Multiple Pulmonary Arteriovenous Malformations: An Unusual Cause of Shortness of Breath and Recurrent Strokes

OBJECTIVE

To discuss an uncommon case of a patient with multiple pulmonary arteriovenous malformations (PAVMs) presenting with dyspnea on exertion and recurrent strokes.

BACKGROUND

A 79-year-old woman with recent onset recurrent cerebrovascular accidents (CVAs) was referred to cardiology for evaluation of dyspnea on exertion. Clinical examination was unrevealing.

METHODS

A transthoracic echocardiogram (TTE) with agitated saline was suggestive of an extra-cardiac shunt. Subsequent chest computed tomographic angiography (CTA) demonstrated five large PAVMs.

RESULTS

The patient underwent transcatheter coil embolization of the five PAVMs, resulting in marked improvement in dyspnea and resolution of the shunt on bubble study echocardiography.

CONCLUSIONS

Although PAVMs are rare, they remain an important entity to consider when evaluating patients with extracardiac shunts. They may present with nonspecific features such as dyspnea on exertion and recurrent CVAs. All patients with multiple PAVMs should undergo thorough skin screening for telangiectasia as well as radiologic imaging to screen for additional AVMs in the liver and brain in order to exclude hereditary hemorrhagic telangiectasia (HHT).

A case report of congenital umbilical arteriovenous malformation complicated with liver failure after surgical excision

RATIONALE

Few case reports of umbilical arteriovenous malformation (AVM) have been reported. Herein, we report a neonatal case of umbilical AVM who underwent liver failure after surgical excision.

PATIENT CONCERNS

The patient was a girl delivered at a gestational age of 39+5 weeks showing cyanosis and heart murmur.

DIAGNOSES

Cardiac echography, abdominal ultrasonography (USG), and computed tomography revealed suspecting the umbilical AVM.

INTERVENTIONS

On the eighth day after birth, because of the aggravation of heart failure, emergency surgery for excision of umbilical AVM was performed.

OUTCOMES

In postoperative state, worsened laboratory test of liver function and coagulopathy indicated the liver failure. Abdominal USG revealed that the portal vein (PV) flow primarily occurred from the left PV to the inferior vena cava via ductus venosus and coarse hepatic echogenicity. After conservative management, laboratory findings of liver function and the flow direction of the left PV were normal, as demonstrated by abdominal USG within 50th postoperative day.

LESSONS

Careful preoperative evaluation of an AVM of a large size with significant blood flow should be performed, and the possibility of liver failure after surgery should always be considered.

Macro- and microcirculation patterns of intrahepatic blood flow changes in patients with hereditary hemorrhagic telangiectasia

AIM

To evaluated vascular dynamic processes in the liver of hereditary hemorrhagic telangiectasia (HHT) patients by ultrasound (US) considering quantitative analytic methods.

METHODS

The imaging features on US and contrast-enhanced ultrasound (CEUS) in 18 patients diagnosed with HHT were retrospectively analyzed. Regarding CEUS, real-time contrast harmonic imaging and sulfur hexafluoride-filled microbubbles were used.

RESULTS

HVaMs were identified in all 18 patients. By US, the two major Caselitz criteria could be detected in 55.6% patients. "Color spots" were detected in 72.2% of the cases. Respecting sonographic grading criteria by Buscarini, grade 3 could be demonstrated most frequent (40%). By CEUS, all the patients showed quick and early hyperenhancement during the arterial phase. Significant lowest time to peak (TTP) and highest area under the curve (AUC) values were identified in the hepatic artery (TTP: 69.8%; AUC: 100%) and highest TTP and lowest AUC in the hepatic parenchyma and the portal vein.

CONCLUSION

For the first time we analyzed CEUS findings of a group of HHT patients regarding macro- and microcirculation. Our data demonstrate significant differences in TTP and AUC values in the four selected regions: hepatic artery, shunt region, portal vein and hepatic parenchyma.

Efficacy of computed tomography for the diagnosis of postpartum hemorrhage

The authors evaluated the diagnosis of the cause of post-partum haemorrhage (PPH) by computed tomography (CT). They retrospectively transferred 15 patients with PPH from local clinics between January 2010 and December 2011. CT revealed diverse causes. Only two cases had no additional finding on CT. They found deep tearing extending to the lower uterine segment and uterine artery in two cases, whereas five cases were an arteriovenous malformation, and one case was a uterine pseudoaneurysm.

Pulmonary Arterio-Venous Malformation (PAVM): A Rare Case Report

A 6-year-old boy from Comilla, was admitted in Dhaka Medical College Hospital with exertional dyspnea, central cyanosis, clubbing and was finally diagnosed as pulmonary Arterio-Venous Malformation (PAVM) by bubble contrast echocardiography, and pulmonary CT angiography. As PAVM is rare in children, it is often not thought of in differential diagnoses and the diagnosis remains in disguise. In this report, we described the clinical presentation of 6-year-old child with PAVM and also how to investigate the case to get the diagnosis.

