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.

[Pelvic arteriovenous malformation : a case report]

A 70-year-old male presented with intermittent macroscopic hematuria. There was no history of previous trauma or pelvic operation. At first, we were unable to clarify the origin of the hematuria, but 3D computed tomography revealed an arteriovenous malformation (AVM) consisting of multiple feeding vessels arising from the bilateral, especially right, internal iliac artery. Treatment with transcatheter arterial embolization (TAE) with a combination of lipiodol and N-butyl-2-cyanoacrylate twice was effective. He needs to be followed up carefully for recurrence of AVM.

High prevalence of pulmonary hypertension in patients with hereditary hemorrhagic telangiectasia

OBJECTIVE

Hereditary hemorrhagic telangiectasia (HHT) is a vascular disorder causing mucocutaneous telangiectases and visceral arteriovenous malformations (AVMs). Pulmonary hypertension (PH) is considered an uncommon complication of HHT whose impact on the survival of these patients is currently unknown.

METHODS

From January 1995 to December 2008, 29 hospitalized patients with definite HHT were included and followed until January 2011. Data on demographics, clinical symptoms and survival were recorded. PH was classified according to echocardiographic probability.

RESULTS

A CT angiogram was performed in 24 of the 29 patients with HHT and AVMs were detected in 16 of them (67%): hepatic in 58%, pulmonary in 33% and spinal in 3%; 37% had both pulmonary and hepatic AVMs. Transthoracic Doppler echocardiography (TTE) was performed in 21 patients. PH was considered possible in 4 (14%) and probable in 9 (31%). The mean age at diagnosis was lower in patients with PH than in patients without PH (54±16.5 years vs 73±8.8 years, p=0.002). PH was more prevalent in patients with AVMs (56 vs. 23%, p=0.036). The mean follow-up of the entire cohort was 6±4.4 years (range: 2 months-17 years), during this time 18 patients died (62%; mean age 73±8.1 years). Patients with PH died at a younger age (68±8.4 vs. 79±2.7 years, p=0.015) than those without PH.

CONCLUSIONS

PH is a severe condition that significantly reduces survival on HHT patients. PH should be suspected in all HHT patients with dyspnea and hepatic AVMs.

Surgical removal of pulmonary arteriovenous malformations subsequent to total cavopulmonary connection conversion long after a Björk procedure

Because the cavopulmonary shunt procedure is widely used for palliation of complex congenital heart diseases, pulmonary arteriovenous malformations (PAVMs) are relatively well-known complications. The reported patient was a 23-year-old woman who experienced PAVMs in the right lower lobe after a classical Glenn anastomosis and Björk procedure for tricuspid atresia. Her arterial oxygen saturation (SaO2) 14 years after the Björk procedure was ~80 %. She then underwent a total cavopulmonary connection (TCPC) conversion to reduce her PAVMs in the right lower lobe using the "hepatic factor." However, her situation remained unchanged, and she experienced severe systemic cyanosis (SaO2, 70 %) and dyspnea during physical exertion without hemoptysis due to increased blood flow to the PAVMs. Although interventional embolization was considered, it was impossible due to considerable dilation of the main PAVM. Thus, right lower lung lobectomy was performed. After surgery, the patient's SaO2 increased to 90 %. To the authors' knowledge, this is the first case report of a lung resection for residual PAVMs after TCPC conversion.

Uterine arteriovenous malformation

Uterine arteriovenous malformation (AVM) is a little known condition of which, to date, very few cases have been described. It has a very diverse symptomatology, even though in most cases, it is diagnosed during a severe and acute haemorrhagic event. Its treatment can vary from expectant management to hysterectomy; however, current evidence suggests that the embolisation of uterine arteries is the most effective approach, especially if fertility is to be preserved. We present a case report classified as AVM, with additional images that show the appearance of this pathology in a short span of time. This case has a number of peculiarities: unusual persistence of human chorionic gonadotropin hormone (β-HCG), asymptomatic patient, quick establishment of the lesion and its duration with unchanging characteristics and finally its spontaneous resolution without further consequences. This entity shows an aetiopathogenesis, that is, not well established or described. We discuss its physiopathology and aetiopathogenesis.

