[Clinical analysis of interventional embolization for 9 cases with frontal arteriovenous malformation]

PURPOSE

To investigate the efficacy and safety of interventional embolization in the treatment of frontal arteriovenous malformation (AVM).

METHODS

A retrospective study was used to analyze 9 patients with frontal AVM who were treated in Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine. The patients were treated with interventional embolization under the guidance of DSA. The scope of lesions was observed through DSA, and the injection dose of sclerosing agent was predicted so that the drug could be injected into the lesion cavity. The efficacy, adverse reactions and complications of all patients were observed and analyzed.

RESULTS

Among the 9 patients, there were 7 males(77.8%) and 2 females(22.2%), aged from 1.5-20 years old. Local swelling or mass was the main reported symptom(66.7%). The blood supply arteries of the cases involved in this study included superficial temporal artery and ophthalmic artery. All patients received interventional embolization treatment under general anesthesia, a total of 19 times (each patient received 1-6 times, average 2.1 times/person), and the average single dose of absolute ethanol was 9.0 mL. A total of 80 coils (4.2 coils/time on average) were used for 5 times (80 coils/19 times) with absolute ethanol embolization. In addition, bleomycin was used 3 times, pingyangmycin was used 2 times, and 3% polydocanol was used 1 time to assist embolization. Among the 9 cases included in this study, 4 cases were cured, 3 cases were basically cured, 2 cases were improved, and the effective rate of treatment was 100%. No local or systemic complications were reported in all patients.

CONCLUSIONS

In the treatment of frontal arteriovenous malformation, correct diagnosis according to clinical and imaging manifestations, and interventional embolization with anhydrous ethanol according to DSA angiography results can reduce trauma, improve symptoms, control lesions, and obtain relatively satisfactory treatment results. This scheme is safe and effective.

CT chest-cerebral angiography for basilar artery occlusion caused by pulmonary arteriovenous malformation

Early diagnosis of basilar artery occlusion (BAO) based only on clinical findings is challenging. We present a fully recovered case of BAO caused by pulmonary arteriovenous malformation (PAVM) that was diagnosed early using a protocol for CT angiography (CTA) and promptly treated with endovascular therapy (EVT). A woman in her 50s complained of vertigo with normal level of consciousness (LOC). On arrival, her LOC decreased to a Grass Coma Scale score of 12, and we performed a CT chest-cerebral angiography protocol. Head CTA showed BAO, and an intravenous tissue plasminogen activator was administered, followed by EVT. Chest contrast-enhanced CT showed PAVM in segment 10 of the left lung, which was treated with coil embolisation. For patients with a complaint of vertigo, BAO should be suspected, even if they have an initially normal LOC. A CT chest-cerebral angiography protocol is useful for prompt diagnosis and treatment of BAO and can reveal undetermined causes.

Hemorrhage and necrosis of the liver caused by hepatic arteriovenous malformations in a fetus: A case report

RATIONALE

Hepatic arteriovenous malformations (HAVMs) are a rare disorder reported in association with hereditary hemorrhagic telangiectasia (HHT), known as Rendu-Osler-Weber syndrome. HAVMs are usually detected in adulthood.

PATIENT CONCERNS

A 29-year-old pregnant woman underwent a routine prenatal examination at 37 weeks of pregnancy.

DIAGNOSIS AND INTERVENTIONS

There were fetal liver anomalies detected by prenatal ultrasonography and were managed. Furthermore, a hepatic mass was detected and was subsequently analyzed by fetal magnetic resonance imaging. There were no typical imaging findings in this case which was once misdiagnosed as a hepatoblastoma.

OUTCOMES

Considering the massive hepatic lesion, labor induction was performed on a pregnant woman to avoid adverse maternal and fetal outcomes. Histopathological examination confirmed the diagnosis of HAVMs. Lesions detected by imaging were determined to be hemorrhagic and necrotic.

LESSONS

Prenatal hepatic hemorrhage and necrosis due to an arteriovenous malformation are rare. The authors describe their observations and results.

Inferior mesenteric artery arteriovenous malformation, a rare cause of ischemic colitis: A case report

RATIONALE

An arteriovenous malformation (AVM) is an abnormal tangle of blood vessels that connects the arteries and the veins. Because normal capillary bed is partially or completely absented in the AVM, the blood passes quickly from the arteries to the veins, which disrupts normal blood flow and oxygen supply to the surrounding tissues. This is called "steal phenomenon," and in the inferior mesenteric artery (IMA) territory, this may lead to abdominal pain, gastrointestinal bleeding, portal hypertension, and even ischemic colitis.

PATIENT CONCERNS

A 67-year-old man presented to our emergency department because of left side abdominal pain.

DIAGNOSES

The abdominal computed tomography with contrast enhancement revealed a cluster of abnormal vascular lesions abutting the IMA with early opacification of the left colonic marginal vein. In addition, poor enhancement of segmental colonic wall was found from proximal descending colon to middle rectum. The diagnosis of AVM of the IMA and ischemic colitis was made.