[Pancreatic arteriovenous malformation as cause of acute pancreatitis treated by endovascular access]

Arteriovenous malformation in the pancreas is a rare anatomic abnormality that may produce acute pancreatitis. The diagnosis was suspected by computed tomography with intravenous contrast and by magnetic resonance imaging and it was confirmed by arteriography of the celiac trunk and superior mesenteric artery. The treatment received was endovascular, although the other valid option for the treatment of this disease is the surgical resection. The objective of this communication is to present a case of acute pancreatitis due to arteriovenous malformation treated by endovascular approach.

Adjunct to Embolize the High-Flow Fistula Part of Arteriovenous Malformation Using a Double-Lumen Balloon Catheter

OBJECTIVE

The purpose of this study is to report our initial experience of Onyx embolization of the high-flow fistula part of arteriovenous malformation (AVM) using a double-lumen balloon catheter.

METHODS

A Scepter C balloon catheter was used in 2 patients with AVMs associated with high-flow fistulas. The fistulas were located in the anterior cerebral artery and the middle cerebral artery.

RESULTS

Onyx embolization was successful in 2 cases, resulting in elimination of the high-flow fistula part of the AVM. There were no treatment-related events.

CONCLUSIONS

The double-lumen Scepter balloon appears to be a safe and convenient device for Onyx embolization of high-flow fistulas.

[Image Fusion of Dyna CT and Digital Subtraction Angiography for Arteriovenous Malformations]

Both Dyna CT,a rotational faultage reconstructed technique,and digital subtraction angiography(DSA)play important roles in the diagnosis and treatment of arteriovenous malformations(AVM).Three-dimensional Dyna CT can provide the spatial information of AVM nidus,while two-dimensional DSA can provide the time information for distinguishing arteries and veins.To illustrate the location relationship of the nidus,arteries and veins at the same time,these two imaging modalities need to be fused.In this paper,a two-dimensional to three-dimensional back projection and growing method is proposed,which realizes the image fusion of two-dimensional DSA and threedimensional Dyna CT and achieves the differentiation of arteries and veins in Dyna CT.The experimental results showed that the fusion image could present both the position information of AVM nidus and the dynamic information of the blood vessels.Therefore,the proposed method can help surgeons locate the AVM abnormality and make operation plan more accurately.

Management and outcome of sonographically diagnosed uterine enhanced myometrial vascularity / arteriovenous malformations following early pregnancy events: a single center experience

.

An Unusual Case Of Urinary Bladder Arteriovenous Malformation

A 45-year-old male presented with haematuria and urinary frequency. Computed Tomography (CT) urogram revealed gross thickening of the left bladder wall. Histology showed large vessels cuffed by eosinophonilic material suggestive of urinary bladder arteriovenous malformation (AVM). No further intervention was carried out as symptoms resolve after the resection. Follow up rigid cystoscopy and CT at 3 months showed resolution of all visible pathology and no evidence of recurrence.

[Uterine arteriovenous malformation as cause of uterine bleeding of sudden onset. Doppler ultrasound utility, other imaging methods and the minimally invasive treatment]

BACKGROUND

Uterine arteriovenous malformation is a rare disorder that can cause sudden life-threatening vaginal bleeding.

OBJETIVE

To present the clinical features in addition to the use of office gynecologic ultrasound and other imaging techniques in the diagnosis and minimally-invasive treatment of a patient with sudden vaginal bleeding resulting from a uterine arteriovenous malformation.

CASE REPORT

A 31 year old woman presented sudden onset vaginal bleeding requiring the transfusion of 3 units of red blood cells. An initial diagnosis of uterine arteriovenous malformation was made using an office gynecological ultrasound and Color Doppler sonography. The patient was referred to interventional radiology for confirmation of the diagnosis and patient care. The diagnosis and localization of the uterine arteriovenous malformation was confirmed using magnetic resonance imaging. Therapeutic management proceeded with superselective angiography and embolization of the supplying arteries resulting in immediate symptomatic resolution.

CONCLUSION

The use of office gynecologic ultrasound in combination with other imaging techniques is an important tool in the diagnosis and localization of uterine arteriovenous malformation. Embolization of supplying arteries is considered a safe and effective therapeutic option due to advances in radiologic intervention techniques. Advantages of this procedure include a minimally-invasive technique, low morbidity and preservation of uterine function.