Use of carotid compression in a patient with arteriovenous malformation

We report a case of a patient with a high flow arteriovenous malformation (AVM)i n the orbit, who developed a severe compartment syndrome, and was successfully treated with manual carotid compressions. The patient suffered a progressive proptosis, restriction of ocular motility and decreased of the visual acuity of the right eye. Embolization had a high risk of serious complications due to fistula location, so an alternative treatment consisting in carotid compressions was prescribed. Manual carotid compression is a non-invasive alternative technique to treat AVMs in patients with high risk of embolization episodes.

[Surgical and endovascular treatment of lung arteriovenous malformations]

The article summarizes the experience of surgical treatment of 47 patients (1964-2012 yy) with lung arteriovenous malformations (LAVM). Men were 29, women - 18. Age varied from 6 to 49 years. 20 patients had solitary lung arteriovenous malformations, the rest 27 had multiple malformations. Before 1983 the main diagnostic means was the angiopulmonography, since that the multyspiral computed tomography has been used. Before 1980 all patients received major surgical treatment, i.e., lobectomy (n=29), pneumonectomy (n=1) and 1 explorative thoracotomy. After 1980 the endovascular embolisation under the X-ray control took the leading place among the treatment options for these patients. 11 patients had 17 embolisations; the lung resection was performed only in 3 cases. All negative outcomes (4 lethal and 8 complications) were registered before the 1980. The were no lethal outcomes after the endovascular embolisation; only 3 patients had complications. All patients demonstrated satisfactory and good outcomes, considering objective parameters and quality of life early and long after the endovascular embolisation.

Conservative management of cesarean scar pregnancy with uterine arteriovenous malformation: a case report

BACKGROUND

Cesarean scar pregnancy is a rare type of ectopic pregnancy in which implantation occurs in a previous lower segment cesarean scar. It may be associated with uncontrolled hemorrhage ending in hysterectomy. It can become potentially life threatening for the patient when it further gets complicated by uterine arteriovenous malformation (AVM). To the best of our knowledge there are only a few previous reports of AVM complicating a scar pregnancy. It is still unclear which treatment is most optimal.

CASE

We describe a case of a scar pregnancy complicated by uterine AVM. The diagnosis was made using 3D color Doppler ultrasound, showing a highly vascular tumor in the isthmic region of the uterus. Computed tomography angiography supported the diagnosis. The patient underwent selective embolization of the uterine artery followed by weekly intramuscular injections of methotrexate. Recovery was uneventful.

CONCLUSION

The decision regarding mode of treatment should be made by the patient and the clinician based on the local expertise and experience. Judicious use of medical management (methotrexate) and uterine artery embolization may prevent hysterectomy and allow preservation of fertility.

Contralateral de novo intraosseous arteriovenous malformation in a child with arteriovenous malformation of mandible treated by endovascular embolotherapy. A case report

We describe our experience of the development of contralateral de novo intraosseous AVMs in a ten-year-old girl with AVMs of the mandible who underwent endovascular embolotherapy. She initially presented with intermittent oral bleeding. Computed tomography and digital subtraction angiography demonstrated intraosseous AVMs within the right mandible. The AVMs were treated by transosseous direct-puncture and transarterial embolization with Guglielmi detachable coils and n-butyl cyanoacrylate glue. However, de novo intraosseous AVMs developed within the previously healthy contralateral mandible and resulted in dangerous oral bleeding. Therefore, we suggest regular follow-up and prompt retreatment of any residual mandibular AVMs in patients undergoing endovascular or surgical treatment to prevent subsequent development of "secondary" AVMs and life-threatening oral bleeding.

Fetal left brachiocephalic vein in normal and abnormal conditions

OBJECTIVES

To establish values of fetal left brachiocephalic vein (LBCV) dimensions during normal pregnancy and determine whether routine assessment of the LBCV may help in identifying fetuses with congenital abnormalities of this vessel.

METHODS

Fetal LBCV was assessed prospectively during ultrasound examinations in 431 normal singleton pregnancies. The visualization rate of the transverse view of the upper fetal chest at the level of drainage of the LBCV into the superior vena cava (SVC) by two-dimensional (2D) and 2D plus color Doppler ultrasound was evaluated. Reference ranges of LBCV diameter during non-complicated pregnancies were established. Interobserver and intraobserver measurement variability was analyzed. In addition, a retrospective review of the hospital medical records of 91 pregnancies with fetuses diagnosed with LBCV abnormalities was performed.