INTERVENTIONS

The patient underwent left hemicolectomy as well as the AVM resection.

OUTCOMES

He was discharged uneventfully after the surgery without complications.

LESSONS

IMA AVM carries the risk of ischemic colitis. computed tomography scan is helpful not only to the diagnosis of AVMs but also to exclude other lesions as well. Treatment options include endovascular embolization, surgical intervention, and a combination of both. Due to the complexity of this disease, treatment requires a case-specific multidisciplinary approach and a coordination of medical, radiological, and surgical staffs.

Arteriovenous malformation of the small intestine presenting with a transfusion-dependent anaemia in pregnancy

Gastrointestinal bleeding that originates in the small intestine is often difficult to diagnose. Bleeding from a small intestinal arteriovenous malformation (AVM) is rare, with congenital AVMs more commonly located in the rectum or sigmoid. There is a relative paucity of cases reported in the literature. In the gastrointestinal tract, it can cause acute and chronic bleeding, which can be fatal. Although the incidence of small bowel AVMs is quite low, such lesions can be identified as the bleeding source in patients with obscure gastrointestinal bleeding (OGIB) harbouring severe, transfusion-dependent anaemia. It can be exceedingly difficult to localise and diagnose gastrointestinal tract bleeding, particularly in cases of occult small bowel AVMs. CT angiography and capsule endoscopy can help to establish the diagnosis. Laparoscopy is an appropriate and beneficial treatment modality for small bowel resection. The authors present the case of a primigravida woman in her late 20s diagnosed with a symptomatic transfusion-dependent anaemia during her pregnancy. She developed OGIB and despite no history of chronic liver disease became encephalopathic. Due to her physical deterioration and uncertain diagnosis, her caesarean section was performed at 36+6 weeks to expedite investigations and treatment. She was diagnosed with a jejunal AVM and underwent coiled embolisation of her superior mesenteric artery. She became haemodynamically unstable and underwent a laparotomy and small bowel resection. A full non-invasive liver screen was negative, however, her MRI liver described multiple focal nodular hyperplasia (FNH) lesions raising the possibility of FNH syndrome in the context of a previous AVM malformation. A prompt stepwise, multimodality diagnostic approach is required to prevent patient morbidity and mortality.

Diagnosis and Management of Persistent Pulmonary Arterio-venous Malformations following Embolotherapy

Embolotherapy is the primary treatment for pulmonary arterio-venous malformations (PAVMs). Approximately, 2-25% of PAVMs demonstrate persistence following embolization. Early identification and treatment of persistent PAVMs are critical to mitigating life threatening complications. The presence of prior embolic devices and complex angioarchitecture of persistent PAVMs pose technical challenges during repeat embolotherapy. In this article, we review patterns of persistence, factors affecting the persistence, endovascular treatment techniques, and outcomes.

Prenatal Clinical Findings in RASA1-Related Capillary Malformation-Arteriovenous Malformation Syndrome

Pathogenic variants in RASA1 are typically associated with a clinical condition called “capillary malformation-arteriovenous malformation” (CM-AVM) syndrome, an autosomal dominant genetic disease characterized by a broad phenotypic variability, even within families. In CM-AVM syndrome, multifocal capillary and arteriovenous malformations are mainly localized in the central nervous system, spine and skin. Although CM-AVM syndrome has been widely described in the literature, only 21 cases with prenatal onset of clinical features have been reported thus far. Here, we report four pediatric cases of molecularly confirmed CM-AVM syndrome which manifested during the prenatal period. Polyhydramnios, non-immune hydrops fetalis and chylothorax are only a few possible aspects of this condition, but a correct interpretation of these prenatal signs is essential due to the possible fatal consequences of unrecognized encephalic and thoracoabdominal deep vascular malformations in newborns and in family members carrying the same RASA1 variant.

Ophthalmic artery occlusion following n-butyl cyanoacrylate embolization of an orbital arteriovenous malformation

A 33-year-old pregnant woman presented with six months of right-sided proptosis. Neuroimaging revealed a right orbital arteriovenous malformation arising from the second segment of the ophthalmic artery. As she was 9 weeks pregnant, the decision was made to monitor her closely. Over the following six months, her proptosis progressed, accompanied by decreased visual acuity, afferent pupillary defect, and red desaturation concerning for compressive optic neuropathy. After planned c-section, she underwent embolization with n-butyl cyanoacrylate. Upon awakening after embolization, she had no light perception vision from her right eye and was found to have ophthalmic artery obstruction. She ultimately developed a blind painful right eye and underwent enucleation with histopathology demonstrating glue in the central retinal artery, posterior ciliary arteries, and choroid. This case highlights ophthalmic artery occlusion as a rare complication of orbital arteriovenous malformation embolization and demonstrates correlating histopathological findings, which have not previously been reported.