Cerebral magnetic resonance angiography

Magnetic resonance angiography (MRA) is an accurate non-invasive tool for imaging the cerebral vessels. It provides morphologic information about the cerebral vessels relying on blood flow as the physical basis for generating contrast between stationary tissues and moving spins. 'Selective' MRA gives functional information about the cerebrovascular system such as flow direction, origin of flow, and presence or absence of collaterals. Arteries and veins can be imaged selectively due to their usually opposite flow directions. Although at a relatively early stage of development, MRA has already become a widely used tool for the study of the cerebrovascular system.

MULTICENTRE COMPARISON OF PATIENT AND DETECTOR DOSE FOR X-RAY-GUIDED EMBOLISATIONS OF ARTERIOVENOUS MALFORMATIONS IN THE BRAIN

Dosimetric benchmarking at four hospitals was performed to investigate incident entrance dose and dose rate on a phantom, and entrance detector dose and dose rate for protocols that are used in routine clinical practice for complex neuroradiological treatment of arteriovenous malformations (AVMs). Measurements were performed with a head phantom that simulates the attenuation and scattering of the human head for the lateral and posteroanterior (PA) views. For fluoroscopy, the measured incident entrance dose rate and entrance detector dose rate were in the range of 44-172 and 0.3-1.3 μGy s(-1), respectively. The pulse rate in fluoroscopy varied between 6.3 and 15 frames per second (fps). For digital subtraction angiography (DSA), incident entrance dose per frame and entrance detector dose per frame were in the range of 744-2800 and 2.6-8.1 μGy/frame, respectively. Optimisation of acquisition parameters such as pulse rate in fluoroscopy, dose per frame in DSA, beam filtration and tube voltage may further improve imaging protocols and lower the patient dose in very complex X-ray-guided embolisations of AVMs in the brain. However, differences in these acquisition parameters observed in this study were relatively small, suggesting that a relatively high degree of optimisation has already been achieved.

Transarterial Embolization of Anomalous Systemic Arterial Supply to Normal Basal Segments of the Lung

PURPOSE

To evaluate transarterial embolization (TAE) for the management of anomalous systemic arterial (ASA) supply to normal basal segments of the lung.

METHODS

Thirteen patients with ASA supply to normal basal segments of the lung underwent TAE. All patients presented with hemoptysis and had complete-type anomalies on pre-TAE or post-TAE computed tomography (CT). The anomaly was unilateral in all patients; 11 lesions were located in the left lung and 2 in the right. All patients underwent embolization with coils (n = 10) or a vascular plug (n = 3). Procedural success, clinical efficacy, and complications were assessed. Mean post-TAE CT and clinical follow-up was 25.4 and 42.1 months, respectively.

RESULTS

Technical success was achieved in 100 % of cases. Several changes were noted on follow-up CT: complete obstruction of the ASA in all cases, normal (n = 11) or decreased (n = 2) density of the affected lung parenchyma, reduction of the primary enlarged inferior pulmonary vein in all cases, and pulmonary infarction and thickening of the corresponding bronchial artery (n = 4). The main complication was pulmonary infarction in four cases.

CONCLUSION

TAE is a safe, effective, and minimally invasive therapeutic option for patients with ASA supply to normal basal segments of the lung.

High-resolution Vessel Wall Magnetic Resonance Imaging in Intracranial Aneurysms and Brain Arteriovenous Malformations

Over the last several years, the advent of intracranial high-resolution vessel wall magnetic resonance imaging (VW-MRI) has provided a new lens with which to view cerebrovascular disease that has not previously been available with conventional imaging. It has already fundamentally changed the way that steno-occlusive diseases are evaluated at many academic centers. This review focuses on current and emerging applications of intracranial high-resolution VW-MRI in the clinical evaluation of intracranial aneurysms and brain arteriovenous malformations. Examples are provided from our clinical practice.

Endovascular treatment of arteriovenous malformations

Cerebral arteriovenous malformations (AVM) are tangles of blood vessels that permit shunting of blood from the arterial to venous phase without intervening capillaries. The malformation's arterialization of a low-pressure system creates a risk of rupture that is substantially higher when associated with an aneurysm. The annual hemorrhage rate is 2.2% per year as reported in the randomized trial of unruptured brain AVMs (ARUBA; rupture risk is increased after the first event. Ruptured AVMs have a 10% mortality rate and 20%-30% morbidity rate. The treatment of choice for AVMs is microvascular resection with or without preoperative embolization. Surgical risk can be stratified based on the Spetzler-Martin grading system. Liquid embolic material and coils may be used for the treatment of AVM associated aneurysms, especially in the setting of acute rupture as a bridge to delayed surgical resection. There is some limited reported success in total endovascular treatment of AVMs, but this is not considered standard therapy at this time. Stereotactic radiosurgery (SRS) has been recently described but mainly limited to AMVs deemed too risky to approach in an open fashion and limited to 2.5cm-3cm in size. The delayed protection from hemorrhage (approximately 2-3 years) and high marginal failure/recurrence rate are the greatest concerns.

