformation, and arteriovenous malformation (as main defect) in overgrowth extremity. Arteriovenous malformation presents the criterion for distinguishing Parkes Weber syndrome from Klippel-Trenaunay syndrome, which is substantial for treatment strategy. The primary management goal should be patient's quality of life improvement and complication reduction. Embolization alone/combined with surgical resection targeting occlusion or removal of arteriovenous malformation "nidus" reliably leads to clinical improvement.

Surgical and Endovascular Management of Arteriovenous Malformation: Case Series from a Single Center

Management of arteriovenous malformation (AVM) remains a major challenge to vascular surgeons. A multidisciplinary approach was introduced in our hospital to manage these cases from October 2003 to date. This is a report of our experience in their management. A prospective study was done on all patients with symptomatic AVM admitted to our unit between October 2003 and May 2006. All patients had preoperative duplex scanning and magnetic resonance imaging with or without conventional angiography. A multidisciplinary team assessed and treated these cases according to the type of malformation. Thirty-two cases were included in this study, with a mean follow-up of 18.3 months. Of these, 20 cases were predominantly venous and treated with surgical excision ( n = 14) or ethanol sclerotherapy ( n = 6). Twelve cases were predominantly arterial or arteriovenous shunting; 10 were treated with preoperative embolization followed by surgical excision and the remaining 2 with superselective embolization alone. The overall complication rate was high (31%). However, all were minor and settled down conservatively. No recurrence was observed in the early follow-up period. Management of AVM by a surgical and endovascular approach can deliver excellent results, with acceptable morbidity and no recurrence in the early follow-up period.

Holmium Laser Enucleation of the Prostate and Iatrogenic Arteriovenous Fistula Treated by Superselective Arterial Embolization

Iatrogenic pelvic pseudoaneurysm with concomitant arteriovenous fistula has been described as a rare and challenging complication, which may occur during transurethral resection of the prostate. We provide the first report of this complication after holmium laser enucleation of the prostate for the treatment of benign prostatic hyperplasia. The attempt to control the bleeding by conversion to open surgery and placement of haemostatic stitches into the prostatic fossa failed. Angiography with superselective arterial embolization proved to be a modern, quick, safe, and efficient treatment of this uncommon complication.

Recurrent arteriovenous malformation on palate after embolization combined surgical resection: preoperative magnetic resonance features and intraoperative angiographic findings

Angiography is the gold standard for the diagnosis and complete resection of arteriovenous malformations (AVMs). The absence of residual AVM after surgery is commonly believed to reduce the risk of future hemorrhage. However, AVMs can recur after proven complete angiographic resection can occur, albeit rarely, especially in the pediatric population. We report a rare case of a recurrent AVM two years after complete resection in an adult patient. This case report shows that AVMs in adults can recur despite their rarity and despite postoperative angiography confirming complete removal. Moreover, in this case, the recurrent AVM involved a new feeding vessel that was not involved with the initial lesion.

Intracardiac and intravascular leiomyomatosis associated with a pelvic arterio-venous fistula

An intravenous leiomyomatosis is a rare benign smooth muscle tumor originating from myometrial veins. The leiomyomatosis occasionally extends from the pelvic vein into the right cardiac chambers. A pelvic arterio-venous fistula (AVF) is also a rare pelvic vascular malformation. The massive arterio-venous shunting causes high output cardiac failure. We present a very rare case of intravascular and intracardiac leiomyomatosis associated with a pelvic AVF. The patient had congestive heart failure before surgery. We successfully performed one-stage surgery to remove the leiomyomatosis as well as the uterus and left ovary with the pelvic AVF.

Concomitant transarterial and transvenous embolization of a pelvic arteriovenous malformation using a new liquid embolic agent, squid-12 and detachable coils

We describe a complex congenital pelvic AVM with multiple feeding arteries arising from the side branches of the right internal iliac artery and a single draining vein in a male patient. Concomitant transarterial and transvenous embolization with a new liquid embolic agent Squid-12 and metallic coils enabled a complete embolization at a single session. Squid-12 is composed of ethylene vinyl alcohol copolymers and its lower viscosity makes it a promising agent for the treatment of AVMs. The patient showed prompt resolution of the symptoms and complete devascularization of the AVM lesion was persisted on the 1-month control angiography. The patient was asymptomatic on the 6th month follow-up.