[ROBOT-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY WITHOUT TRANSCATHETER ARTERIAL EMBOLIZATION FOR A PATIENT WITH PROSTATE CANCER AND PELVIC ARTERIOVENOUS MALFORMATION: A CASE REPORT]

We performed robot-assisted laparoscopic radical prostatectomy (RARP) without transcatheter arterial embolization (TAE) for a 72-year-old male patient with prostate cancer and pelvic arteriovenous malformation (AVM). Though lymphatic dissection was made contralateral to the AVM, the operation time (robotic: 2h 40 min, and total: 3h 2 min) was not long. Moreover, the blood loss amount of 250 ml was less than those in the past reports of preoperative TAE. Robotic surgery, a dissection of an abnormal arterial branch from the internal iliac artery before the division of the bladder neck, bunching of the deep dorsal vein complex, and resection of the vascular pedicle connecting with AVM in the final step of prostatectomy, contributed to the safe operation. Moreover, the surgical margin was negative in the pathological report,and the prostate specific-antigen was 0.006 ng/ml 3months following the operation. In addition, CT revealed the same size of AVM and no postoperative complication. It has been demonstrated that in the absence of TAE for pelvic AVM, RARP for prostate cancer is safe and effectively controls cancer.

Acquired uterine arteriovenous malformation in a patient with cornual pregnancy: A case report

INTRODUCTION

Acquired uterine arteriovenous malformation (uAVM) is a rare disease and could occur after dilation and curettage, cesarean section, or neoplastic processes.

PATIENT CONCERNS

A 29-year-old female presented with acute right lower abdominal pain and positive beta human chorionic gonadotropin (β-hCG).

DIAGNOSIS

A 6 cm ectopic right cornual pregnancy was found on ultrasound examination.

INTERVENTIONS

She underwent a laparoscopic resection of the cornual ectopic pregnancy. She returned with extensive vaginal bleeding 6-month post surgery, and eventually diagnosed with arteriovenous malformation at the previous surgical site by Color Dopplor endovaginal ultrasound. Percutaneous transcatheter uterine artery embolization (UAE) was attempted, however, vaginal bleeding continued. She was taken to the operation room for a hysteroscopic ablation of uAVM.

OUTCOMES

Complete cessation of the bleeding was achieved without hysterectomy.

CONCLUSION

We report an extremely unusual case of acquired uAVM after a wedge resection of cornual pregnancy. Ultrasound evaluation of patients with post-operative persistent bleeding should be considered for evaluation of a possible arteriovenous malformation.

Endovascular management of pulmonary arteriovenous malformations presenting as multiple brain abscesses

Pulmonary arteriovenous malformations (PAVMs) are rare vascular lesions characterised by abnormal connections between the pulmonary artery and vein bypassing the pulmonary capillary bed and causing right-to-left shunt. Paradoxical embolism is known to occur in these cases, leading to inoculation of septic focus in the systemic circulation. We report a case of multiple PAVMs who presented clinically with seizures and altered sensorium. On radiological work-up, multiple brain abscesses and large PAVMs were evident. The patient was successfully treated by endovascular embolisation of the PAVMs using a vascular plug and multiple coils. The patient showed complete clinical recovery and resolution of brain abscesses on follow-up.

Pyogenic brain abscess associated with an incidental pulmonary arteriovenous malformation

Pulmonary arteriovenous malformations (PAVMs) are rare and often asymptomatic vascular anomalies that can be associated with serious neurological consequences due to right-to-left shunting. We report a case of a woman in her 80s without substantial medical history who presented with a headache, weakness and personality changes, and was found to have a pyogenic brain abscess requiring emergent neurosurgical evacuation. The abscess grew oral flora, suspected to have reached the brain via an incidentally discovered PAVM. With drainage and antibiotics, the patient achieved a full recovery and the PAVM was embolised. To our knowledge, this is the oldest presentation of a PAVM-associated brain abscess in the published literature. Older patients may present without the typical signs and symptoms of a given illness, which complicates accurate diagnosis and treatment. Primary care physicians can help facilitate timely care and positive clinical outcomes.

Recurrent pulmonary arteriovenous malformation in a patient with Sjögren syndrome: A case report

RATIONALE

Pulmonary manifestations of Sjögren syndrome (SS) are variable and may involve the airway or lung parenchyma and increase the risk of vascular and malignant disease. However, to date, only one case of pulmonary arteriovenous malformation (AVM) has been reported in a patient with SS. Here, we report a rare case of recurrent pulmonary AVMs with aggravating multiple cysts in a patient with SS during a period of 14 years.

PATIENT CONCERNS

A 45-year-old woman was diagnosed with SS and pulmonary AVM in the right lung. Her AVMs were embolized successfully and she was followed up annually for 14 years. Eleven years after the initial treatment, her chest computed tomography showed new pulmonary AVMs in the left lung with aggravating multiple cysts.

DIAGNOSIS

We diagnosed her with SS according to the American-European consensus group criteria of 2010. Chest computed tomography and angiographic findings confirmed the recurrence of pulmonary AVMs.

INTERVENTIONS

The patient's recurrent pulmonary AVMs were successfully treated by embolization.