Sonographic features and management options of uterine arteriovenous malformation. A case report

Uterine arteriovenous malformation (AVM), an extremely rare condition, is defined as an abnormal connection between artery and vein. Although the pelvis is a common site for AVM, the uterus is involved occasionally and the true incidence is unknown. The objective of this study was to discuss diagnostic features and management options of AVMs. In this paper six cases of AVMs have been reported with a review of diagnosis and management options.

Case Report: Brown Fat Accumulation of Tc-99m Macroaggregated Albumin in a Lung Perfusion Study in a Patient With Multiple Lung Arteriovenous Malformations and Right-to-Left Shunting

An 18-year-old man was preoperatively assessed for a varicocele and found to be hypoxemic. A Tc-99m macroaggregated albumin lung perfusion scan showed right-to-left shunting, evidenced by increased radiotracer uptake in the brain, kidneys, thyroid gland, and bilateral supraclavicular areas, a typical location for brown adipose tissue. Chest computerized tomography angiogram study showed supraclavicular fat density areas and multiple pulmonary arteriovenous malformations.The authors report a rare case of brown fat visualization on a lung perfusion scan in a patient with right-to-left shunting, likely because of increased perfusion to activated brown adipose tissue.

Application of Onyx for Renal Arteriovenous Malformation With First Case Report of a Renal Hyperdense Striation Sign: A CARE-Compliant Article

Onyx is an emerging treatment modality for visceral vascular malformations, especially in cases in which delicate nidal penetration of the arteriovenous malformation (AVM) is desired. A computed tomography (CT) image presentation of hyperdense striations along the renal medulla secondary to the tantalum powder has not been previously reported. A 65-year-old woman presented to our institution with intermittent gross hematuria and left flank pain for 10 days. Both CT and conventional angiographies confirmed cirsoid-type renal AVM, which was successfully treated with Onyx. Follow-up CT after treatment revealed presence of hyperdense striations along the renal medulla, which resolved during later image follow-up. Despite its frequent usage in neural intervention, the application of Onyx in visceral AVM is gradually gaining interest, especially in cases in which delicate nidal penetration of the AVM is desired. Renal hyperdense striation sign should be recognized to avoid confusion with embolizer migration, and further studies in patients with renal function impairment may be helpful in understanding its influence of renal function.

Radiology Case of the Month:Diagnosis and Treatment of an Acquired Uterine Arteriovenous Malformation in a 26-Year-Old Woman presenting with Vaginal Bleeding

Arteriovenous malformations (AVMs) are a rare source of potentially life-threatening uterine bleeding, and should be suspected in patients presenting with metromenorrhagia. Histologically, AVMs are characterized as having both arterial and venous tissues without an intervening capillary network.1 The etiology may be either congenital or acquired secondary to prior uterine surgery or uterine malignancy.2 Congenital lesions are thought to result from arrested vascular development and contain a nidus of multiple feeding arteries anastomosed to multiple draining veins. In contrast, acquired lesions contain small fistulas between a single feeding artery and draining vein.4 While angiography is considered the gold standard for diagnosing AVMs, its limitations include exposure to contrast and radiation and the inability to accurately detect the degree of pelvic extension.5 As a result, ultrasound (US) with color Doppler is the imaging modality of choice in suspected AVM and can be confirmed noninvasively with magnetic resonance imaging (MRI).6 Angiography remains the preferred method of imaging when there is a high index of suspicion of AVM in a patient who may potentially undergo embolization as treatment.3 Historically, the definitive treatment for AVMs has been either hysterectomy or uterine artery ligation. However, embolotherapy has become a well-recognized alternative to surgery since the first reported case in 1982.5 One of the advantages of embolotherapy is the preservation of reproductive structures. Currently, treatment for AVMs is based on the patient's desire to maintain fertility. The objective of this study was (1) to describe the diagnostic features of an AVM on Doppler ultrasound in a patient who presented with vaginal bleeding and (2) discuss the treatment and outcome of this patient using uterine artery embolization.

Use of three-dimensional power Doppler sonography in the diagnosis of uterine arteriovenous malformation and follow-up after uterine artery embolization: Case report and brief review of literature

Arteriovenous malformations (AVM) of the uterus can cause life-threatening hemorrhage. Unexplained, heavy vaginal bleeding in a reproductive age woman should raise suspicion for an AVM. Here a 37-year-old woman had increasingly severe vaginal bleeding for 15 days. Serum β-hCG was elevated. Two-dimensional transvaginal ultrasound suggested retained products of conception. Before dilation and curettage (D&C), color Doppler and three-dimensional (3D) power Doppler demonstrated findings indicative of uterine AVM. A bilateral uterine artery embolization was performed without complications. Three months after uterine artery embolization, 3D power Doppler ultrasonography found complete resolution of the AVM. This case illustrates the importance of assessing both gray-scale and 3D power Doppler, and the ability of postprocedure Doppler to assess resolution.