RESULTS

Sonographic assessment of the fetal LBCV was consistently achieved in the second and third trimesters and in some fetuses in the first trimester of pregnancy. In normal fetuses LBCV diameter increased significantly throughout pregnancy, with a mean value of 0.7 mm at 11 weeks and 4.9 mm at term. Dilation of the fetal LBCV was noted in five cases of intracranial arteriovenous malformation and six cases of supracardiac type total anomalous pulmonary venous connection. Abnormal course of the LBCV was noted in 12 fetuses. In 63 fetuses with a persistent left SVC and a right SVC the LBCV was absent.

CONCLUSION

This is the first study describing an effective sonographic approach for the assessment of fetal LBCV dimensions during pregnancy. The normative data may provide an additional means of detecting rare anomalies of systemic and pulmonary veins during pregnancy.

Neurofibromatosis-1 with intraventricular haemorrhage and pectus excavatum

This case report describes the occurrence of intraventricular haemorrhage in a teenage boy, who was later found to have neurofibromatosis-1, cerebral vascular disease and pectus excavatum.

Temporary alopecia after embolization of an arteriovenous malformation

Alopecia after head and neck radiotherapy has been extensively reported in the literature. However, alopecia after endovascular procedures is seldom reported in the dermatological literature. Prolonged fluoroscopic imaging during these procedures may cause serious radiation injuries to the skin, such as dermatitis or alopecia. Radiation-induced temporary alopecia is a peculiar form of radiodermitis that occurs over the areas of the scalp that receive the highest doses of radiation. Although repopulation of alopecic patches occurs spontaneously without treatment, it is important to recognize this disorder to establish a correct diagnosis and inform patients about this transient side effect. We report a 44-year-old woman presenting with temporary alopecia after embolization of an arteriovenous malformation.

Contraction of the Amplatzer Vascular Plug I and II in pulmonary artery and systemic venous collateral vessels is safe and of no hemodynamic or vascular consequence in short- and mid-term follow-up

BACKGROUND

The Amplatzer Vascular Plug (AVP) I and AVP II have been used successfully to occlude moderate-large venous collateral vessels (VC) and pulmonary arteriovenous malformations (PAVM) in children and adults with congenital heart disease.

PURPOSE

To report our experience in 4 patients who underwent device occlusion of systemic venous collaterals (3 patients) and device closure of pulmonary arteriovenous malformation (1 patient) that developed contraction of the AVP.

METHODS

The records of all patients who underwent device occlusion utilizing both AVP I and AVP II between November 2006 and January 2011 were retrospectively reviewed. All available follow-up chest x-rays were reviewed and compared with angiograms obtained post device occlusion. A device 30%-50% larger than the targeted vessel was utilized to occlude the vessel.

RESULTS

Four patients were identified with a mean age of 21 years (range, 7 years and 2 months-52 years) and mean weight of 60.6 kg (range, 15.3-131.5 kg). Two patients received AVP I and 2 patients received AVP II. One patient who received the 12 mm AVP I showed moderate contraction. The 3 other patients who received AVP I (6 mm) and AVP II (10 mm, 12 mm) all demonstrated device contraction to the original shape of the device. Mean follow-up time of 24 months (range, 12-40 months) has shown no evidence of hemodynamic or vascular compromise.

CONCLUSIONS

Short to mid-term follow-up indicate that contraction of AVP I and AVP II is safe with no evidence of hemodynamic or vascular compromise. Continued long-term follow-up is warranted.

Endovascular embolization for symptomatic perimedullary AVF and intramedullary AVM: a series and a literature review

INTRODUCTION

Perimedullary arteriovenous fistula (AVF) has shunt on the spinal cord surface and it can be treated with surgery, or endovascular embolization. Intramedullary arteriovenous malformation (AVM) has its nidus in the cord and is difficult to treat either by surgery or endovascular technique. We report our experience with endovascular embolization in the treatment of perimedullary AVF and intramedullary AVM.

METHODS

Four consecutive cases of spinal perimedullary AVF and six intramedullary AVM were retrospectively reviewed. These cases were evaluated and treated at Beijing Tiantan Hospital, China, over a 2-year period. A review of previously reported cases was also performed.

