Arteriovenous Malformation of the Uterus: A Review and Update.

Arteriovenous malformation of the uterus (AVMU) is a very rare and uncommon condition, because it has been documented that less than 100 cases of AVMU have been reported in the literature. AVMU is potentially a life-threatening condition with regard to the fact that some cases of AVMU could manifest with profuse bleeding from the uterus via the vagina. AVMU could either be congenital AVMU which is less common or acquired AVMU with pregnancy noted to have a role to play in the pathogenesis of AVMUs. The true incidence of AVMU is stated to be difficult to ascertain in view of the fact that some cases of bleeding that have been caused by AVMU do tend to conservative, medical management and many of these AVMUs could remain undiagnosed. The most common manifestations of AVMUs tend to be abnormal uterine bleeding that could be episodic, intermittent, continuous, mild or torrential which could lead to severe anaemia or shock. Some AVMUs could be found incidentally based upon radiology imaging for a different condition. Other symptoms of AVMUs do include: Metrorrhagia; Menorrhagia; Bleeding following a miscarriage; Bleeding following dilatation and curettage; Bleeding subsequently after hysterectomy; Bleeding associated with trophoblastic disease; Bleeding following caesarean section; Post-partum haemorrhage; Intermittent vaginal bleeding; Continuous vaginal bleeding; Post-menopausal bleeding; Acute abdominal pain with hemoperitoneum; Pallor; Dizziness; Weakness; Drowsiness; Being unwell following delivery of a baby; Bleeding following therapeutic abortion; Tachycardia; Supra-pubic pain at times; hypotension. Diagnosis of AVMU tends to be made based upon radiology imaging with utilization of ultrasound scan / Doppler scan of the uterus and pelvis, Contrast Computed Tomography scan, and Contrast Magnetic Resonance Imaging Scan, as well as by selective angiography which tends to be ensued by treatment with embolization of the feeding vessels to the AVMU. The treatment of AVMUs these days has ranged between conservative and medical management that includes hormones for small AVMUs, Hysterectomy, which tends to be a definitive treatment that removes the AVMU but does leave the individual not being able to maintain her future fertility, as well as selective angiography and super-selective embolization of the uterine arterial branches feeding the AVMU, which does tend to maintain the future fertility of the patients and which has the advantage of being undertaken under local anaesthesia. Questions that should be on the minds of clinicians include should doppler ultrasound scan of the uterus be undertaken with regard to all women who develop persistent vaginal bleeding pursuant to or during management of miscarriage, considering that there are very few interventional radiologists in many hospitals. This means that selective angiography plus super-selective embolization cannot be undertaken in district hospitals should all women who have suspected AVMU that have severe bleeding that may require surgical operation be referred to a tertiary hospital so that they could possibly benefit from the undertaking of selective angiography and embolization of their AVMUs instead of hysterectomy to enable them to maintain their future fertility? It is also important for clinicians to be made aware of the existence of AVMUs so that they could appreciate the risk factors as well as the clinical manifestations who should be suspected of possibly having AVMUs. Clinicians also need to learn about various conservative and expectant methods of treating AVMUs including hormonal treatment. Clinicians also need to appreciate the future implications for future fertility of women who have AVMUs. Possible treatment options that have not been utilized for the treatment of AVMUs include: (a) Radiology image-guided cryotherapy of AVMU, (b) Radiology image-guided radiofrequency ablation of AVMU, and (c) Radiology Image-guided Irreversible electroporation of AVMU. There is a global need for the training of more interventional radiologists all over the world including in the developing countries as well as some of the developed countries to that they can undertake embolization of AVMUs as well as they can provide various interventional radiology treatment options for various other conditions.

Tran's Arterial Embolization of an Unusual Pleomorphic Rhabdomyosarcoma in Adulthood for Better Preoperative Conditioning

Rhabdomyosarcomas, being the most common sarcomas of childhood, have an extremely poor prognosis, and pleomorphic rhabdomyosarcomas occur very rarely in adults. Despite advanced diagnostics, it is not uncommon for such tumours to be misinterpreted. The 73-year-old patient was diagnosed with a swelling on the inner side of the left thigh 3 years previously after a minor trauma, which was interpreted as a small well-revascularised haemangioma in original CT angiography. While this mass showed little change over the last 2.5 years, a sudden progression of growth occurred 6 months ago. With the working diagnosis of a haemangioma, differential diagnosis of a schwanoma, the vessels supplying the tumour from profunda femoral artery were visualised preoperatively in a selective angiography and embolised. Shortly before the operation, dupex sonography revealed a renewed hypervasculariasis of the tumour. The supplied vessels from the superficial femoral artery and from the main left profunda trunc were embolised with Embosphere Microspheres 500-700 (Merit). Complete devascularisation of the tumour was achieved, so that the tumour could be resected very effectively in accordance with the compartment. The histological work-up of the tumour resulted in the diagnosis of a pleomorphic rhabdomyosarcoma grade II with tumor-free margins. Preoperative embolisation could be an effective method for preoperative conditioning of such rhabdomyosarcoma. Using this example, this study discusses the current diagnostic and therapeutic options for adult rhabdomyosarcomas.