OUTCOMES

Although her multiple cystic lung lesions had been aggravating during 14 years, she received embolization for the pulmonary AVMs twice and developed no complication related to these procedures. Currently, the patient is 56 years old and still alive with good performance state.

LESSONS

To date, only one case of pulmonary AVM has been reported in a patient with SS. The patient died 2.5 years after the diagnosis without recurrence of AVM. Here, we present a rare case of recurrent pulmonary AVMs associated with aggravating multiple cysts in both lungs, which were observed during long-term follow-up, in a patient with SS.

Interventional embolization combined with surgical resection for treatment of extracranial AVM of the head and neck: A monocentric retrospective analysis

Objectives

The aim of this study was to demonstrate the efficacy and feasibility of treating patients with extracranial arteriovenous malformations (AVM) of the head and neck with interventional embolization followed by surgical resection.

Methods

We reviewed the charts of all patients between 2012 and 2021 with extracranial AVM of the head and neck scheduled for interdisciplinary treatment according to University Hospital RWTH Aachen’s protocol and conducted standardized interviews using a newly developed questionnaire. Interview results, as well as clinical examination and radiographic outcome results were analyzed to help determine the efficacy of our treatment approach.

Results

We included 10 patients (8 female, 2 male), with a mean age of 33.5 (11–61) years who were scheduled for treatment of the AVM with interventional embolization followed by surgical resection. In 6 of the 10 patients (60%) the lesion was located in extracranial soft tissue only. In one patient (10%), the lesion was located in bone tissue only. A combined intraosseous and oral soft tissue lesion was seen in the remaining 3 patients (30%). Radiographic resolution was achieved in 62.5% of cases and a significant decrease of symptoms was identified (p = 0.002). None of the patients reported dissatisfaction and no major complications occurred.

Conclusion

An interdisciplinary treatment approach combining neuroradiological interventions with surgical resection appears to be an effective treatment with an acceptable complication rate. Patients treated according to our protocol showed a high satisfaction rate, regardless of the radiographic outcome. Standardized follow-up allows for early detection of recurrences and helps with subjective patient satisfaction.

Image-Guided Embolotherapy of Arteriovenous Malformations of the Face

PURPOSE

To evaluate the safety and outcome of image-guided embolotherapy of extracranial arteriovenous malformations (AVMs) primarily affecting the face.

MATERIALS AND METHODS

A multicenter cohort of 28 patients presenting with AVMs primarily affecting the face was retrospectively investigated. Fifty image-guided embolotherapies were performed, mostly using ethylene-vinyl alcohol copolymer-based embolic agents. Clinical and imaging findings were assessed to evaluate response during follow-up (symptom-free, partial relief of symptoms, no improvement, and progression despite embolization), lesion devascularization (total, 100%; substantial, 76-99%; partial, 51-75%; failure, < 50%; and progression), and complication rates (classified according to the CIRSE guidelines). Sub-analyses regarding clinical outcome (n = 24) were performed comparing patients with (n = 12) or without (n = 12) subsequent surgical resection after embolotherapy.

RESULTS

The median number of embolotherapy sessions was 2.0 (range, 1-4). Clinical outcome after a mean follow-up of 12.4 months (± 13.3; n = 24) revealed a therapy response in 21/24 patients (87.5%). Imaging showed total devascularization in 14/24 patients (58.3%), including the 12 patients with subsequent surgery and 2 additional patients with embolotherapy only. Substantial devascularization (76-99%) was assessed in 7/24 patients (29.2%), and partial devascularization (51-75%) in 3/24 patients (12.5%). Complications occurred during/after 12/50 procedures (24.0%), including 18.0% major complications. Patients with subsequent surgical resections were more often symptom-free at the last follow-up compared to the group having undergone embolotherapy only (p = 0.006).

CONCLUSION

Image-guided embolotherapy is safe and effective for treating extracranial AVMs of the face. Subsequent surgical resections after embolization may substantially improve patients' clinical outcome, emphasizing the need for multimodal therapeutic concepts.

LEVEL OF EVIDENCE

Level 4, Retrospective study.

Fertility Outcomes After Uterine Artery Embolization for Symptomatic Uterine Arteriovenous Malformations: A Single-Center Retrospective Study in 33 Women

PURPOSE

To describe the clinical and fertility outcomes after uterine artery embolization (UAE) for symptomatic uterine arteriovenous malformations (AVMs).

MATERIALS AND METHODS

This single-center retrospective study included 33 patients with uterine AVMs who underwent UAE at our institution between May 2013 and May 2021. The inclusion criteria were diagnostic features of uterine AVM as detection of the nidus and early venous drainage on angiography. The exclusion criteria were high levels of beta-human chorionic gonadotropin indicative of gestational trophoblastic neoplasia. Polyvinyl alcohol (PVA) with a diameter of 500-700 µm (with or without Gelfoam/Glue) was used in 32 procedures and, Glue (with lipiodol) was used in one. The patients were followed up for 31 months (range, 6-90 months). Angiograms, medical records, and phone interviews were used to describe the technical and clinical success, complications, and pregnancy outcomes.