Pelvic vascular malformations

Vascular malformations (VMs) comprise a wide spectrum of lesions that are classified by content and flow characteristics. These lesions, occurring in both focal and diffuse forms, can involve any organ and tissue plane and can cause significant morbidity in both children and adults. Since treatment strategy depends on the type of malformation, correct diagnosis and classification of a vascular lesion are crucial. Slow-flow VMs (venous and lymphatic malformations) are often treated by sclerotherapy, whereas fast-flow lesions (arteriovenous malformations) are generally managed with embolization. In addition, some cases of VMs are best treated surgically. This review will present an overview of VMs in the female pelvis as well as a discussion of endovascular therapeutic techniques.

Pelvic arteriovenous malformation treated by transarterial glue embolisation combining proximal balloon occlusion and devascularisation of multiple feeding arteries

We present a case of a 70-year-old man with abdominal aortic aneurysm and coincident pelvic arteriovenous malformation (AVM). Before the operation for the aneurysm, we embolised the pelvic AVM that had multiple feeding arteries and an aneurysmal-dilated draining vein. After decreasing the number of the feeding arteries by coil embolisation, an n-butyl-2-cyanoacrylate/lipiodol mixture (1:1) was injected into the prominent feeding artery and nidus with proximal balloon occlusion of the right internal iliac artery to decrease the flow to the nidus. The mixture (1:4-8) was also added for the finer feeding arteries that became apparent after the initial procedure to embolise the rest of the nidus. A follow-up study showed no contrast enhancement of the nidus and aneurysmal draining vein.

Giant congenital malformation of the perirectal plexus in computed tomography imaging - case report

BACKGROUND

Congenital arteriovenous malformation (AVM) in the pelvic area is uncommon in males.

CASE REPORT

The described case is of a giant lesion of this type that caused recurrent hemorrhaging in the lower part of the gastrointestinal tract. Preliminary diagnosis of vascular pathology was made on the basis of an endoscopic examination that revealed numerous pulsating protuberances of the rectal wall, in which blood flow was identified by means of transrectal ultrasonography. Complementing the diagnostics with a CT revealed a considerable extent of malformation, as well as its morphology and anatomical relations with the surrounding tissues.

RESULTS

Following a two-year follow-up period, the malformation did not progress or demonstrate any intensification of clinical symptoms, therefore the patient continues to undergo conservative treatment.

Surgical Treatment with or without Embolotherapy for Arteriovenous Malformations

OBJECTIVE

The management of arteriovenous malformations (AVMs) remains challenging due to the high rate of recurrence of these lesions. Surgical resection is the only potential cure; however, it is often difficult to perform and carries a risk of massive hemorrhage. The purpose of this study was to review our experience with AVMs treated by surgical resection.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of nine patients with AVM, treated with surgical resection. We treated these patients with excision surgery with or without embolotherapy.

RESULTS

Eight were treated with surgical resection with embolotherapy and one was treated with a simple surgical resection. Five patients with AVMs were cured. However, two cases of AVM recurred after total excision, and AVMs remained in two cases of partial excisional surgery in which the lesions involved the joints.

CONCLUSIONS

Total excision of AVMs leads to a cure; however, total excision is not adequate in cases of AVMs involving the joints. Multidisciplinary treatment may offer good results in reducing the morbidity. To minimize complications related to surgery, aggressive control of blood flow to the lesion, preoperatively, with appropriate embolotherapy is essential, and a complete resection with a chance of cure will be increased.

The use of Onyx for embolization of peripheral vascular malformations in pediatric patients

PURPOSE

The management of congenital peripheral vascular malformations (VMs) can present a difficult therapeutic challenge. Endovascular transcatheter embolization of peripheral VMs is widely accepted as a first therapeutic option for many VMs. However, data describing the use of Onyx are limited in children with peripheral VMs. Our aim is to retrospectively evaluate the results of transcatheter arterial embolization with Onyx for peripheral VMs in children.

MATERIALS AND METHODS

We analyzed clinical and imaging records of 16 patients who underwent 25 embolization procedures by using Onyx for peripheral VMs. In eight cases, embolization procedures were performed once; in seven cases, twice; and in one case, thrice.

RESULTS

Embolization was technically complete in 4 patients and incomplete in 12 patients. Clinically, complete success was achieved in nine patients, and partial success was achieved in six patients. In one patient, reflux to the anterior and posterior tibial arteries caused peripheral ischemia, and the patient was referred to undergo plastic surgery. There were no complications in the other 15 patients.

