Glue Embolization of Lower Limb

Procedure/Surgery Name: Endovascular Glue Embolization of lower limb/leg Arterio-Venous Malformation (AVM)

Doctors: Dr. Bhavesh Arun Popat, Dr. Karan M Anandpara

A 29 year old female

Progressively increasing painful swelling on anterior aspect of right distal leg of 4 months duration
No skin changes
Minimal right distal leg edema
Tender on palpation +
Distal pulses (ATA, DPA and PTA) palpable +

Local Ultrasound and Doppler – echogenic ill defined soft tissue area with few serpiginous vascular channels within s/o vascular malformation
MRI – confirmed the findings of USG; arterial feeders with intralesional nidus noted s/o likely arterio-venous malformation (AVM)

Abnormal leash of vessels
Internal nidus
Atleast 4 arterial feeders from anterior tibial artery
Early draining vein – washout from accompanying anterior tibial veins
Distal main anterior tibial artery and DPA shows slow, but antegrade adequate distal flow

Complex arterio-veneous malformation (avm) of lower limb/leg with multiple arterial feeders from anterior tibial artery.

Staged; combined ultrasound and fluoroscopic percutaneous and sos endovascular glue embolisation
Followed by surgical excision

Percutaneous USG guided access taken
Catheter in the right popliteal artery via left CFA access
Endovascular contrast injection to localize the nidus and to monitor residual lesion
Following this, multiple percutaneous access taken to target various components of the AVM
Manual hand compression given to prevent inadvertent reflux into the draining vein
Endovascular embolization attempted, but ultimately was not done due to high probability of reflux into the main anterior tibial artery due to intra-nidus vascular communication. Therefore, percutaneous embolization done with Glue

Essential to classify vascular malformations appropriately – Venous, lymphatic, AVM, combined vascular malformations
Set ‘realistic expectations’
Multiple procedures
Difficult to treat completely
Team Work

CaseStudy