PMC6717946_01
Computed tomography volume rendering reconstruction. Pelvic right-sided arteriovenous malformation. Multiple branches of the right internal iliac artery entangling and feeding the nidus located in the wall of an outflow venous aneurysm (asterisk). Multiple further outflow veins to the iliac venous system (arrow)
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Subsequent computed tomography angiography (CTA) confirmed the presence of a large venous aneurysm (approx. 10 cm in diameter), which transpired to be an outflow vessel of a predominantly right-sided pelvic AVM, supplied by multiple visceral branches of the right internal iliac artery (IIA) (Figure 1).
Selective digital subtraction angiography of the right internal iliac artery. Multiple arterial branches (in dark) supplying an aneurysmal outflow vein (in white)
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Access was acquired via the left femoral artery, and selective DSA of the right IIA depicted multiple vessels supplying the AVM (Figure 2).
Non-subtracted (A) and subtracted (B) digital subtraction angiography. Detachable coils in the outflow veins (short arrow) essentially decreasing the outflow from the arteriovenous malformations. Venous aneurysm still patent (long arrow)
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US guidance was subsequently utilised to directly puncture and fill the venous aneurysm with pushable fibre coils (Nester, MRey coils, Cook Medical) (Figure 3A). A control DSA depicted minor thrombosis of the venous aneurysm and a moderate decrease in AVM perfusion, due to slower outflow through the coiled draining veins (Figure 3B).
Direct percutaneous puncture of the venous aneurysm (short arrow) - embolisation with pushable coils and thrombin (long arrow) (A). Control digital subtraction angiography showing complete thrombosis of the venous outflow with no persisting perfusion through the arteriovenous malformations (B)
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Utilising direct puncture of the venous aneurysm (Figure 4A), six Nester coils were advanced and control DSA depicted stagnant flow in a notably diminished active zone of the aneurysm. The disturbed outflow and decreased inflow finally resulted in total AVM occlusion (Figure 4B).
Follow-up digital subtraction angiography. No visible arteriovenous shunts within totally embolised arteriovenous malformation
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Monthly US follow-ups and a final follow-up DSA after seven months showed no recanalisation of the AVM (Figure 5).