CONCLUSION

With future studies to better characterize the safety profile of this agent in peripheral vasculature, embolization with Onyx may become a valuable treatment option for peripheral VMs in pediatric patients.

Pelvic arteriovenous malformation treated by superselective transcatheter venous and arterial embolization

We describe a rare case of hematuria and hemospermia associated with pelvic arteriovenous malformation (AVM) in a male patient treated by transcatheter embolization. Understanding AVM hemodynamics contributes to the elucidation of its pathology and improves the outcome of embolization. In the present case, multiple arteriolar components shunted to the initial part of a single dominant outflow vein. Superselective embolization of a draining vein and feeding artery with an n-butyl cyanoacrylate/lipiodol mixture and polyvinyl alcohol particles was effective in terms of shunt disappearance and minimizing the need for subsequent arterial embolization.

Transcatheter arterial embolotherapy: a therapeutic alternative in obstetrics and gynecologic emergencies

Transcatheter arterial embolization has become a major treatment modality in a variety of clinical applications, including management of bleeding related to a broad spectrum of obstetric and gynecologic disorders. Embolotherapy has a well-documented role in the management of pelvic and genital tract hemorrhage in the postpartum and postoperative/postcesarean setting. It is also an integral part in the treatment armamentarium of abdominal and cervical ectopic pregnancy, arteriovenous malformation, and gynecologic neoplasms, including more recently, uterine leiomyomata. Based on experiences accumulated over the past decades, embolotherapy has been proven to be highly effective with success rate in the 90 to 100% range in the appropriate clinical settings. It provides visualization of the bleeding site and enables targeted, minimally invasive therapy to achieve hemostasis, which allows preservation of the uterus and hence fertility. In hospitals where experienced personnel and technology is available, transcatheter arterial embolization should be considered in the emergent management of obstetric and gynecologic hemorrhage, particularly when local and conservative measures fail to attain hemostasis.

Vascular malformations involving the female pelvis

Vascular malformations (VM) are classified by flow characteristics and channel content. They can involve any organ and tissue plane, and occur in focal and diffuse forms. Slow-flow vascular malformations (venous and lymphatic malformations) are typically treated by sclerotherapy, whereas fast-flow lesions (arteriovenous malformations) are managed with embolizations. Some VMs, such as VMs of the rectum or uterus, are best dealt with surgically. This review will present a summary of the conditions, their imaging features, and some useful endovascular therapeutic techniques.

Surgical treatment of patients with congenital vascular malformation-associated aneurysms

OBJECTIVES

Aneurysms associated with congenital vascular malformation (CVM) comprise critical complication. We review our experience with extracranial CVM-associated aneurysms and attempt to clarify their clinical features.

PATIENTS AND METHODS

The prevalence, site, size and morphology of the accompanying aneurysms of 48 consecutive CVM patients, who were managed at our hospital from 1999 to 2008, were evaluated. After diagnosis or treatment, the patients were followed up, and the recurrence of aneurysms and patient survival were assessed.

RESULTS

CVM-associated aneurysms were found in 14 patients (29%). CVMs were classified according to the Hamburg classification. The patients were classified into groups as follows: four (31%), in the 'predominantly arteriovenous (AV) shunting defect type'; eight (47%), 'combined vascular defects + predominantly AV shunting defects type'; and two (11%), 'combined vascular defects type'. All aneurysms except one situated at the CVM were saccular, whereas nine were fusiform aneurysms; all the ruptured aneurysms and seven out of the nine enlarging aneurysms were saccular. Surgical treatment was performed 8 times in six patients. During the postoperative follow-up period, recurrence and an aneurysm rupture were encountered in one patient each.

CONCLUSION

Aneurysm is not a rare complication of CVM. It is important to treat CVM before the emergency presents. In addition to the treatment for malformation, regular screening for and proper management of the aneurysms in CVM patients are indispensable.

Curative treatment of pelvic arteriovenous malformation--an alternative strategy: transvenous intra-operative embolisation

OBJECTIVES

Pelvic arteriovenous malformations (AVMs) are difficult to treat. Arterial embolisation is the most common strategy but often has poor results. We report an alternative surgical approach of controlled intra-operative transvenous embolisation with long-term results in seven cases.

