Pressure Cooker Technique for the Treatment of a Pelvic Arteriovenous Malformation Associated with a Giant Venous Aneurysmal Dilatation

Abstract

Dear Editor, The pressure cooker technique has recently been described as a specific technique for embolization of cerebral arteriovenous malformations. The principle of this technique is to create a plug of coils and glue between the catheter tip and the detachment zone of a previously placed DMSO-compatible microcatheter. The embolic agent is forced to completely fill the nidus of the AVM without disruption increasing the technical success by avoiding reflux of the embolic material which leads to premature termination of the procedure [1–3]. We present a rare case of a 46-year-old man with pAVM associated with a giant venous aneurysmal pouch, treated by endovascular route, using liquid embolic material and the ‘‘pressure cooker’’ technique. The patient presented with mild pelvic discomfort and recent episodes of dysuria. He had a history of laparoscopic bilateral spermatic vein ligation due to bilateral varicocele, 12 years ago. CT angiography demonstrated a pelvic AV shunt associated with a giant aneurysmal venous dilatation (Fig. 1). On catheter angiography, a high-flow arteriovenous shunt was clearly demonstrated, with multiple arterial feeders of mixed type (fistulas and nidus) originating from the right internal iliac artery (IIA), with no recruitment of arterial supply from the contralateral side. On the venous side, a giant venous aneurysmal dilatation, due to prominent venous stenoses of the drainage towards the inferior vena cava, was evident. The vascular multidisciplinary team decision was to proceed with endovascular treatment. A detailed informed consent was obtained. The procedure was performed under local anaesthesia. A 7Fr arterial sheath was placed in the ipsilateral right common femoral artery (CFA) and a 6F arterial sheath in the left CFA. A 5F Cobra 1 catheter was placed through the left femoral sheath into the right IIA, and a 1.5F microcatheter with 1 3-cm detachable tip (Apollo; Covidien, USA) was advanced distal into the main arterial feeder, at the level of the arteriovenous shunting zone. A 7Fr guiding catheter was placed through the right access into the right IIA, and a 2.7F microcatheter (Progreat ; Terumo, Japan) was advanced into the main arterial feeder with the tip proximal to the distal tip of the Apollo microcatheter (Fig. 2). Subsequently, the main arterial feeder was proximally occluded with six pushable microcoils (10 9 140 mm and 8 9 140 mm; Nester; Cook, USA) via the 2.7Fr microcatheter, and finally with injecting a 50% mixture of cyanoacrylate glue (GEM; Viareggio, Italy) in Lipiodol in between the coil mass, entrapping the Apollo microcatheter into the occluded segment of the main arterial feeder, with the Apollo’s tip & Konstantinos Palialexis [email protected]