A Case of Catheter Embolization of a Pelvic Arteriovenous Malformation Facilitated by Through and Through Guidewire Technique

<p>A woman in her childbearing age with a large pelvic mass was referred to our department. Contrasted computed tomography revealed an oval pelvic arteriovenous malformation (PAVM) with the longest diameter of 60 mm. The PAVM had a sole tortuous arterial feeder branching from the fifth lumbar artery, and a venous outlet to the left common iliac vein (LCIV). Because of the acute branch separation angle of the lumbar artery and the distal tortuosity, the tip of the catheter could not be stabilized at the appropriate positions for embolization through the right common femoral arterial access. From the right brachial arterial (RBA) access, the X-ray opaque tip of a 0.014 inch guidewire was able to be advanced partially into the PAVM. However, the stabilization was not robust enough to support the tracking of a microcatheter or delivery sheath through the angulation before the arterial pedicle. In contrast, from the left common femoral venous (LCFV) access, the guidewire could be easily advanced into the PAVM but not into the arterial gate of the PAVM. The tip of the guidewire from the RBA was snared, and brought out through the LCFV access sheath, creating an RBA–LCFV stabilizing wire. The tip of a 6 Fr sheath could then be advanced and stabilized in the arterial pedicle sufficiently. Three self-expandable nitinol mesh devices were used to embolize the arterial pedicle and the fifth lumbar artery. After the arterial inflow embolization, the PAVM was packed coil-embolized. The final angiography confirmed the complete obliteration of PAVM, with no occurrence of post-procedural complications. The patient was discharged on the second postoperative day. She had an uneventful course of pregnancy and bore a child 18 months after the procedure. Two years after the embolization, computed tomography revealed a volume reduction of PAVM with the maximum diameter decreased to 32 mm.</p>