RESULTS

Thirty-three patients with a mean age of 31.2 ± 5.4 years (range, 21-42 years) were included in this case series. Technical success was reported in all patients (100%). Bleeding control was also achieved in 32 (96%) patients. Pelvic and puncture site pain and groin hematoma were reported as minor complications (grade 1 according to CIRSE classification). Six pregnancies (33%) occurred after uterine artery embolization. Four women had full-term pregnancies without complications and delivered healthy newborns. Another two women were in the second trimester of pregnancy with a favorable fetal condition. No post-embolization miscarriage was reported.

CONCLUSION

The UAE is safe and effective in controlling vaginal bleeding caused by uterine AVMs, allowing successful future pregnancies.

[Cutaneous capillary malformations with cerebral implementation]

Capillary malformations - arteriovenous malformation, hereditary hemorrhagic telangiectasia and Sturge-Weber syndrome - are rare diseases in which cutaneous capillary malformations (CM) may be associated with cerebral vascular malformations. The clinical presentation of each disease is described with focus on how to distinguish them in the clinic and differential diagnoses are listed. This review finds that upon thorough and careful examination of patients, cutaneous CM might be a diagnostic hallmark for underlying disease and therefore a significant clinical observation.

Atypical case of arteriovenous malformation invading into a pedicled medial arm flap

A 54-year-old woman who had previously undergone total excision of an arteriovenous malformation (AVM) of lower lip and chin along with pedicled medial arm flap reconstruction, presented with recurrence of swelling in the same region. The patient reported progressive difficulty in feeding, talking and constant aching pain besides aesthetic concerns. On evaluation, recurrence of AVM with invasion into the flap substance was identified. We performed debulking surgery, which resulted in a considerable reduction in pain and improved lower lip functioning and aesthetic appeal of the face. This case is unique due to the rare presentation of an AVM invading the normal flap tissue. Such a finding has never been reported before for a pedicled flap, along with details of the histopathology and imaging description. There are lacunae in the understanding of the progression of vascular malformations and this additional information will add to the existing literature on AVM.

A Computational Framework for Pre-Interventional Planning of Peripheral Arteriovenous Malformations

PURPOSE

Peripheral arteriovenous malformations (pAVMs) are congenital lesions characterised by abnormal high-flow, low-resistance vascular connections-the so-called nidus-between arteries and veins. The mainstay treatment typically involves the embolisation of the nidus, however the complexity of pAVMs often leads to uncertain outcomes. This study aims at developing a simple, yet effective computational framework to aid the clinical decision making around the treatment of pAVMs using routinely acquired clinical data.

METHODS

A computational model was developed to simulate the pre-, intra-, and post-intervention haemodynamics of a patient-specific pAVM. A porous medium of varying permeability was employed to simulate the sclerosant effect on the nidus haemodynamics. Results were compared against clinical data (digital subtraction angiography, DSA, images) and experimental flow-visualization results in a 3D-printed phantom of the same pAVM.

RESULTS

The computational model allowed the simulation of the pAVM haemodynamics and the sclerotherapy-induced changes at different interventional stages. The predicted inlet flow rates closely matched the DSA-derived data, although the post-intervention one was overestimated, probably due to vascular system adaptations not accounted for numerically. The nidus embolization was successfully captured by varying the nidus permeability and increasing its hydraulic resistance from 0.330 to 3970 mmHg s ml-1. The nidus flow rate decreased from 71% of the inlet flow rate pre-intervention to 1%: the flow completely bypassed the nidus post-intervention confirming the success of the procedure.

CONCLUSION

The study demonstrates that the haemodynamic effects of the embolisation procedure can be simulated from routinely acquired clinical data via a porous medium with varying permeability as evidenced by the good qualitative agreement between numerical predictions and both in vivo and in vitro data. It provides a fundamental building block towards a computational treatment-planning framework for AVM embolisation.

Post-traumatic Renal Arteriovenous Malformation Discovered after 2 Years of Blunt Trauma: Diagnosis and Management

Blunt trauma to the kidney is usually minor and self-limiting. In some cases, the patient may present with intractable hematuria or persistent flank pain and discomfort, which necessitates aggressive management. It is very rare and unusual to find a renal arterio-venous malformation following blunt trauma. This unusual presentation should be kept in mind when a patient presents with hematuria and history of blunt abdominal trauma. We report the case of a young male who suffered blunt abdominal trauma two years back, and continued to have on-and-off hematuria. After extensive work up, a diagnosis of renal arterio-venous malformation was made. His case was managed promptly with renal angio-embolization. Key Words: Blunt trauma, Arterio-venous malformation (AVM), Angio-embolisation, kidney.