MATERIALS AND METHODS

Between 1980 and 2008, we treated seven patients (four men, three women, mean age 50 years). Indications were rectal bleeding (one case), urinary tract problems (four cases), oedema of lower limb (one case) and high-output cardiac failure (one case). Four of them had previous operations and three had previous attempts for embolisation. Embolisation of the malformation was performed through the internal iliac vein. This was done after clamping of all the feeding and draining vessels. The agent used was cyanocrylate (one case), Ethibloc (one case) and bone wax (five cases).

RESULTS

Mortality was 0%. Complications occurred in two patients (28,5%), one pulmonary embolism and one regressive femoral paresis. Three patients were re-operated for various reasons. The mean follow-up period was 6 years (1-12 years). Symptoms resolved in all patients, while control by computed tomography (CT) angioscan revealed one residual shunt.

CONCLUSION

Complete surgical excision of pelvic AVMs is not always possible. Embolisation does not offer a permanent cure. Intra-operative transvenous embolisation of persisting complex AVMs appears to be an alternative approach with good immediate and long-term results. Ethylene glycol appears to be the most suitable agent.

Exaggerated increase in cardiac output during exercise in patients with peripheral high-flow arteriovenous malformations

PURPOSE

To test the hypothesis that cardiac output (Q) in patients with arteriovenous malformations (AVMs) is normal at rest and increases disproportionately during exercise.

MATERIALS AND METHODS

Q was measured in eight patients with large peripheral AVMs and in nine healthy subjects using a noninvasive carbon dioxide (CO₂)-based differential Fick method. Subjects were tested while seated at rest and during mild exercise (repeated leg straightening while sitting). Oxygen consumption (VO₂) was monitored as an index of the degree of exercise.

RESULTS

Average resting Q was similar between AVM patients and healthy subjects (7.40 L/min ± 3.29 vs 6.13 L/min ± 0.94, respectively, P = .29). During exercise, AVM patients showed a smaller increment in VO₂ (0.50 L/min ± 0.11 vs 0.78 L/min ± 0.26, P = .012) but with more apparent effort and shortness of breath compared with healthy subjects. The change in Q per unit change in VO₂ (ΔQ/ΔVO₂) was greater in AVM patients than in healthy subjects (16.00 L/min ± 6.50 vs 9.79 L/min ± 5.33, P < .045).

CONCLUSIONS

Exercise intolerance in AVM patients may be due to an imbalance in ΔQ/ΔVO₂ resulting from increased shunting through the AVM. Exercise provocation may increase the sensitivity of Q in the clinical evaluation of AVM patients.

Arteriovenous malformation arising on persistent sciatic vessels

BACKGROUND

A persistent sciatic artery is a rare congenital anomaly, and an arteriovenous malformation arising on persistent sciatic vessels is extremely rare.

METHODS

This report presents the case of a 30-year-old female with persistent sciatic vessels complicated with an arteriovenous malformation in the right buttock. It was surgically inaccessible, and a three-staged transcatheter embolization using 20% N-butyl-cyanoacrylate/80% lipiodol was performed.

RESULTS

The arteriovenous malformation was shown to have been extinguished by multidetector computed tomography.

CONCLUSIONS

This report presents the first case of persistent sciatic vessels complicated with an arteriovenous malformation treated by transcatheter embolization.

Cystoscopic management of an extruded coil from arteriovenous fistula embolization using arthroscopic instruments

Pelvic arteriovenous malformation (AVM) is a rare condition in which a section of blood vessels lacks a capillary network, resulting in blood from an artery being delivered directly to a vein. This condition may be congenital or acquired. Percutaneous selective embolization can obliterate AVMs and has increasingly been used for management. Management involves transcatheter embolization with either inert glues, balloons, or fibered titanium coils that are designed to limit the flow through feeding vessels. We describe one potential complication of transcatheter embolization that involves necrosis of the bladder wall with a novel technique for endoscopic management of an extruded coil in the bladder.

Post-traumatic pelvic pseudoaneurysm and arterio-venous fistula: combined endovascular and surgical approach

Post-traumatic pelvic pseudoaneurysms are rare and challenging to manage. We describe the combined endovascular and surgical strategy used, to successfully treat a large internal iliac pelvic pseudoaneurysm combined with arterio-venous fistula, in a patient presenting 20 years following an elective caesarean section.

Spontaneous internal ilio-iliac fistula in an elderly woman presenting as heart failure

Acquired intra-abdominal arteriovenous fistulas (AVFs) are a rare disorder where the communication most commonly occurs between abdominal aorta and inferior vena cava. Ilio-iliac AVF has been reported previously, but is exceedingly rare. We present a case of spontaneous ilio-iliac AVF in an elderly woman who presented with symptoms of right heart failure where the diagnosis was not considered. The computed tomographic (CT) and angiographic features are described. The current status of management as well as a review of the literature is also presented.