RESULTS

There was no significant difference in the presentations (P = 0.348), level of lesions (P = 0.350), arterial suppliers (P = 0.801), and associated vascular anomalies between perimedullary AVF and intramedullary AVM, except for age (P = 0.014) and treatment modalities (P = 0.003). The patients with perimedullary AVFs were younger in our cases; the age at onset of symptoms averaged 25.8 years compared to 31.7 years for intramedullary AVMs. There was a significant male predominance for both lesions, and a significantly higher incidence of subarachnoid hemorrhage than in spinal dural AVFs. Regarding treatment, endovascular coil embolization is frequently used in perimedullary AVF and liquid embolic agent is an effective therapeutic choice in intramedullary AVM.

CONCLUSION

Perimedullary AVF and intramedullary AVM are dissimilar with dural AVF in clinical characteristics. Our experience suggests that the endovascular treatment of spine perimedullary AVFs and intramedullary AVMs is feasible and effective. Endovascular treatment for intramedullary AVMs is still challenging, the main problem is acute ischemia injury of the spinal cord.

Prenatal diagnosis of a pulmonary arteriovenous malformation

Pulmonary arteriovenous malformations (PAVMs) are caused by abnormal communications between pulmonary arteries and pulmonary veins. They are most often congenital, and may occur as isolated lesions or part of complex congenital syndromes. We describe a case of PAVM in a 16-week-old fetus. To the best of our knowledge this is the first case to be described in the literature of diagnosis, at such an early gestational age, of PAVM with the shunt found between the main pulmonary artery and pulmonary vein.

[Combination of multiple distal posterior fossa aneurysms with cerebellar AVM]

A rare combination of distal aneurysms of SCA and PICA with cerebellar AVM is presented. Case report demonstrates successful simultaneous surgical treatment of all abovementioned anomalies.

Use of intraoperative endoscopy to localize bleeding in the small intestine

INTRODUCTION

Bleeding within the small intestine is difficult to diagnose and localize because it typically occurs at a slow rate. These patients may undergo multiple transfusions and repeated endoscopy, contrast studies, bleeding scans, and angiography before the bleeding source is identified.

CASE REPORT

We report a case of 64-year-old woman, where both endoscopic and angiographic techniques were used to localize protracted bleeding. During endoscopic treatment, the arteriovenous malformations continued bleeding. However, highly selective angiography and intraoperative endoscopy outlined the segments of small intestine for resection. This case reviews the evaluation, localization and treatment of small intestine bleeding.

DISCUSSION

Localizing the site of protracted bleeding in the small intestine beyond the duodenum bulb can be problematic. For some patients, the course of examinations and transfusions can take years. The small intestine is an uncommon site for gastrointestinal hemorrhage, and only 3%-5% of gastrointestinal bleeding occurs between the ligament of Treitz and the ileocecal valve. The length and location of the small intestine, along with other anatomical factors, make this area difficult to assess with endoscopy or radiology. In this case of protracted bleeding, highly selective angiography and intraoperative endoscopy were used to locate the source of the bleeding.

Hepatic nodules associated with an inferior mesentric arteriovenous malformation

Splanchnic arteriovenous malformation (AVM) is a rare condition in which patients present with portal hypertension, which thus causes bleeding varices and ascites. However, to our knowledge, hepatic nodules associated with splanchnic AVM have not yet been described. We herein first report the case of a 78-year-old man with inferior mesenteric AVM presenting with portal hypertension and multiple hepatic nodules dominantly supplied by the portal vein. This unique case not only extends the spectrum of hepatic nodules resulting from abnormal hepatic circulation, but also provides clues for better understanding the etiology of hepatic nodules.

Pregnancy-related uterine arteriovenous malformations: experience from a single medical center

PURPOSE

The purpose of this article was to investigate clinical ultrasonographic findings and the outcomes of post-pregnancy patients with acquired uterine vascular abnormalities including arteriovenous malformations (AVMs).

MATERIALS AND METHODS

We performed a computerized database search for all patients with ultrasonographic findings of a vascular abnormality including AVM in our referral center between 2000-2008. An ultrasound finding of vascular abnormality was defined as an area of strong hypervascularity within the myometrium and the presence of marked turbulence. The inclusion criteria for angiography were abnormal vaginal bleeding in a hemodynamically stable patient, bhCG serum levels ≤ 30 mIU/ml, and ultrasound demonstration of large (≥ 15 mm on the larger side of the vessel) or multiple vascular lesions.

