A 51 y.o. presents for a swelling in the buttock
AVM presenting as a mass in the buttock
What is it?
Our patient had an AVM of the pelvis which eroded through an ulcer in the skin. The AVM was from multiple feedings arteries from the profunda femoris and the internal iliac draining into the L common femoral vein. In the ED she initially stopped bleeding and IR was scheduled to embolize the next day but then she began to have a massive arterial hemorrhage and developed hemorrhagic shock in the ED. She was taken to IR after the massive tranfusion protocol was initiated and the BP remained 70 in spite of blood and pressors. Only 20 per cent of the AVM could be embolized but the bleeding was stopped by embolization and suturing the skin closed. She developed ATN with a creatinine was 6.0. Further definitive treatment was postponed until her kidneys recover. A REBOA was considered but general surgery felt the bleeding could be managed better with direct pressure.
AVMs are abnormal connections between arteries and veins causing high flow in the venous limb. They can occur in the brain, neck, spine, arms, legs and liver. The incidence of AVM is one in 10,000 individuals. If you have an AVM there is a 4% risk of bleeding per year.
Uterine AVM presenting with vaginal bleeding and diagnosed with US. While US is the first modality for diagnosis, MRA is often used as well.
AVMs can be congenital or acquired with the congenital form having more feeding vessels and being more difficult to embolize. Ischemia of the distal extremity and thrombosis are known complications of AVMs. One of the more common forms of acquired AVMs are uterine AVMs which occur after abortion or childbirth and cause life threatening vaginal bleeding.
Greene A, Orbach D. Management of AV malformations. 2011 Clin Plastic Surg;38(1):95-106.
Belfort M. Postpartum hemorrhage: Medical and minimally invasive management.
Sridhar D, Vogelsang R. Diagnosis and treatment of uterine and pelvic AVM: a review of etiology, clinical presentation and imaging findings, and treatment options, 2018 Endovascular Today, Jan
Yazawa H, Soeda S, Hiraiwa T, el al. Prospective evaluation of the incidence of uterine vascular malformation developing after abortion or delivery. Minimally Invasive Gynecology 2013;20:360-67.