Uterine arteriovenous malformation treated with selective embolisation of uterine arteries: a case report

Uterine arteriovenous malformation (AVM) is a very rare gynaecological condition, which can potentially lead to life-threatening abnormal uterine bleeding. In most cases uterine AVM is associated with prior pregnancy or pelvic surgery. We present the case of young woman seven weeks after medical termination of pregnancy diagnosed with heavy uterine bleeding due to uterine AVM, which was successfully treated with selective embolisation of uterine arteries.

Bilateral acute pyelonephritis with left renal artery aneurysm as a cause of bilateral spontaneous subcapsular haematoma: lessons learnt

Forniceal ruptures after acute pyelonephritis are relatively common. Bilateral spontaneous subcapsular haematoma (SSCH) is an uncommon sequela to pyelonephritis. We report a case of SSCH where the underlying cause of haematoma was a vascular anomaly. A 38-year-old woman with diabetes presented with fever, flank pain and shock following cystoscopy and Double J stenting done elsewhere. CT abdomen showed left subcapsular renal haematoma, managed by pigtail insertion. Postoperative CT showed right renal subcapsular haematoma and left moderate renal subcapsular haematoma. Renal angiogram showed pseudo-aneurysm on the left middle polar artery for which selective embolisation was performed. Physicians and urologists who come across SSCH for which no definite aetiology could be identified should keep in mind the possibility of an underlying vascular anomaly that could precipitate such a condition. The purpose of this report is to highlight the importance of remembering vascular causes in such unexplained cases of SSCH.

Endovascular repair of de novo post-stenotic aortic coarctation aneurysms with complex collateral supply: two cases with long and medium term follow-up

Purpose To report the technical details and outcomes of the endovascular repair of two cases of de novo post-stenotic aortic coarctation aneurysms complicated by complex collateral supply. Case presentations Two patients with thoracic aortic aneurysms complicated by complex aneurysm sac collaterals distal to a previously untreated thoracic aortic coarctation have been treated at our institution. Open surgical intervention was deemed to carry a high risk of haemorrhage due to the degree and complexity of arterial collateralisation. In the first case, selective embolisation of collateral vasculature was performed prior to successful exclusion of the aneurysm with a thoracic endovascular stent-graft and then balloon-expandable stent dilatation of the coarctation stenosis. In the second case, the additional technique of using a jailed sheath within the aneurysm sac allowed for selective embolisation of previously inconspicuous collaterals after deployment of the stent-graft and stent combination. Results Technical success was achieved in both patients with successful occlusion of the aneurysm, with no recorded complications or aneurysm sac perfusion in the long and medium term follow up periods respectively. Conclusion De novo post stenotic aortic coarctation aneurysms are rare. Endovascular repair is a safe and durable technique that provides a less invasive alternative to open surgical repair. The use of a jailed sheath allows for complete selective embolisation of complex collaterals avoiding a type II aneurysm endoleak.

Primary free fibula reconstruction in life-threatening haemorrhage from high flow arteriovenous malformation of mandible

ABSTRACT Background: High flow arteriovenous malformation (AVM) of the mandible is rare, but it can present as a life-threatening emergency with severe intraoral bleeding for the first time. The gold standard of treatment for an AVM of the mandible is selective embolisation combined with resection and subsequent reconstructions. With the advent of advanced multidisciplinary techniques aimed at definitive therapy, surgical resection and primary reconstruction can provide an ideal anatomical and functional cure. There are no previous reports on primary resection and reconstruction for life-threatening haemorrhage from high flow AVM of the mandible. Aim: We discuss our approach aimed at definitive therapy in life-threatening intraoral bleeding from large high flow AVM of the mandible. Subjects and Methods: Four patients were managed for life-threatening intraoral bleeding during 2015–2017. Compression was applied over the bleeding point before the airway could be secured by endotracheal tube. Under general anaesthesia, the external carotid artery (ECA) was temporarily occluded using an umbilical tape loop ligature to control the bleeding. Emergency selective embolisation was done, followed by curative resection and primary mandible reconstruction using free fibula flap. Outcome assessed. Results: Temporary occlusion of the ECA successfully controlled the bleeding immediately and facilitated selective embolisation and definitive therapy. All the four cases were successfully reconstructed with a good outcome. There was no recurrence during the follow-up period. Conclusion: In life-threatening intraoral bleeding from large high flow AVM of the mandible, emergency selective embolisation followed by curative resection and primary reconstruction is safe in achieving an ideal cure.