Sonographic diagnosis of arteriovenous malformation of the uterus and pelvis

Abstract

Congenital arteriovenous malformations (AVM) of the pelvic organs are uncommon. They have been reported under different names such as cirsoid aneurysm, arteriovenous fistula, and arteriovenous malformation. Several cases of cirsoid aneurysm of the uterus have been reported in the l i t e r a t~r e l -~ in women of childbearing age who had had multiple childbirth, or an abnormal menstrual or obstetric history. Nulliparous women with AVM are very rare (only two nulliparous women in a review of the l i t e r a t~r e .~.~) .In rare cases pelvic AVM may occur in males.8-'0 The oldest patient in which this condition has occurred is a 63-yr-old female." We report an unusual case of a 72-yr-old woman presenting for the first time with postmenopausal bleeding in whom clinical examination steered the workup to ultrasonic evaluation which provided the diagnosis by real-time ultrasound study. CASE REPORTA 72-yr-old retired female nurse gravida 0, para 0, widowed for 7 yr, was referred to the gynecological oncology service for excruciating cramps in the lower abdomen and vaginal bleeding of recent onset. A curettage had failed due to hemorrhage from accidental laceration of anterior vaginal wall. She had had a cardiac murmur since 1927 (when she was 19 yr old) and bilateral vein stripping for varicose veins was carried out in 1950 at age 41. Age at menarche was 14 yr. Ultrasound examination showed numerous cystic lesions in the pelvis (Fig. 11, some of which were noted in the uterus (Fig. 2) while others were present in the adnexa, probably involving the ovaries. Some of these lesions were observed to show a slight change in size during the realtime study. There were a few tortuous veins which appeared to be of greater than normal caliber. The right iliac artery exhibited a bounding pulse. These findings were felt to be highly suggestive of an arteriovenous malformation of the uterus with extension into the pelvis. A highly vascular lesion with cystic changes such as a leiomyosarcoma could not be entirely excluded, but in the absence of any solid components and the presence of pelvic and adnexal extension, this was considered unlikely. Angiographic examination showed a large arteriovenous malformation in the pelvis supplied by branches from both internal iliac arteries ( Fig. 3) with large tortuous draining veins (Fig. 4). There was no evidence of any tumor. At surgery, the uterus was soft and larger than expected for the patient's age. Large dilated vessels were seen in the right utero pelvic ligament. The right round ligament was extremely dilated and deformed with large vessels. Ligation of all identifiable feeding blood vessels, partial resection of the AVM, bilateral salpingo- 295

Pseudoaneurysm of the Uterine Artery After an Uncomplicated Spontaneous Vaginal Delivery

“…12 However, sonographic demonstration of the neck in a uterine artery pseudoaneurysm may be difficult because of the small size of the parent artery, 18 as may have been the case with our patient. Sensitivity of sonography for detection of pseudoaneurysms of the femoral artery approaches 95%, 14 although, to our knowledge, there are currently no published figures for sonographic sensitivity in relation to uterine artery pseudoaneurysms. However, in reported cases of uterine artery pseudoaneurysms after vaginal [2][3][4] and cesarean 4-8 deliveries, sonography with Doppler imaging was successful in making the diagnosis in all but 1 case 8 when implemented in the diagnostic workup.…”

“…12 Other uterine vascular anomalies include acquired and congenital arteriovenous malformations (AVMs), consisting of a complex tangle of arterial and venous vessels without an intervening capillary network. 13 Uterine AVMs may also present with uterine bleeding and may be acquired as a result of traumatic etiologies, including injury after dilation and curettage procedures 14 and cesarean deliveries. 15 Alternatively, the less common congenital uterine AVM results from anomalous differentiation in the primitive capillary plexus, giving rise to an abnormal communication between arteries and veins.…”

Uterine Arteriovenous Malformation: Ultrasonographic, Magnetic Resonance and Radiological Findings

“…Torres et al [11] first used gray-scale US to describe this anomaly as multiple anechoic structures with a serpentine contour within the myometrium. US seemed to be a good screening test; however, these gray-scale morphologic features of AVMs in the uterus are often confusing and nonspecific [5,11,12]. With the development of color Doppler US, the diagnosis of uterine AVM can easily and convincingly be made [6,8,[13][14][15].…”

“…With the development of more sophisticated diagnostic techniques, several options are now available for confirming the diagnosis. Previously reported cases have been diagnosed preoperatively by means of contrast-material-enhanced computed tomography (CT) [3,4], ultrasonography (US) [5,6], and magnetic resonance imaging (MRI) [7][8][9][10].…”

Conservatively treated pelvic arteriovenous malformation: Noninvasive sonographic monitoring during subsequent pregnancy

“…However, in recent years, Doppler sonography and color Doppler sonography have been increasingly used to identify and measure blood flow in normal and abnormal vessels. 2,3 These modalities may therefore have a role in the follow-up of arteriovenous fistulas.…”