Meandering pulmonary veins mimicking arteriovenous malformation

We report a case of preoperative incidental finding in a 34-year-old man with a significant aortic insufficiency. Preoperative chest x-ray was suspicious for arteriovenous malformation in the right lung. Chest CT angiography discovered an anomalous course of the left superior pulmonary vein crossing the mediastinum to the contralateral hemithorax, joining the right superior pulmonary vein before entering the right inferior pulmonary vein and forming a common trunk of right inferior pulmonary vein.

Arteriovenous malformation of the thyroid gland as a very rare cause of mechanical neck syndrome: a case report

INTRODUCTION

Vascular malformations of the thyroid gland represent a very rare, often accidentally diagnosed, disease that in the case of eufunctional goitre may be the cause of mechanical neck syndrome. The authors present here the complex differential-diagnosis and treatment approach and stress the importance of histopathology for determining the final diagnosis.

CASE PRESENTATION

Using various imaging methods (ultrasound, multidetector computed tomography of the neck), the cause of breathing difficulties in a 64-year-old old man from the Czech Republic with normal thyroid gland function was found to be an arteriovenous malformation of the left lobe of his thyroid gland, 80 × 70 × 55 mm in size, reaching retrosternally between the major arteries branching from his aortic arch and displacing his trachea 10mm to the right. In preparation for surgery, he underwent a radio-interventional procedure with embolisation of the arteries supplying the left lobe. This was followed by a lobectomy on the left via a partial sternotomy. The definitive histology result confirmed that the arteriovenous malformation was the benign cause of the mechanical neck syndrome.

CONCLUSIONS

The case report presented here extends the differential diagnostic options in cases of mechanical neck syndrome. It describes a very rare disease of the thyroid gland, which prior to surgery may arouse suspicion of malignancy. It stresses the importance of close team cooperation between the endocrinologist, interventional radiologist and surgeon within the framework of preoperative diagnosis as well as preparation for surgery. Determination of the definitive histopathological diagnosis requires a pathologist experienced in such issues.

Ultrasonography as a complementary exam in the diagnosis of oral arteriovenous malformation

The Doppler ultrasonography (DU) in cases of arteriovenous malformations (AVMs) is not widely use by dentists and there are a lack of information on the topic in the literature. AVM is common in the region of the head and neck and are commonly confused with hemangiomas (congenital). Appropriate classification is essential for therapeutic decision. The diferential diagnosis is based on clinical history, diascopy, and, if necessary, diagnostic imaging. This article present two cases of oral AVM in which DU was crucial in detecting a venous and/or arterial component in purplish lesions in the tongue and buccal mucosa, with positive diascopy. In our cases, after DU, we found a predominance of blood component within the lesion and therefore both patients were referred to the head and neck surgeon for surgical removal of the lesion. Only in the presence of a venous component does outpatient treatment become feasible. Given the predominance of the arterial component, outpatient procedures are contraindicated. Therefore DU is an important supplementary test, being of great importance in the clinical decision and treatment plan for oral AVMs and should become a routine part of the dentist front of vascular lesions of medium to large size.

Segmentation and reconstruction of cerebral vessels from 3D rotational angiography for AVM embolization planning

Diagnosis and computer-guided therapy of cerebral Arterio-Venous Malformations (AVM) require an accurate understanding of the cerebral vascular network both from structural and biomechanical point of view. We propose to obtain such information by analyzing three Dimensional Rotational Angiography (3DRA) images. In this paper, we describe a two-step process allowing 1) the 3D automatic segmentation of cerebral vessels from 3DRA images using a region-growing based algorithm and 2) the reconstruction of the segmented vessels using the 3D constrained Delaunay Triangulation method. The proposed algorithm was successfully applied to reconstruct cerebral blood vessels from ten datasets of 3DRA images. This software allows the neuroradiologist to separately analyze cerebral vessels for pre-operative interventions planning and therapeutic decision making.

