Figure 7.

Massive arteriovenous malformation (AVM) of the pelvis in a 46-year-old woman with vaginal bleeding following a cervical biopsy. The AVM was diagnosed after a pregnancy and had been embolized 6 times previously using NBCA through the arterial route. (A) Scout radiograph from an arteriogram shows radiopaque embolic material from previous arterial embolizations. (B) The abdominal aortogram shows massive flow through a right pelvic AVM. There is enlargement of all of the adjacent branches of the internal iliac arteries as well as the median sacral and superior hemorrhoidal arteries. (C) Venous drainage, however is solely into a large varix of the internal iliac vein, internal obturator vein. (D) Selective angiogram in the distal anterior division of the right internal iliac artery shows shunting through a myriad of tiny arterial branches in the wall of the varix. (E) Transvenous (via a right internal jugular vein) catheterization and venography of the draining varix shows marked dilatation and tortuosity of the right internal iliac vein. (F) Road map image of the varix obtained by injecting contrast medium through a catheter inserted percutaneously through the anterior pelvic wall into the varix. Note, the transvenous catheter is placed from above, as well as the radiopaque anchors of a bird's nest filter placed from the right internal jugular venous approach, to contain the embolic devices and prevent pulmonary embolism. (G) Road map image obtained during injection of n-butyl-2-cyanoacrylate (NBCA), after placement of numerous large Nester platinum fiber coils within the varix. (H) Right internal iliac arteriogram following transvenous embolizations. The shunt is dramatically reduced, but there is still opacification of small arteries and veins and part of the varix. (I,J,K) Aortography 2 months after transvenous embolization shows regression of most of the feeding arteries with a smaller residual shunt into the varix, now draining through the left obturator internal vein. (L) Percutaneous venogram after cannulation of the draining varix through the anterior pelvic wall confirms placement of the catheter within the residual draining varix. Hydrocoils (0.035 inch) were placed in the varix and after confirming slowing of the flow, 10 mL of absolute ethanol was injected. (M) Oblique radiograph of the pelvis at the end of the second transvenous embolization shows extensive packing of the varix with coils and NBCA. (N,O,P) Postembolization aortogram shows no further arteriovenous shunting. Late images demonstrated normal opacification of the iliofemoral veins and inferior vena cava.