De novo arteriovenous malformations in post-thrombotic limbs

A 50-year-old woman presented with progressive, painful and disabling swelling of the left lower limb following a left ovarian cyst excision 2 years ago. She had gross oedema of the left lower limb with multiple pubic varices. Contrast-enhanced CT and digital subtraction imaging revealed diffuse arteriovenous malformation (AVM) with feeders from the left internal iliac artery and a short segment significant stenosis of the proximal left common iliac vein. She underwent angioplasty and stenting of the left iliac vein. Her symptoms dramatically improved following the procedure and her limb swelling regressed within 6 months. The occurrence of post-thrombotic AVMs has been long established in the dural and portal systems. This report deals with an analogous phenomenon following iatrogenic deep venous thrombosis of the left lower limb, its pathogenesis, natural history and a review of treatment options.

Pulmonary arteriovenous malformations: A case of missed diagnosis in a neonate

Pulmonary arteriovenous malformation (PAVM) is a congenital vascular abnormality that can cause persistent cyanosis in children. PAVMs can go undetected till adulthood; however, there have been several neonatal cases reported over the years. This case report describes a classical manifestation of a child with isolated PAVM whose diagnosis was likely missed during the neonatal period. A high level of clinical awareness of this condition is crucial as early diagnosis and appropriate treatment can prevent lifethreatening complications and mortality. Diagnosis was confirmed by computed tomography pulmonary angiography and percutaneous transcatheter embolotherapy resulted in complete resolution of symptoms.

Combined endovascular and surgical management of a case of Cobb syndrome

Cobb syndrome is a rare neurocutaneous disorder characterised by spinal and cutaneous vascular malformations in a metameric distribution. Managing such cases is a challenge for the interventionists and neurosurgeons as the results are often suboptimal. We describe a case of Cobb syndrome in a young male child who presented clinically with acute paraparesis and lower backache. On radiological workup, an intradural perimedullary complex spinal arteriovenous fistula was seen with presence of subarachnoid haemorrhage in the spinal canal and compressive myelopathy. There was a haemangioma in paraspinal muscles and a maculopapular cutaneous lesion in the lower back. He was treated with combined endovascular embolisation and surgical intervention and showed significant clinical improvement on follow-up.

Venous thrombosis via pulmonary arteriovenous malformation causing acute myocardial infarction in a relatively young female patient

Pulmonary arteriovenous malformation (PAVM) is a probable cause of thromboembolic diseases such as acute myocardial infarction (MI); however, few cases have been reported. A woman in her early 40s developed acute-onset chest pain; an ECG showed ST-elevated MI. Emergency catheter angiography showed that the culprit lesion was a thrombus that was treated successfully with aspiration. She had a history of deep venous thrombosis and CT revealed PAVM. It was likely that the venous thrombus had moved into the coronary artery through the PAVM. Catheter embolisation of the PAVM was performed and she did not experience any other cardiac event until 6 months after embolisation.

Selective Arterial Embolisation of Uterine Arteriovenous Malformation in an Infertile Patient, subsequent Term Pregnancy and Postpartum Recurrence

Uterine arteriovenous malformation (AVM) is a rare entity. This report describes selective catheterisation and embolisation of a uterine AVM in an infertile woman, subsequent spontaneous pregnancy and postpartum recurrence of the AVM treated with a second embolisation procedure. A 22-year woman presented with menometrorrhagia and failure to conceive. Pelvic magnetic resonance imaging showed a large uterine AVM. Selective catheterisation and embolisation of the AVM was performed. The patient conceived spontaneously two months later and delivered vaginally. A second embolisation was performed due to recurrence of uterine AVM at six months postpartum. This is the first case reporting postpartum recurrence of a pre-conceptionally treated uterine AVM. Selective catheterisation and embolisation is a minimally-invasive, fertility-preserving procedure that successfully treats uterine AVM and should be the treatment of choice when the patient desires pregnancy. Successful pregnancy and vaginal delivery following embolisation is possible; however, an increased awareness of postpartum AVM recurrence is required. Key Words: Fertility, Pregnancy, Therapeutic embolisation, Uterus, Arteriovenous malformation.

Management of acquired uterine arteriovenous malformation associated with retained products of conception

PURPOSE

To evaluate the efficacy and safety of different treatments for acquired uterine arteriovenous malformation associated with retained products of conception (UAVM-RPOC) and investigate the role of uterine artery embolization (UAE) in acquired UAVM-RPOC.

MATERIALS AND METHODS

This was a retrospective study of consecutive patients who presented with UAVM by ultrasound after recent termination pregnancy. 48 patients were included in this study, divided into two groups (massive and minor bleeding groups) according to vaginal bleeding. The treatments were analyzed between groups. Technical and clinical success of UAE was analyzed.

RESULTS

Of the 48 patients, 11 patients were in the massive bleeding group, and 37 were in the minor bleeding group. 5 patients were referred for UAE in each group, and UAE was a priority for patients with unstable hemodynamics (chi-square value=5.524, p=0.022). Conservative management, dilation and curettage (D&C), operative hysteroscopy, and UAE were performed in 16 (33%), 18 (38%), 7 (15%) and 13 (27%) patients, respectively. Two patients following ectopic pregnancy suffered uncontrollable bleeding during D&C and required UAE. Three patients underwent UAE before surgery to prevent hemorrhage. The technical and clinical success rate of UAE was 100%. No complications or recurrence occurred.