RESULTS

16 women were identified, of whom 10 (63 %) underwent uterine artery embolization. Angiography confirmed the pre-interventional ultrasound diagnosis of AVM in all cases. AVM feeding arteries were on the left side of the uterus in 80 % of the cases. Residual tissue was ultrasonographically detected in five patients: 2 underwent hysteroscopy and guided curettage following embolization and three received methotrexate. All tissue samples were benign. One small vascular abnormality resolved spontaneously.

CONCLUSION

An acquired uterine vascular abnormality including AVM should be considered in the work-up of post-pregnancy vaginal bleeding.

Cesarean scar pregnancy: a rare cause of uterine arteriovenous malformation

A 38-year-old gravida 4, para 2 woman with a history of two Cesarean sections and one curettage was referred to our hospital, because of painless vaginal bleeding and 6 weeks + 2 days of amenorrhea. The first diagnosis was Cesarean scar pregnancy, managed with methotrexate. Subsequently, an arteriovenous malformation developed, which was diagnosed with color Doppler imaging. The diagnosis was confirmed with angiography. Successful bilateral uterine artery embolization was performed with ethylene vinyl alcohol copolymer (Onyx), n-butyl-2-cyanoacrylate (Histoacryl), and gelfoam.

[Role of duplex Doppler for superficial "angiomas"]

Diagnosis of superficial vascular anomalies, previously called "angiomas", is basically clinical. Ultrasound and duplex Doppler imaging is a simple and helpful tool to confirm the clinical diagnosis and/or to suggest further required imaging modalities. The purpose of this work is to demonstrate the usefulness of duplex Doppler and ultrasound for exploring vessel and soft tissue components of vascular anomalies.

Role of external beam radiotherapy for arteriovenous malformation of the pancreas

Pancreatic arteriovenous malformation (PAVM) is rare and is mainly reported from Asian countries. We incidentally encountered an asymptomatic, early-stage PAVM in a patient who presented with portal venous distention, Child B liver cirrhosis, and hepatoma. The PAVM had multiple feeding arteries and drainage into the portal vein and varices. Because surgery was not indicated, after considering the risks and bene-fits the patient chose treatment with 40 Gy of conformal radiotherapy for 4 weeks. Computed tomography performed 6 months later revealed reduction in the size of the PAVM. Treatment had lasting effects for 18 months without significant toxicity. As observed in many reports of radiotherapy for various AVMs, the radiotherapy may stall self-augmenting growth of the AVM. Conventional fractionated radiotherapy of 40 Gy may be a useful choice for early-stage PAVM.

Pancreatic arteriovenous malformation: a case report and literature review

Most pancreatic arteriovenous malformations (PAVM) present due to gastrointestinal bleeding or abdominal pain, but these patients may be asymptomatic. Increased portal vein flow from these malformations can lead to portal hypertension and gastrointestinal bleeding. Diagnosis is often made by imaging, and early diagnosis has led to successful surgical resection or percutaneous embolization. We report a patient with PAVM, diagnosed by CT and angiography, who has remained asymptomatic for 2 years without treatment.

Dynamic 4D MR angiography versus multislice CT angiography in the evaluation of vascular hepatic involvement in hereditary haemorrhagic telangiectasia

PURPOSE

Hereditary haemorrhagic telangiectasia (HHT), or Rendu-Osler-Weber disease, is a rare autosomal dominant disorder characterised by mucocutaneous or visceral vascular abnormalities that may be widely distributed throughout the cardiovascular system. The purpose of this study was to compare multislice computed tomography angiography (MSCTA) and 4D dynamic contrast-enhanced magnetic resonance angiography (D-MRA) for evaluating vascular hepatic involvement in patients with HHT.

MATERIALS AND METHODS

Fifty-two consecutive HHT patients underwent MSCTA and D-MRA examinations for systematic analysis of vascular visceral involvement. The images from the two techniques were reviewed independently by two expert radiologists to identify the following vascular abnormalities: telangiectases or large vascular masses; perfusion disorders [transient hepatic attenuation differences (THADs)]; hepatic arteriovenous malformations (HAVMs). Data, as well as diameters of the common hepatic artery and portal vein, were compared with Cohen's kappa statistic, Student's t test and receiver operating characteristic (ROC) curve analysis, as appropriate.

