PMC6005803_01
a. First presentation of AVM in 2014. The patient had open ligation of his radial artery and as well as embolization performed. Despite surgical and embolization therapy, bleeding was poorly controlled, requiring prolonged bandage over the right thumb as seen in the above picture. b. Subsequent presentation of AVM in 2017. Severe skin necrosis with bone exposure and torrential bleed were noted. c. 6 months post surgery with good wound healing and cessation of bleeding.
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He lost the use of his thumb as he constantly required a heavy compression dressing to arrest the torrential haemorrhage (Fig. 1a). At presentation, there was torrential, life threatening arterial bleeding, necrosis with exposed bone, and macerated skin from prolonged bandaging (Fig. 1b), as well as symptomatic anaemia. He had recovered well 8 months post-surgery (Fig. 1c).
a. Baseline angiography was obtained for evaluation. An angiogram was obtained, revealing a previously ligated radial artery, feeding branches from the ulnar artery and palmar arches. b. Large draining veins. c. With a pneumatic tourniquet and elastic bands at the base of the phalanges as mechanical constrictors, vascular stasis was achieved to reduce reflux and non target embolization of the digital arteries.
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Diagnostic angiography revealed a previously ligated radial artery, feeding branches from the ulnar artery and palmar arches (Fig. 2a), as well as large draining veins (Fig. 2b).
a. The prominent draining veins were punctured with a 21G needle. A 4Fr microcatheter guidewire was advanced to cannulate the nidus. b. Absolute ethanol with lipiodol in 1:1 ratio was injected and incubated in the AVM for 3-5mins. c. Post ethanol embolization angiogram revealed suboptimal results with persistent contrast filling of the AVM. d. Direct puncture and embolization with 20% cyanoacrylate glue and ethanol was repeated. e. Multiple runs of glue and ethanol embolization were performed via different approaches, i.e inferior approach with cannulation via ulnar artery/palmar arch, superior approach with placement of embolization catheter via the digital artery of the index finger. f. Post embolization check angiogram revealed no further feeding arteries or contrast enhancement.
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Using the direct puncture method, a 21 G needle was directed into the prominent draining veins, checking backflow of blood by gentle aspiration (Fig. 3a). France) into the AVM (Fig. 3b). Five minutes after ethanol injection, an angiogram was performed to evaluate the response to embolisation. However, a post-embolisation angiogram revealed suboptimal results with persistent contrast filling of the AVM (Fig. 3c). Braun, Melsungen, Germany) by mixing 2 mL lipidiol and 0.5 mL glue together with ethanol (Fig. 3d). Multiple runs of glue and ethanol were performed to achieve best results, with careful manipulation and repeat aspiration of remnant ethanol post-embolisation (Fig. 3e). A completion angiogram revealed no further collaterals to the AVM (Fig. 3f).