Repair of a Large Iliac Vein Aneurysm Secondary to a High-flow Pelvic Arteriovenous Malformation Under Deep Hypothermic Circulatory Arrest
William J. Quinones-Baldrich, M.D..
UCLA Med Ctr, Dept of Surgery, Los Angeles, CA, USA.
OBJECTIVES:: Repair an enlarging venous aneurysm secondary to a high flow pelvic AV malformation.
METHODS: : A 14-year-old male presented with a left iliac vein aneurysm in 2012 secondary to high-flow pelvic arteriovenous malformation (AVM), chronic abdominal pain and high-output congestive heart failure (CHF). Despite several embolization interventions with coils and Onyx®, the patient continued to have episodes of CHF. MRI in 2012 demonstrated a left iliac vein aneurysm with a diameter of 13 cm . To reduce flow from the AVM, endografts from inferior vena cava to left external iliac vein were deployed successfully treating CHF. The venous aneurysm continued to grow to a diameter of 18.5 cm in 2017 with abdominal pain and hydronephrosis. Surgical repair was recommended.
RESULTS: A stent was placed in the left ureter. The aneurysm was exposed through a left retroperitoneal incision. Under deep hypothermic circulatory arrest, the aneurysm was opened, thrombus and coils removed and several arterial feeders as well as the primary nidus of inflow by the internal iliac vein were suture-ligated. The excess aneurysm sac was resected and closed primarily with pledgets over the previously placed endografts. He was discharged on post-operative day 9 with normal neurologic function. At 18 month follow-up, he had complete resolution of abdominal pain and hydronephrosis and resolution of the venous aneurysm on MRI.
CONCLUSIONS: Pelvic arteriovenous malformations are notoriously difficult to treat due to the complexity of multiple feeding vessels. Open repair carries a significant risk of uncontrolled hemorrhage. Deep hypothermic circulatory arrest reduces this risk and thus facilitates open repair. Few reported cases in the literature have described repair of pelvic arteriovenous malformations in this fashion. Our limited experience suggest that open repair under deep hypothermic circulatory arrest is a feasible and potentially effective alternative in the management of these very complex lesions.
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