[Combined treatment of arteriovenous malformations of the head and neck]

An arteriovenous malformation (AVM) is a vascular developmental abnormality conditioned by impaired embryonic morphogenesis and characterized by the development of an abnormal connection between arteries and veins. More than 50% of the total number of patients suffering from this pathology are those having the pathological foci localizing in the area of the head and neck. At present, a combined method is both a generally accepted and the most radical one used for treatment for AVM. However, in the majority of cases, excision of the malformation leaves an extensive and complicated defect of tissues, whose direct closure leads to coarse cicatricious deformities. Over the period from 2004 to 2012, we followed up a total of 37 patients presenting with arteriovenous malformations of the head and neck. At admission the patients underwent preoperative examination including clinical tests, ultrasound duplex scanning, arteriography, MRT, and computed tomography. 24-72 hours prior to the operative intervention the patients were subjected to embolisation of the main vessels supplying the vascular malformation. Excision of the AVM was in 8 cases followed by primary closure of the postoperative wound, in 17 patients the defect was closed by transposition of the axial flaps, and 12 subjects underwent free transplantation of composite complexes of tissues. Relapse of the disease was revealed in 17 patients. In the majority of cases, relapses developed during the first year after the operative intervention (10 cases). The control of the disease's course was obtained in 20 patients. In 8 of the 12 patients with free transplantation of flaps we managed to obtain long-term control over the disease's course (more than 5 years). Hence, free microsurgical transplantation of compound complexes of tissues may be considered as a method of choice for closing the defect after excising an AVM in the area of the head and neck. Replacement of the defect with a well-vascularized tissue complex considerably improves regional haemodynamics, decreases tissue ischaemia, and is capable of providing longterm control over the disease's course.

Coil Migration to the Pulmonary Artery during Endovascular Embolization Treatment in a Patient with Arteriovenous Malformation in the Right Ear

Coils are typically utilized as one of the most popular embolization agents. Coil migration to the pulmonary artery rarely occurs and is associated with a high tendency of severe pulmonary or cardiovascular complications. We herein present a 25-year-old man with arteriovenous malformations in the right ear. Two coils 4-mm in diameter and 3-mm in length migrated to the pulmonary artery during embolization. No further damage related to the coil migration was found during a 2-year follow-up period. In addition, the possible mechanisms of coil migration are discussed.

Huge Pulmonary Arteriovenous Malformation, Venous Thromboembolism and Anticoagulation Treatment in a Patient with Hereditary Hemorrhagic Telangiectasia

Hereditary hemorrhagic telangiectasia (HHT) usually presents in association with pulmonary arteriovenous malformations (PAVMs). In addition, the incidence of venous thromboembolism tends to be increased in these patients. A 74-year-old female with HHT presented with cyanosis and hypoxemia. Contrast-enhanced multislice computed tomography (MSCT) revealed two left PAVMs and one in the right upper lobe. Both left PAVMs were treated with embolotherapy. Follow-up MSCT revealed an incidental pulmonary embolism in the right pulmonary branches. Deep venous thrombosis was confirmed and anticoagulation was initiated. Follow-up MSCT revealed the resolution of thromboembolism. Finally, embolotherapy was performed. This case illustrates the chronic adaptation to hypoxemia and adds further evidence to the relative safety of anticoagulation treatment in these patients.

Spinal arteriovenous malformation: use of intraoperative color Doppler ultrasonography guidance for surgical resection. Case report

Spinal arteriovenous malformations (AVMs) may be associated with sensory and motor deficits, bowel or bladder dysfunction, radicular pain or deficit, and back pain. Hemorrhage can occur in the parenchyma leading to the acute onset of symptoms. Neurosurgical resection is one of the way of treatment. Several techniques including intraoperative angiography, dye-injection and the micro Doppler method have proven to be useful during the surgical resection of spinal vascular lesions. Herein, we report our experience with intraoperative ultrasonography (IOUS) and color Doppler ultrasonography guidance for visualizing a spinal cord AVM during surgery. IOUS is a time-saving and noninvasive method for intraoperative imaging of spinal AVM.

Risk factors of hematomyelia recurrence and clinical outcome in children with intradural spinal cord arteriovenous malformations

BACKGROUND AND PURPOSE

Few published data are available concerning the risk of re-bleeding of spinal cord AVM after an hematomyelia and concerning the long-term clinical outcome. Our aim was to assess the risk of recurrence and long-term clinical outcome after hematomyelia in children with spinal cord AVMs.

MATERIALS AND METHODS

This single-center retrospective study reviewed the clinical and radiologic data of 28 children younger than 18 years of age with arteriovenous malformation who had experienced at least 1 episode of hematomyelia between 1988 and 2012. Long-term clinical outcome was assessed by the American Spinal Injury Association Impairment Scale, and radiologic review included MR imaging and angioarchitecture on angiography (blinded to clinical information) before treatment and at recurrence.

