PMC6319539_01
Contrast-enhanced MDCT shows (a) a suspicious giant pelvic AVF (arrows), (b) confirmed by Color Doppler
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Fig1
Tomography (MDCT) confirming the presence of choriocarcinoma, but also showing a giant pelvic aneurysm suspecious for AVF (Fig. 1), lung metastases and pulmonary thrombo-embolisms. The diagnosis of AVF was confirmed by a Color Doppler Ultrasound examination showing a typical arterialized, low-resistance blood flow of the pelvic veins (Fig. 1). The case was discussed within a multidisciplinary gynaecological and radiological meeting.
Diagnostic arteriography from the right hypogastric artery shows (a) a giant AVF with early opacification of the right gonadal vein and the inferior vena cava. DSA performed with a microcatheter shows peripheral arterial branches sustaining the fistula (b), embolized using coils (c) and PVA particles (d)
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Fig2
AVF sustained by branches of both hypogastric arteries with early opacification of the right gonadal vein and the inferior vena cava (Fig. 2). After selective catheterization of right (Fig. 2) and left (Fig. 3) hypogastric arteries, using a coaxial microcatheter (Carnelian 2.2, Tokai, Medical Products, Sarayashiki Taraga Kasugay-city, Japan), the afferent branches to AVF were subsequently embolized using first detachable coils (Interlock, Boston Scientific, Natick, MA, AVF in-flow (Figs. 2 and 3). A transfemoral phlebography with selective catheterization of the right gonadal vein showed multiple thrombi (Fig. 4), leading to the pulmonary embolism previously detected at the contrast-enhanced MDCT. Using a right transjugular approach, an Amplatzer plug was finally placed at the confluence of the right gonadal vein in the vena cava (Fig. 4), not only to reduce AVF out-flow but also to occlude the right gonadal vein, preventing further episodes of pulmonary embolism. Metrorrhagia almost disappeared after the procedure. A contrast-enhanced MDCT examination performed 24 h after the embolization confirmed the correct placement of the plug (Fig. 4) and the significant reduction in volume and enhancement of the AVF.
DSA shows branches of the left hypogastric artery sustaining the AVF (a), embolized also using Squid (arrow) (b)
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Fig3
AVF in-flow (Figs. 2 and 3). A transfemoral phlebography with selective catheterization of the right gonadal vein showed multiple thrombi (Fig. 4), leading to the pulmonary embolism previously detected at the contrast-enhanced MDCT. Using a right transjugular approach, an Amplatzer plug was finally placed at the confluence of the right gonadal vein in the vena cava (Fig. 4), not only to reduce AVF out-flow but also to occlude the right gonadal vein, preventing further episodes of pulmonary embolism. Metrorrhagia almost disappeared after the procedure. A contrast-enhanced MDCT examination performed 24 h after the embolization confirmed the correct placement of the plug (Fig. 4) and the significant reduction in volume and enhancement of the AVF.
Diagnostic phlebography via trans-femoral of the right gonadal vein shows (a) multiple thrombi (arrows). Amplatzer plug placement (arrows) via trans-jugular to occlude the right gonadal vein (b) to simultaneously reduce AVF-outflow and avoid pulmonary embolism. Contrast-enhanced MDCT after 24 h confirms (c) the correct placement of the plug (arrows)
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Fig4
AVF in-flow (Figs. 2 and 3). A transfemoral phlebography with selective catheterization of the right gonadal vein showed multiple thrombi (Fig. 4), leading to the pulmonary embolism previously detected at the contrast-enhanced MDCT. Using a right transjugular approach, an Amplatzer plug was finally placed at the confluence of the right gonadal vein in the vena cava (Fig. 4), not only to reduce AVF out-flow but also to occlude the right gonadal vein, preventing further episodes of pulmonary embolism. Metrorrhagia almost disappeared after the procedure. A contrast-enhanced MDCT examination performed 24 h after the embolization confirmed the correct placement of the plug (Fig. 4) and the significant reduction in volume and enhancement of the AVF.
After the second arterial embolization performed 6 months later, the final aortography shows the complete AVF occlusion
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Fig5
The second embolization, combined with a complete response to systemic chemotherapy confirmed by beta-HCG levels normalization with disappearance of pulmonary metastases, determined the complete AVF resolution (Fig. 5).