K.E.M. Radiology
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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Embolisation of a bleeding AVM in the thigh
Contributed by : Armaandeep Singh Aulakh
Introduction:
Arteriovenous malformations (AVMs) can result in dermatological manifestations, such as a reddish, eczematous reaction, angiodermatitis and ulcerations (1,2),. Some cases result in life-threatening congestive heart failure or even intractable bleeding. Some AVMs may lead to skin ulcerations which may bleed due to high flow in the feeder arteries. We report a case of a leg ulcer bleeding profusely due to underlying AVM supplied by branches superficial femoral artery. It was embolised using NBCA glue via transarterial and transvenous approach.
Case presentation:
A 40-year-old man suffering from arteriovenous malformation (AVM) involving the left lower limb presented with bleeding ulcer secondary to trivial trauma along the medial aspect of lower one third of left thigh. Profuse spurt of blood was noted from the base of the ulcer (Fig 10a) . A tight compression dressing was applied to control the bleeding in the emergency surgical services of our hospital. The patient was referred to department of Interventional Radiology, Digital subtraction angiography was performed and subsequent embolization of AVM involving the left lower thigh was planned. Using the right 6F femoral access and Balkin cross over sheath, the left lower limb angiogram was performed. Multiple arterial feeders arising from superficial femoral artery were noted feeding the nidus with femoral vein being the major draining vein ( Fig 1 , 2).
Fig 1, 2; Left SFA angiogram shows large AVM involving the thigh with multiple feeders from the branches of the SFA. Early opacification of multiple dilated venous pouches and femoral vein is seen.
Using eV3 Marathon microcatheter and glue of various concentration, trans arterial embolization of the nidus was performed and extensive glue cast involving the nidus was obtained (Fig3 &4).
Fig 3: Selective catheterization of arterial feeders done with microcatheter and embolization done using 16 % NBCA (n butyl cyanoacrylate) .
Fig 4: Glue cast in the AVM
However, the patient had blood tinged oozing from the ulcer next day. Hence patient was taken for another session of embolization. A decision was taken to perform the procedure via venous access. An occlusion balloon was inflated and placed in the proximal left SFA to decrease the arterial inflow (Fig 5).
Fig 5 : Inflation of compliant balloon in SFA to reduced arterial in flow.
Retrograde left great saphenous vein (GSV) access was obtained with a SL10 microcatheter and a microwire was advanced till the AVM nidus (Fig 6 &7).
Fig. 6: Retrograde access in the left GSV to reach the nidus via transvenous approach.
Fig 7: Injection of NBCA via transvenous approach
A 16 % NCBA glue- lipiodol mixture was used for embolization. At this step, a decision was taken to release the pressure bandage around the ulcer. On releasing the pressure bandage the glue was seen tracking from the nidus to the bleeding site and subsequent oozing of glue from the bleeding site was noted and the track got sealed (Fig 9 &8)
Fig 8, 9 : Pressure bandage over the oozing ulcer released to allow glue to track along the flow of blood leading to hemostasis and deeper penetration of AVM.
Final glue cast was noted along the nidus reaching the skin surface and complete haemostasis was achieved (Fig 10a, b).
Fig 10 a, b : Photographs showing spurt of blood from AVM and post embolisation hemostasis.
Fig 11: Final SFA angiogram shows significant obliteration of AVM with glue cast.