A case of atrial septal defect associated with anomalous sinoatrial node artery in pulmonary atresia with intact ventricular septum

An 11-year-old boy affected by pulmonary atresia with intact ventricular septum (AP-IVS) was listed for percutaneous pulmonary valvuloplasty and closure of multi-fenestrated atrial septal defect (ASD). Intraprocedural transesophageal echocardiography arose the suspect of abnormal coronary artery pattern while selective angiography documented a single sinoatrial node artery (SANa) with an unusual retro-aortic course. As consequence, we proceeded to effectively close the defects with a not self-centering device placed in the most central side hole. This case supports the hypothesis that sometimes arrhythmic complication during ASD closure procedures might be due to unrecognized injury of the SANa.

A case of pediatric paraspinal arteriovenous fistula with multiple fistulas

Paraspinal arteriovenous fistula (AVF) is a rare vascular malformation. This is the first described case of a pediatric paraspinal AVF along nonvertebral segmental nerve with multiple fistulas. An 8 months-old girl was found to have a continuous murmur on the back on chest auscultation. Enhanced computed tomography revealed a segmental nerve AVF of the right thoracic spine. Selective angiography of the right T8 and T9 intercostal arteries demonstrated a high flow fistula at the level of the neural foramen, with drainage to the epidural and azygos veins. The fistulas point was visualized using Volume rendering(VR) and Minimum Intensity Projection(MIP) images. Endovascular treatment from the right T8 and T9 feeding arteries was provided using coils and n-butyl-2-cyanoacrylate(NBCA). Postembolization angiography demonstrated complete occlusion of the fistulas. The postoperative course was uneventful. We discuss the first case of a pediatric paraspinal AVF along nonvertebral segmental nerve with double holes of fistulas with literature review.

Radiation Diagnosis and Therapy of Vertebral Hemangiomas

The literature review is devoted to the current radiation methods for studying vertebral hemangiomas. The significance of basic (radiography, computed tomography, and magnetic resonance imaging) and additional (Doppler ultrasound, scintigraphy, and selective angiography) diagnostic techniques is analyzed and their role in determining the indications for surgical treatment is clarified. The priority of computed tomography over other imaging methods for this pathology is established. The use of radiation therapy for vertebral hemangiomas at the present stage of medicine development is highlighted.

Carotid chemodectoma: treatment experience

The article presents the results of the examination and treatment of 6 patients with carotid chemodectomies who were treated at the clinic of maxillofacial surgery at Kharkov National Medical University. An analysis of the results of treatment. On the example of the results obtained for the differential diagnosis and selection of the optimal nature of surgical intervention when patients approach the maxillofacial surgeons, it is necessary to use ultrasound and computed tomography, and in doubtful cases selective angiography.

Management of Multiple Arteriovenous Malformations of the Small Bowel

A 62-year-old Japanese female was referred to our hospital with gastrointestinal bleeding. Although small-bowel bleeding was suspected, no bleeding source was identified by enhanced computed tomography (CT), video capsule endoscopy (VCE), and double-balloon enteroscopy (DBE). Five years later, the patient had recurrent intermittent bloody stools with a significant decrease in hemoglobin levels. Although no active bleeding was observed on antegrade DBE, we detected a pulsatile submucosal uplift accompanied by a small red patch on the top of the uplift in the jejunum. Arteriovenous malformation (AVM) was suspected as the cause of small-bowel bleeding. Multiple-phase CT showed a number of small vascular ectasias during the arterial phase in the jejunum, and we confirmed the presence of multiple AVMs in the jejunum by selective angiography. To identify the location of the lesions and determine the minimal surgical margins, we performed intraoperative selective angiography with indocyanine green (ICG) injection. This technique allowed us to clearly observe the region and perform segmental small-bowel resection with minimal surgical margin. The patient reported that she has had no gastrointestinal bleeding at the two years follow-up visit.