RESULTS

Sixteen children (57%) experienced 1 episode of hematomyelia, while 12 children (43%) experienced recurrence. Girls and boys were equally affected (sex ratio, 1:1), and mean clinical follow-up was 5.7 ± 4.4 years. The risk of recurrence was higher for AVMs of the cervical and upper thoracic spine, 12 (100%) versus 11 (69%) (P = .01). A high American Spinal Injury Association scale score at last follow-up was reported for 11 children (39%), and the risk of recurrence tended to be associated with poorer functional prognosis (7 [64%] versus 5 [29%], P = .07). At the time of recurrence, perimedullary venous drainage was the main factor associated with recurrence (P = .002). Occlusion rate ≥50% was associated with a decreased risk of recurrence (P = .047).

CONCLUSIONS

In the present series, cervical and upper thoracic spinal cord AVMs and microarchitecture were predictive of the risk of hematomyelia recurrence. Perimedullary venous drainage was one of the main parameters associated with recurrence. Functional prognosis was better in patients with a single episode of hematomyelia.

Uterine arteriovenous malformation after gestational trophoblastic disease: a report of two cases

BACKGROUND

Uterine arteriovenous malformation (AVM) is considered a rare condition. Diagnosis is critical because patients are at risk of significant vaginal hemorrhage that has been traditionally managed with surgery.

CASE

We report 2 cases of uterine AVM after gestational trophoblastic disease in young women who were treated with uterine artery embolization, allowing preservation of reproductive capability.

CONCLUSION

Embolization addresses both the preservation of future reproductive function and the prevention of major surgery and anesthesia. Success rates have been quoted as > 90% with minimal complications after uterine artery embolization.

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.

Concurrent pancreatic head and tail arteriovenous malformations in a 40-year-old gentleman: the first published report

CONTEXT

Pancreatic arteriovenous malformations (AVMs) are uncommon in the gastrointestinal tract. Less than 100 cases have been identified in the medical literature. Approximately 10% of all pancreatic AVMs are sporadic.

CASE REPORT

Herein, we report the first documented case of sporadic concurrent pancreatic head and tail AVMs in a 40-year-old gentleman who presented with a 10-day history of epigastric pain and one episode of hematemesis. Patient denied any history of traumatic incidents, cigarette smoking, alcohol abuse, chronic gastric/duodenal ulcer, chronic pancreatitis, chronic hepatic disease, difficulty swallowing, respiratory compromise, or weight loss. Physical examination and laboratory results were unremarkable. Contrast-enhanced computed tomography scan showed two hypervascular masses involving the pancreatic head and tail. The celiac trunk angiogram showed proliferating vascular networks involving the pancreatic head and tail. The superior mesenteric angiogram demonstrated significant vascular contribution to the pancreatic head arteriovenous malformation only. Due to the extreme locations of pancreatic AVMs in the head and tail, surgical resection of both lesions (leaving behind the normal pancreatic body) was not possible. Instead, patient underwent intraoperative irradiation therapy (IORT). During the procedure, patient was surgically operated to retract healthy organs/tissues, and then a single concentrated dose of radiation therapy was precisely applied to both pancreatic head and tail AVM lesions. Patient had an uneventful postoperative recovery and was discharged home on the second postoperative day in stable condition. The patient is to be seen in clinic in a 4-month-period during which patient will be completing a 12-month period of postoperative IORT.

CONCLUSION

This is the first documented case of sporadic concurrent pancreatic head and tail AVMs. Angiography is the gold standard diagnostic modality.

Management of bleeding uterine arteriovenous malformation with bilateral uterine artery embolization

PURPOSE

To evaluate the technical feasibility and clinical outcome of bilateral uterine artery embolization (UAE) as a first-line therapeutic option for bleeding uterine arteriovenous malformation (AVM).

MATERIALS AND METHODS

Between 2002 and 2012, 19 patients were diagnosed with acquired uterine AVM clinically and through imaging studies. The clinical characteristics, angiographic features, technical success rate of embolization, procedure-related complications, imaging, and clinical follow-up data were assessed. Clinical success was defined as immediate symptomatic resolution with disappearance of vascular abnormality on subsequent imaging studies.

RESULTS

A total of 20 bilateral UAE, with or without embolization of extra-uterine feeders, were performed as the first-line treatment. Technical and clinical success rate was 90.0% (18/20) and 89.5% (17/19), respectively. Embolization was incomplete in two patients who had residual extra-uterine fine feeders to the AVM or a procedure- related complication (ruptured uterine artery); the former showed slow regression of the vascular malformation during the observation period, while the latter underwent a successful second bilateral UAE. Immediate clinical success was achieved in the remaining 17 patients after a single session and no recurrence of bleeding was found. Recovery to normal menstrual cycle was seen in all 17 patients with clinical success within one or two months, two of whom subsequently had uneventful intrauterine pregnancies carried to term.

CONCLUSION

Bilateral UAE is a safe and effective first-line therapeutic option for the management of bleeding uterine AVMs. However, incomplete embolization due to unembolizable feeders or difficult access into the uterine artery may lead to suboptimal treatment.

