Minimally Invasive Approach to Pelvic Arteriovenous Malformation (AVM) Refractory to Embolization

Abstract

Study Objective To describe a minimally invasive approach to hysterectomy and excision of a pelvic AVM after embolization failed twice. Design Case report. Setting Single center academic institution. Patients or Participants A 33-year-old female presented with chronic pelvic pain after a cesarean section. Ultrasound and CT angiogram showed a left-sided dilated vessel with turbulent flow adjacent to the uterus consistent with pelvic AVM. The AVM persisted despite two embolizations by vascular surgery. Interventions Upon abdominal entry, extensive vascularity was noted in the left gonadal vessels, paravesical space, and pararectal space. A 5cm AVM was noted adjacent to the uterus. Each of the multiple blood vessels leading to the AVM, including those to the bladder serosa, were isolated, fulgurized, and cut. Concomitant left ureterolysis was completed. The paravesical space dissection involved separating dense bladder adhesions, left ovarian fossa, external iliac vein and medial umbilical ligament, from the malformation. Blood vessels from the deep sidewall encircling and feeding the AVM were serially fulgurated and separated from the ureter. The ascending branch of the uterine artery on the underside of the AVM was serially fulgurated. Lateral to the ureter, the uterine artery from origin to insertion was unroofed and excised. The AVM was excised by isolating it from the level of the cervix upwards along the pelvic sidewall and uterus. The remainder of the modified radical hysterectomy was uncomplicated. Measurements and Main Results Estimated blood loss was 50cc. Total surgical time was 4.5 hours. The postoperative course was uncomplicated. Final pathology was consistent with AVM. At her post-operative appointment, the patient experienced a significant reduction of symptoms. Conclusion In the absence of large series or randomized trials, we suggest that robotic-assisted surgery is a valid treatment option for pelvic AVM in the setting of failed embolization. To describe a minimally invasive approach to hysterectomy and excision of a pelvic AVM after embolization failed twice. Case report. Single center academic institution. A 33-year-old female presented with chronic pelvic pain after a cesarean section. Ultrasound and CT angiogram showed a left-sided dilated vessel with turbulent flow adjacent to the uterus consistent with pelvic AVM. The AVM persisted despite two embolizations by vascular surgery. Upon abdominal entry, extensive vascularity was noted in the left gonadal vessels, paravesical space, and pararectal space. A 5cm AVM was noted adjacent to the uterus. Each of the multiple blood vessels leading to the AVM, including those to the bladder serosa, were isolated, fulgurized, and cut. Concomitant left ureterolysis was completed. The paravesical space dissection involved separating dense bladder adhesions, left ovarian fossa, external iliac vein and medial umbilical ligament, from the malformation. Blood vessels from the deep sidewall encircling and feeding the AVM were serially fulgurated and separated from the ureter. The ascending branch of the uterine artery on the underside of the AVM was serially fulgurated. Lateral to the ureter, the uterine artery from origin to insertion was unroofed and excised. The AVM was excised by isolating it from the level of the cervix upwards along the pelvic sidewall and uterus. The remainder of the modified radical hysterectomy was uncomplicated. Estimated blood loss was 50cc. Total surgical time was 4.5 hours. The postoperative course was uncomplicated. Final pathology was consistent with AVM. At her post-operative appointment, the patient experienced a significant reduction of symptoms. In the absence of large series or randomized trials, we suggest that robotic-assisted surgery is a valid treatment option for pelvic AVM in the setting of failed embolization.