Figure 1
Arteriovenous malformation, located in the right shoulder
A selective right subclavian artery DSA showing the AVM with several hypertrophic arterial feeders arising from the subclavian and axillary arteries.
Endovascular treatment of soft tissue vascular malformation
SectionInterventional radiology
Case TypeClinical Cases
AuthorsPratali A, Granai G, Conti A, Vignali C, Bartolozzi C
Connected authors
34 years, male
Clinical History
A 34-year-old male patient presented with a history of right shoulder pain which had persisted for the past several years and had worsened in the last few months, associated with a growing palpable
mass.
Imaging Findings
A 34-year-old male patient presented with a history of right shoulder pain which had persisted for the past several years and had worsened in the last few months, associated with a growing palpable
mass. The patient had undergone a color-Doppler sonography (CDS) examination, which had demonstrated arteriovenous malformation (AVM) with high arterial flow signals and low resistivity indices. A
magnetic resonance angiography (MRA) procedure had confirmed the CDS findings. The patient had been referred to our institute to undergo percutaneous embolization. Digital subtraction angiography
(DSA) had been performed, which had depicted the presence of multiple arterial feeders arising from the homolateral subclavian and axillary arteries. By means of selective and superselective
catheterization, the inflow arteries had been embolized using metallic coils. Post-procedural DSA had demonstrated an almost complete devascularization of the lesion. After treatment, the pain had
decreased and a CDS examination had confirmed a marked reduction of intralesional vascularization. Three months later, because of pain recurrence, the patient again underwent computed tomography
(CT), that revealed bone erosions of the humeral head, while MRA depicted the recurrence of the AVM. Therefore, the patient underwent a repeat superselective embolization of the arterial feeders by
means of tissue adhesive followed by percutaneous puncture of the venous side, and the administration of an ethanol injection. The subclavian vein occlusion was performed by a balloon catheter to
avoid ethanol wash-out. After the treatment, the symptoms markedly decreased. On follow-up, two years later, CDS and MRA revealed persistance of the AVM, yet with a marked reduction of
vascularization and diameter.
Discussion
AVMs are congenital vascular lesions characterized by hypertrophic in-flow arteries and shunting through a primitive vascular nidus into tortuous dilated out-flow veins. The symptoms vary according
to the lesion's location and size, and the presence of complications such as aestethic damage, pain, tissue ulceration, nerve deterioration, cardiac overload and haemorrhage. CDS and MRA are
essential tools in the diagnostic work-up of AVMs. The CDS procedure allows accurate measurement of flow volumes and resistivity indices, that can be helpful in the initial evaluation and in the
follow-up. MR imaging can accurately depict the involvement of adjacent anatomical structures, such as the muscles and nerves, whereas MRA is able to display arterial feeders and venous drainage. In
addition, MRA represents an important tool in the follow-up of these lesions, in particular after treatment. Treatment is indicated only when the lesion is associated with imparing symptoms or
complications, and it is represented by surgical resection or embolization. Surgical resection can be extremely difficult, in particular when the lesion's location or size require large destructive
resections. Therefore, interventional radiology has emerged as an important therapeutic tool in the management of AVMs. By means of superselective catheterizations and direct puncture techniques, the
AVM nidus can be embolized without damaging the neighbouring structures. In large and complex AVMs, repeated embolizations could be required. Many endovascular embolizing agents can be used; such as
metallic coils, glues, polyvinyl alcohol particles and ethanol. It has been reported that the use of microparticles and acrylic glue is associated with high immediate success rates but these agents
seem to induce neoangiogenesis and lesion recanalization; therefore, they should be used only when surgical resection is planned after the procedure. Ethanol represents a valid sclerosing agent both
in the immediate and late follow-up, with persisting lesion devascularization. Nevertheless, it should be used in low doses and associated with proper vascular occlusion techniques (balloon
catheters, tourniquets, and manual compression) in order to reduce its high local and systemic toxicity. Complications may occur after percutaneous treatment; in the form of cutaneous fistulation and
necrosis, extra-lesional venous thrombosis, and neurological damage. These complications may be avoided through the proper selection of access sites and embolic agent dosage. Interventional radiology
may play an important role in the treatment of AVMs, being able to reduce lesion vascularization and dimensions, with clinical improvement and minimal patient discomfort.
