1Tesnim Besbes, 1Bilel Derbel, 1Sobhi Mleyhi, 2Yasser Ben Cheikh, 1Mohamed Messai, 1Malek Ben Mrad, 1Raouf Denguir

1Department of Cardiovascular Surgery, Rabta Hospital, Tunis, Tunisia; 2Department of Interventional Radiology, Sahloul Hospital, Sousse, Tunisia

Background:

Arteriovenous malformation (AVM) is a congenital vascular malformation consisting of direct communications between the arterial and venous systems through a central nidus. They vary in size, location and presentation with lower limb AVM being the least common. Treatment indication and modalities are challenging and still controversial.

Here in we present the case of an enormous pelvic AVM extending to the lower limb revealed by a hemorrhagic shock.

Case Report:

A 43-year-old male was admitted to our hospital for pain, swelling and bleeding of the right thigh. Patient was diagnosed at the age of 3 years old with AVM of the right thigh. No history of treatment was performed and he was lost to follow up. On admission, patient presented with a huge AVM of the pelvis and the right thigh with a 10 cm in diameter ulcer in the internal right thigh actively bleeding. He was hypotensive and tachycardic. After resuscitation, an angio-CT scan was performed and objectified two huge AVM, 30 cm in long axis each, one in the right pelvis and the second involving the right lower limb. Due to persistent active bleeding the patient was operated, to manage the hemorrhagic shock. Initial strategy was surgical ligation of the bleeding vessels and firm packing. Second, an endovascular approach was dictated. Two endovascular interventions were performed within 5 months, combining afferent vessel embolization and percutaneous injection into the nidus. No procedural incidents were noted however the ulcer was complicated by infection, skin necrosis and sepsis successfully treated with antibiotics and careful wound care. On one-year follow up the patient remained asymptomatic.

Conclusion(s):

AVM is a rare disease and could be potentially life threatening if left untreated and non-surveilled. Effective and safe treatment impels the work of a multidisciplinary team. Endovascular therapy is appealing, highly efficient and multisession therapy could be needed to reduce the risk of complications and to reach an optimal result.