Is Endovascular Therapy the Preferred Treatment for All Visceral Artery Aneurysms?

Endovascular intervention can provide an alternative method of treatment for visceral artery aneurysms. We conducted a retrospective review of all patients with visceral artery aneurysms at a single university medical center from 1990 to 2003, focusing on the outcome of endovascular therapy. Sixty-five patients with visceral artery aneurysms were identified: 39 splenic (SAA), 13 renal, seven celiac, three superior mesenteric (SMA), and three hepatic. Eleven patients (16.9%) had symptoms attributable to their aneurysms, which included a total of four ruptures (6.2%): three splenic and one hepatic. Management consisted of 18 (27.7%) endovascular interventions, nine (13.9%) open surgical repairs, and 38 (58.5%) observations. Mean aneurysm diameter for patients treated expectantly was significantly less than for those who underwent intervention (p = 0.001). Endovascular interventions included 15 (83.3%) embolizations (11 SAA, three renal, one hepatic) and three (16.7%) stent grafts (two SMA, one renal). The initial technical success rate of the endovascular procedures was 94.4% (17/18). However, there were four patients (22.2%) with major endovascular procedure-related complications: one late recurrence requiring open surgical repair, two large symptomatic splenic infarcts, and one episode of severe pancreatitis. These four patients had distal splenic artery aneurysms at or adjacent to the splenic hilum. There were no endovascular procedure-related deaths. Reasons for performing open surgical repair included three SAA ruptures diagnosed at laparotomy and complex anatomy not amenable to endovascular intervention (six patients). One surgical patient had a postoperative small bowel obstruction treated nonoperatively; and there was one perioperative death in a patient operated on emergently for rupture. Endovascular management of visceral artery aneurysms is a reasonable alternative to open surgical repair in carefully selected patients. Individual anatomic considerations play an important role in determining the best treatment strategy if intervention is warranted. However, four of 11 (36.4%) patients with distal splenic artery aneurysms treated with endovascular embolization developed major complications. Based on our experience, traditional surgical treatment of SAA with repair or ligation and concomitant splenectomy when necessary may be preferred in these cases.

Multistage ethanol sclerotherapy of soft-tissue arteriovenous malformations: effect on pulmonary arterial pressure

PURPOSE

To retrospectively investigate how repeat injections of absolute ethanol in therapeutic doses, required for multisession sclerotherapy of large high-flow soft-tissue arteriovenous malformations (AVMs) in patients with normal cardiopulmonary function, affect pulmonary arterial pressure (PAP).

MATERIALS AND METHODS

Study received approval and waiver of informed consent by institutional review board and was conducted in 16 male and 16 female patients with AVMs who underwent repeat sclerotherapy (142 sessions total) with absolute ethanol from July 1997 to December 2003. PAPs were monitored during first session in all patients. In subsequent sessions, PAP was monitored with pulmonary catheter when predicted single dose of ethanol exceeded 3 mL and total amount exceeded 0.25 mL/kg. PAP was measured in 104 sessions. Serum ethanol levels from blood samples obtained at end of each session were reviewed. PAP parameters were analyzed at beginning and end of each session, and highest value was recorded to assess any increase after repeat therapy. Difference between initial and highest PAP values recorded in a session (Delta(max)) was noted to determine any increase during repeat sessions. Possible relationship was reviewed between this value and amount of ethanol used. For sessions without PAP monitoring, mixed model was used for statistical analysis.

RESULTS

Total ethanol used was variable. In 43 sessions, highest mean PAP exceeded 25 mm Hg. Incidence of sustained pulmonary hypertension (mean PAP > 25 mm Hg) at end of each session was 30.8% (32 of 104 sessions). Initial PAP parameters did not increase or decrease during repeat sessions. No significant changes in Delta(max) of systolic and mean PAP were observed with increasing number of sessions. Rather, Delta(max) of diastolic PAP was reduced after repeat sessions (P = .03). There was no significant correlation between serum ethanol level and PAP parameters at end of sessions. Relationships between Delta(max) values of systolic, mean, and diastolic PAP and total ethanol used were not significant.

CONCLUSION

High incidence of acute pulmonary hypertension was observed in each sclerotherapy session without lasting effect on PAP.