[Hereditary haemorrhagic telangiectasia diagnosed in connection with a traffic accident]

Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by vascular dysplasia and haemorrhage. It is manifested by mucocutaneous telangiec-tases and arteriovenous malformations in organs such as lungs, liver and brain. We present a case of HHT. A 16-year-old patient with a history of recurrent epistaxis was admitted to the local hospital with chest pain and desaturation. A CT scan revealed pulmonary arteriovenous malformations.

Ruptured renal arteriovenous malformation successfully treated by catheter embolization: a case report

BACKGROUND

Renal arteriovenous fistula (RAVF) is a comparatively rare malformation. Here, we report a case of ruptured RAVF that was successfully treated by catheter embolization.

CASE PRESENTATION

An 89-year-old female was transferred to our institution with massive gross hematuria in March 2011. Plain abdominal computed tomography (CT) revealed dilated left renal pelvis with high-density contents. Hematoma was suspected. Subsequent plain abdominal magnetic resonance imaging revealed left hydronephrosis and blood retention in the dilated left renal pelvis. No renal or ureteral cancer was evident. Hematuria was conservatively treated using hemostatic agents but hematuria persisted. Repeated urinary cytology revealed no malignant cells. On day 9, the patient went into septic and/or hemorrhagic shock. Fluid and catecholamine infusion, blood transfusion, and antibacterial drugs were rapidly initiated, and the patient's general condition gradually improved. Contrast-enhanced abdominal CT revealed marked expansion of the hematoma in the renal pelvis and microaneurysms in the segmental arteries of the left kidney. Inflammation improved, and a left double-J stent was inserted. Selective renal angiography revealed RAVF with microaneurysms in the left segmental arteries; therefore, catheter embolization using metallic coils was performed, which resolved hematuria.

CONCLUSION

We report a case of ruptured renal arteriovenous malformation, which was successfully treated by catheter embolization.

Gorham-Stout syndrome: a case report

Gorham-Stout syndrome, is an extremely rare disease of the bone, characterized for vascular and lymphatic channels proliferation in bony segments and consequent osseous resorption. There are around 200 cases reported around the world. Although bisphosphonates are used for symptoms relief, there is no standardized treatment established. We present a case that was diagnosed in our centre secondary to a resistant epistaxis and a literature review of this condition.

A successful case of transcatheter arterial embolization with n-butyl-2-cyanoacrylate for pancreatic arteriovenous malformation

A 57-year-old man was referred and admitted to our hospital for treatment of a symptomatic pancreatic mass. Pancreatic arteriovenous malformation (AVM) was diagnosed based on the findings of contrast-enhanced computed tomography (CT) and angiography, and transcatheter arterial embolization (TAE) with N-butyl-2-cyanoacrylate (NBCA) was performed without complications. The patient's symptoms subsequently improved after TAE, and resolution of the pancreatic AVM was detected on contrast-enhanced CT performed six months after the embolization procedure. This case indicates that TAE with NBCA is a safe and effective treatment for pancreatic AVM.

Cumulative radiation dose in patients with hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations

PURPOSE

To determine the cumulative effective dose (CED) of radiation from medical imaging and intervention in patients with hereditary hemorrhagic telangiectasia (HHT) who have pulmonary arteriovenous malformations and to identify clinical factors associated with exposure to high levels of radiation.

METHODS

All patients with at least 1 pulmonary arteriovenous malformation were identified from the dedicated patient database of a tertiary HHT referral centre. Computerized imaging and electronic patient records were systematically examined to identify all imaging studies performed from 1989-2010. The effective dose was determined for each study, and CED was calculated retrospectively.

RESULTS

Among 246 patients (mean age, 53 years; 62.2% women) with a total of 2065 patient-years, 3309 procedures that involved ionizing radiation were performed. CED ranged from 0.2-307.6 mSv, with a mean of 51.7 mSv. CED exceeded 100 mSv in 26 patients (11%). Interventional procedures and computed tomography (CT) were the greatest contributors, which accounted for 51% and 46% of the total CED, respectively. Factors associated with high cumulative exposure were epistaxis (odds ratio 2.7 [95% confidence interval, 1.1-6.3]; P = .02), HHT-related gastrointestinal bleeding (odds ratio 2.0 [95% confidence interval, 1.0-3.8]; P = .04) and number of patient-years (P < .0001).

CONCLUSIONS

Patients with HHT are exposed to a significant cumulative radiation dose from diagnostic and therapeutic interventions. Identifiable subsets of patients are at increased risk. A proportion of patients receive doses at levels that are associated with harm. Imaging indications and doses should be optimized to reduce radiation exposure in this population.