CONCLUSION

UAE is a safe and effective treatment for UAVM-RPOC and a priority for patients with unstable hemodynamics. Conservative management, D&C and hysteroscopy are safe and effective for UAVM-RPOC patients with stable hemodynamics. However, UAVM-RPOC following ectopic pregnancy may have high risks of massive hemorrhage during procedures.

Management of pancreatic arteriovenous malformation: Case report and literature review

INTRODUCTION

Pancreatic arteriovenous malformation (P-AVM) is a rare vascular malformation. Fewer than 200 cases have been reported. The clinical manifestations lack specificity. Common symptoms include abdominal pain, gastrointestinal hemorrhage, and jaundice, which is easily confused with other disorders.

PATIENT CONCERNS

A 42-year-old man received TAE due to abdominal pain caused by P-AVM in a local hospital, melena and abdominal pain occurred in a short time after TAE.

DIAGNOSIS

The patient was diagnosed as P-AVM which was confirmed by computed tomography and digital subtraction angiography.

INTERVENTIONS

A pylorus-preserving pancreatoduodenectomy was successfully performed after diagnosis was made.

OUTCOMES

The patient recovered with no complications two weeks after surgery, and no sign of recurrence was found during the 4-mo follow-up period.

CONCLUSION

In our experience, TAE may have limitations in the treatment of P-AVM and surgical resection should be considered as the treatment of choice.

Congenital pulmonary varix: Two case reports

RATIONALE

Patients with congenital pulmonary varix are asymptomatic and require no treatment, but the radiological characteristics of a pulmonary varix are similar to those of a pulmonary arteriovenous malformation, which requires treatment. Pulmonary angiography is useful for obtaining information about the dynamics of pulmonary blood flow to differentiate a pulmonary varix from a pulmonary arteriovenous malformation for the purpose of treatment planning. Two cases of congenital pulmonary varices that were differentiated from pulmonary arteriovenous malformations based on pulmonary angiography findings are presented.

PATIENT CONCERNS AND DIAGNOSIS

The first patient was an asymptomatic 39-year-old man. Non-contrast-enhanced computed tomography performed as part of the treatment course for pneumonia showed pulmonary arteriovenous malformation in the right lung. Pulmonary angiography was performed and showed that it was a pulmonary varix. The second patient was an asymptomatic 23-year-old woman. As part of her regular health check-up, she underwent plain chest X-ray examination, which showed an abnormal shadow. Non-contrast-enhanced computed tomography was performed, and pulmonary arteriovenous malformation was suspected. However, contrast-enhanced computed tomography findings suggested that the patient had a congenital pulmonary varix rather than a pulmonary arteriovenous malformation. Pulmonary angiography was subsequently performed for diagnosis, and a pulmonary varix was confirmed.

INTERVENTIONS AND OUTCOMES

No treatment was administered to either patient. The first patient was followed up for four years, and the second patient for two years. Both patients had no symptoms or complications during the follow-up period.

LESSONS

Two cases of congenital pulmonary varices were reported. Information about the dynamics of pulmonary blood flow obtained by performing pulmonary angiography was effective in distinguishing between pulmonary arteriovenous malformation and congenital pulmonary varix.

Congenital Renal Arteriovenous Malformation: Diagnostic Clues and Methods

Background and objectives: Renal arteriovenous malformation (AVM) is a rare disease and is difficult to be diagnosed by conventional methods because of its rarity. In this study, we investigated the diagnostic clues, and made an algorithm for the better diagnosis of renal AVM. Materials and Methods: We reviewed 13 patients who were diagnosed with AVM by using renal angiography from 1986 to 2020 at our institutes. We evaluated clinical features, diagnostic tools, treatment modalities, and outcomes after the treatment of patients. Results: All patients were female, and the mean age was 36.9 years (range 19 to 54 years). Twelve (92.3%) patients complained of gross hematuria. Four (30.8%) patients showed symptoms in relation with pregnancy and delivery. Angiographic findings demonstrated cirsoid type in 10 patients and aneurysmal type in 3 patients. Among the 11 patients who underwent computed tomography, AVMs were detected in 3 (27.3%) patients. Renal duplex Doppler was performed in 6 patients, and all of these patients were diagnosed with AVM, demonstrating a vascular turbulence or blood-rich area. Twelve patients were initially treated with transarterial embolization. Nephrectomy was performed in two patients due to persistent bleeding with hypovolemic shock. Conclusions: We should consider possible AVMs in patients who were not detected by conventional work up for hematuria, especially in mid-aged, pregnant, or recently delivered women. Renal duplex Doppler might be the optimal diagnostic modality in these patients. Our diagnostic algorithm could be aid to diagnosis and treatment for renal AVM patients.

