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OBJECTIVE: Arterio-venous malformations (AVMs) are abnormal connections, either congenital or acquired, between an arterial and venous system. These can occur throughout the vascular system, including skin, muscle, and visceral organs, with both benign as well as debilitating symptoms.
Renal AVMs are rare and account for less than 1% of all types of AVMs within the general population. Treatment options for renal AVMs have ranged from embolization to partial nephrectomy. Most fall within two subcategories: cirsoid and the rarer cavernous type. Cavernous AVMs present a particularly challenging entity for endovascular treatment given the high pressure, high flow, and concern for distal migration of coils or other embolization materials, and treatment often deferred to open repair. Here we present a case of a large cavernous renal AVM treated with two types of distal protection with large retrievable coils in order to ensure proper placement and embolization of AVM.
METHODS: A relatively healthy 48 year old, multiparous, woman presented to the clinic with an approximately 10-year history of pelvic and back pain following a fall. CTA as well as duplex ultrasound showed a large AVM in the posterior renal pole of her left kidney, with high flows, as well as pelvic congestion, dilated ovarian vein, and mega-suprarenal cava. Selective angiogram showed a large, high flow, cavernous malformation. Initial arterial access into the malformation and target vessel was gained and stabilized with a long sheath. Subsequently, two types of distal protection were utilized: a balloon and a Wallstent were used to ensure no distal embolization occurred. Large retrievable coils were placed in the target vessel, without any migration.
RESULTS: Completion angiogram showed significantly decreased flow into the malformation, with improved renal perfusion. Patient was discharged the next morning. At one month follow up, patient reports near resolution of symptoms with no change in kidney function. CONCLUSION: Large high flow renal AVMs can present significant challenges for the endovascular surgeon. However, with
selection of appropriate embolization materials, as well as utilization of
currently available tools for distal protection, endovascular treatment can
alleviate the need for nephrectomy and open procedure.