Endovascular therapy of arteriovenous malformation in a male patient with severe post-coital pelvic pain

Abstract

Purpose Congenital pelvic arteriovenous malformations (AVMs) are high-flow vascular lesions consisting of abnormal shunts between arteries and veins within a nidus. The rare presentation and extensive network of vasculature contributes to the difficulty in effective treatment. Optimal therapeutic options are determined based on the clinical presentation, the location of the lesion, and possible complications. Case report A 24-year-old male patient with a history of recurrent pain following sexual intercourse presented with complaints of intense pelvic pain radiating to the perineal area. Computed tomography angiography (CTA) revealed a large venous aneurysm as an outflow vein of a right-sided pelvic AVM. Embolisation of the outflow veins was established along with direct percutaneous delivery of fibre coils and thrombin to the venous aneurysm of the AVM. With recurring symptoms and AVM recanalisation on angiography, another direct puncture and placement of pushable coils was made. Total AVM occlusion was achieved with no recanalisation on follow-up digital subtraction angiography (DSA), and the patient remained asymptomatic. Conclusions Endovascular embolisation of the nidus area may result in a complete occlusion of an AVM. Therefore, a thorough understanding of the vascular anatomy of the AVM is essential in choosing an effective embolisation strategy and to minimise the risk of possible complications.

Endovascular management of a pelvic arteriovenous malformation

“…An initial concern with a stepwise endovascular approach as detailed in this case report would be the necessity of multiple operative sessions to achieve complete obliteration of the aneurysm sac. This contrasts with previously published case reports that utilize a single endovascular procedure to embolize both arterial inflow and venous outflow of the AVM, 4 , 5 , 9 , 12 as well as any open procedures that ligates the AVM and all collateral branches. 7 , 11 , 13 , 14 Nonetheless, this step-wise approach allowed for a more conservative treatment plan, because we could be ensured that all arterial collateral vasculature was embolized before closing off outflow venous structures.…”

“…Intact saccular pelvic aneurysms developing from an AVM as indicated in this case report are rare, especially in male patients. 3 , 6 , 7 , 8 , 9 , 10 , 11 Similar to contemporary literature, we opted to use an endovascular approach for full embolization, including a combined arterial and venous embolization approach to decrease high pressure flow responsible for maintaining the aneurysmal AVM size. Through this approach, we were effective in thrombosing the sac and allowing regression in size, while avoiding an open procedure, aneurysmal rupture, and concordant morbidity.…”

“… 7 , 11 , 13 , 14 These contrasts starkly with endovascular treatment, as follow-up outpatient visits and subsequent imaging studies may be required to ensure and reconfirm complete elimination of arterial flow and shrinking of saccular structure. 4 , 5 , 9 , 12 We postulate that even though endovascular treatment should be considered as high valued care for treatment of aneurysms of this type, this approach may not be the best option for acutely symptomatic or ruptured aneurysms with intraperitoneal bleeding of unknown origin.…”

“…Although surgical ligation of feeding arteries or excision of aneurysmal tissue around or within the AVM is an option, the preferred method of treatment of aneurysmal pelvic AVMs has been through endovascular coil embolization, with both venous and arterial embolization occurring in a single procedure. 4 , 5 , 9 , 12 However, in this case study, we describe the incidental finding of a pelvic AVM that was treated with staged arterial and venous coil embolization. These staged procedures resulted in complete resolution of the aneurysmal flow on follow-up imaging, while preventing any possible rupture owing to remaining collateral arterial flow in a concomitant arterial and venous embolization procedure.…”

“… 3 A vast minority are identified as congenital in nature, especially in male patients, with a limited amount of case studies identified in the literature. 3 , 6 , 7 , 8 , 9 , 10 , 11 …”