RESULTS

Both MSCTA and D-MRA detected one or more of the following hepatic vascular abnormalities in 36/52 cases (telangiectases in 29/52, THADs in 23/52 and HAVMs in 25/52[CE1]). A good concordance was found between the two techniques when determining the type of hepatic shunt (κ=0.9). No statistically significant differences were found when comparing mean common hepatic artery and portal vein diameters (p=0.09 and 0.22, respectively) and their accuracy in predicting HAVMs.

CONCLUSIONS

D-MRA has the same diagnostic accuracy as MSCTA and has the advantage of being less invasive due to the absence of ionising radiation.

An unusual combination of coronary arterial and systemic venous anomalies-clinical implications

A 57-year-old male underwent coronary angiography for exertional angina which showed two left anterior descending coronary arteries (LAD)--a short LAD from the left coronary sinus terminating in the proximal Anterior Inter-Ventricular Sulcus (AIVS), a long LAD from the proximal right coronary artery entering the distal AIVS and an anomalous left circumflex artery from the right coronary sinus. In addition, he also had absent right superior vena cava and a persistent left superior vena cava entering the coronary sinus.

[Clinical application of radiotherapy for the treatment of giant vascular malformations in oral and maxillofacial region]

OBJECTIVE

To discuss the clinical use of radiotherapy in the treatment of giant vascular malformation.

METHODS

Six patients with giant vascular malformation in oral and maxillofacial region were treated by three dimensional radiation therapy in Department of Stomatology, The Second Affiliated Hospital, School of Medicne, Zhejiang University in the last ten years and the cilinical data were reviewed. The treatment results were evaluated by clinical examination and radiology.

RESULTS

No complication was observed during and after the radiotherapy. All patients were satisfied with the aesthetic results. The lesions in MRI were all reduced and even disappeared. There was no sign of recurrence during the follow-up period.

CONCLUSIONS

Three dimensional radiotherapy is safe and effective for oral and maxillofical vascular malformation.

[Rare case of multiple pulmonary nodules--a case report]

The article presents the case of a 44 years old female patient admitted in the hospital for a solitary pulmonary nodule discovered through a chest X-ray performed for left thoracic pain. Despite the young age, a lot of comorbidities were present: severe dyslipidemia, ischemic right cerebellar lesion, degenerative periventricular lesions, chronic autoimmune thyroiditis, uterine fibroma, fibrocystic mastitis, polyglobulia of uncertain etiology and Rendu-Osler disease. The investigation which showed the nature of the pulmonary nodule was the CT scan with intravenous contrast, which demonstrated that the nodules were in fact arterial-venous malformations as part of the Rendu-Osler disease. This case offers the opportunity to discuss about etiopathogeny, morphopathology, criteria of diagnosis and treatment principles in Rendu-Osler disease.

[Diagnosis and treatment of morbus Osler]

Morbus Osler or hereditary haemorrhagic telangiectasia (HHT) is a genetic disorder resulting in development of arteriovenous malformations in the mucosa and in visceral organs. The most common symptom is epistaxis. The disease may, however, cause a variety of other serious manifestations such as pulmonary arteriovenous malformations (PAVM), cerebral arteriovenous malformations (CAVM) and gastrointestinal bleeding. Collaboration between various medical specialties is essential in order to provide an up-to-date treatment and thorough work-up in the individual patient. Disregard of symptoms may result in substantial morbidity and may have serious consequences. This overview presents our current understanding of HHT.

Congenital pelvic arteriovenous malformation presenting with urinary retention: a case report

OBJECTIVE

To report a case of congenital pelvic arteriovenous malformation (pAVM) with urinary retention.

CLINICAL PRESENTATION AND INTERVENTION

A 39-year-old male patient presented with inability to void urine for 8 h. He did not have a history of dysuria or fever, but had increasing urinary frequency and difficulty in voiding over 2 years. Examination revealed a suprapubic mass without external signs of vascular anomaly. A huge, soft, irregular, non-pulsating mass was felt rectally. This mass did not disappear on urinary bladder decompression. Subsequent ultrasound and CT scan revealed pAVMs filling most of the pelvic cavity.

CONCLUSION

To our knowledge, this is the first report of a male patient with congenital pAVM presenting with urinary retention, emphasizing the need for a high index of suspicion for pAVM to avoid potential severe bleeding during suprapubic catheterization for urinary drainage.