Differential Diagnosis List
Arteriovenous malformation, treated with embolization.
Final Diagnosis
Arteriovenous malformation, treated with embolization.
References
[1]
Yakes WF, Rossi P, Odink H.
How I do it. Arteriovenous malformation management.
Cardiovasc Intervent Radiol. 1996 Mar-Apr;19(2):65-71. (PMID: 8729181)
[2]
Yakes WF, Haas DK, Parker SH, Gibson MD, Hopper KD, Mulligan JS, Pevsner PH, Johns JC Jr, Carter TE.
Symptomatic vascular malformations: ethanol embolotherapy.
Radiology. 1989 Mar;170(3 Pt 2):1059-66. (PMID: 2916057)
[3]
Widlus DM, Murray RR, White RI Jr, Osterman FA Jr, Schreiber ER, Satre RW,
Mitchell SE, Kaufman SL, Williams GM, Weiland AJ.
Congenital arteriovenous malformations: tailored embolotherapy.
Radiology. 1988 Nov;169(2):511-6. (PMID: 3175000)
[4]
Gomes AS, Busuttil RW, Baker JD, Oppenheim W, Machleder HI, Moore WS.
Congenital arteriovenous malformations. The role of transcatheter arterial
embolization.
Arch Surg. 1983 Jul;118(7):817-25. (PMID: 6860130)
Case information
| URL: | https://www.eurorad.org/case/2727 |
| DOI: | 10.1594/EURORAD/CASE.2727 |
| ISSN: | 1563-4086 |
Figure 2
Post-procedural DSA
A selective right subclavian artery DSA performed immediately after coil embolization demonstrating an almost complete devascularization of the lesion. No complications occurred.
Figure 3
A bone erosion of the humeral head caused by the AVM
On follow-up three months later, a contrast enhanced CT depicting a large area of bone erosion of the humeral head caused by the AVM, the high iodinated contrast enhancement of the lesion indicating its persistent vascularization.
Figure 4
AVM recurrence demonstrated by the MRA
A follow-up MRA performed three months later, showing recurrence of the AVM. The large arterial feeders and the venous nidus are clearly displayed on the MIP coronal reconstruction.
Figure 5
AVM recurrence demonstrated by the DSA
A selective right subclavian artery DSA performed on follow-up three months later, confirming recurrence of the AVM. Coils previously deployed can be appreciated within the nidus.
Figure 6
Ethanol injection
An image showing how the subclavian vein was temporarily occluded by balloon catheter while, through direct puncture of the venous nidus, ethanol was injected. No complications occurred during or immediately after the procedure.
Figure 7
After the treatment of MRA
An MRA performed on follow-up 24 months later, showing a satisfactory devascularization of a large portion of the AVM; the lesion appears significantly reduced in size.
Arteriovenous malformation, located in the right shoulder
A selective right subclavian artery DSA showing the AVM with several hypertrophic arterial feeders arising from the subclavian and axillary arteries.
Post-procedural DSA
A selective right subclavian artery DSA performed immediately after coil embolization demonstrating an almost complete devascularization of the lesion. No complications occurred.
A bone erosion of the humeral head caused by the AVM
On follow-up three months later, a contrast enhanced CT depicting a large area of bone erosion of the humeral head caused by the AVM, the high iodinated contrast enhancement of the lesion indicating its persistent vascularization.
AVM recurrence demonstrated by the MRA
A follow-up MRA performed three months later, showing recurrence of the AVM. The large arterial feeders and the venous nidus are clearly displayed on the MIP coronal reconstruction.
AVM recurrence demonstrated by the DSA
A selective right subclavian artery DSA performed on follow-up three months later, confirming recurrence of the AVM. Coils previously deployed can be appreciated within the nidus.
Ethanol injection
An image showing how the subclavian vein was temporarily occluded by balloon catheter while, through direct puncture of the venous nidus, ethanol was injected. No complications occurred during or immediately after the procedure.
After the treatment of MRA
An MRA performed on follow-up 24 months later, showing a satisfactory devascularization of a large portion of the AVM; the lesion appears significantly reduced in size.