Renal arteriovenous malformation and venous thrombosis: a tumour-like presentation

Renal arteriovenous malformation is a primarily congenital renal vascular abnormality. It is usually diagnosed incidentally on imaging, and the most common subtype is 'cirsoid', consisting of multiple, enlarged arterial feeders interconnecting with draining veins. We present a 74-year-old woman with an incidental finding of what was at first considered a hypervascularised kidney tumour but turned out to be a left intrarenal arteriovenous malformation associated with a left renal vein thrombosis. Selective endovascular embolisation was performed. The cause-consequence relationship between the arteriovenous malformation and the thrombosis is unique. To our knowledge, no such case has ever been reported.

[Key of Classification and Diagnosis of Spinal Arteriovenous Malformation]

Spinal arteriovenous malformation(AVM)is a rare disease in which blood is received from the spinal feeding arteries. Owing to its rarity, there is limited experience regarding its diagnosis and treatment. In addition, the various classifications that have been proposed historically make it more difficult for the young neurosurgeons to understand this disease. Because delayed initial diagnosis leads to irreversible damage of the spinal cord, neurosurgeons should always consider spinal AVM as one of the differential diagnoses. In order to understand the pathological condition of spinal AVM, it is important to learn basic classification. Spinal AVM is classified as intradural, dural, and epidural. Spinal digital subtraction angiography(DSA)is the gold-standard for the diagnosis of spinal AVM and is indispensable toolfor treatment planning. The purpose of this paper is to summarize a basic classification and diagnosis of spinal AVM.

Pulmonary arteriovenous malformation as a cause of ischaemic stroke in the elderly

Pulmonary arteriovenous malformation (PAVM) is well recognised as a cause of paradoxical brain embolism. The authors report the case of an older woman with a medical history of arterial hypertension who was found unconscious and was discovered to have pulmonary thromboembolism and ischaemic stroke related to a PAVM.

Placental polyp with arteriovenous malformation treated with a gonadotoropin-releasing hormone antagonist

A 35-year-old woman (gravida 1, para 0) underwent termination of pregnancy (ToP) at 12 weeks of gestation. One month after ToP, she experienced significant vaginal bleeding and the mass with blood flow was identified on imaging. The presence of a placental polyp with arteriovenous malformation (AVM) was suspected on transvaginal sonography and MRI. Since the bleeding had ceased when she visited our hospital, we decided to treat the placental polyp with AVM with gonadotropin-releasing hormone (GnRH) antagonist therapy instead of surgery. Two months after GnRH antagonist treatment, the mass and blood flow in the uterus disappeared. Menstruation resumed 1 month after the completion of treatment. In our case, we were able to successfully treat placental polyps with AVM using GnRH antagonist therapy.

Diagnosis of Vascular Rupture Due to Arteriovenous Malformation Using Postmortem Angiography and 3-Dimensonal Printing: A Case Report

ABSTRACT

Postmortem computed tomography (PMCT), PMCT angiography, and 3-dimensonal (3D) printing technology are increasingly applied to forensic practice. Although their effectiveness is undeniably confirmed, their potential role in practice still needs to be further explored. Here, we report a typical case in which such 4 technologies were applied to a woman found dead with stomach content beneath the head on the pillow in her residence. At first, the cause of death was simply considered as hypertensive cerebral hemorrhage after preliminary examination. However, the initial judgment was questioned by her family for her devoid of hypertension history. As indicated by the targeted PMCT with cerebral angiography, the woman died of pathological cerebral hemorrhage due to arteriovenous malformation, which was still unconvincing enough for the family because in violent death, some cerebral hemorrhage could also be located in the same position. Finally, the family came to be convinced when the close connection between the deformed blood vessels and hematoma was perfectly demonstrated by the application of 3D printing technology. This study proved that it can be an efficient tool for identifying the cause of death when the integration is made of 3D printing technology and PMCT angiography, as a more intuitive evidence of forensic science.

Uncontrolled bleeding during tooth extraction from an undiagnosed arteriovenous malformation

Arteriovenous malformations (AVMs) are rare congenital disorders of vascular morphogenesis. These lesions are characterised by high vascular flow with risk of severe bleeding from accidental trauma or surgical manipulation. Although infrequent, potentially life-threatening and fatal oral bleeding has been reported during extraction of tooth associated with AVM. This paper presents a case of uncontrolled bleeding in an adult female patient undergoing mandibular anterior tooth extraction. The bleeding was related to undiagnosed soft tissue AVM in gingivobuccal space. Management of the case with review of previously reported similar cases is presented.

Arteriovenous Malformations-Current Understanding of the Pathogenesis with Implications for Treatment

Arteriovenous malformations are a vascular anomaly typically present at birth, characterized by an abnormal connection between an artery and a vein (bypassing the capillaries). These high flow lesions can vary in size and location. Therapeutic approaches are limited, and AVMs can cause significant morbidity and mortality. Here, we describe our current understanding of the pathogenesis of arteriovenous malformations based on preclinical and clinical findings. We discuss past and present accomplishments and challenges in the field and identify research gaps that need to be filled for the successful development of therapeutic strategies in the future.