Female Pelvic Vascular Malformations

Abstract

Vascular malformations are classified primarily according to their flow characteristics, slow flow (lymphatic and venous) or fast flow (arteriovenous). They can occur anywhere in the body but have a unique presentation when affecting the female pelvis. With a detailed clinical history and the proper imaging studies, the correct diagnosis can be made and the best treatment can be initiated. Lymphatic and venous malformations are often treated with sclerotherapy while arteriovenous malformations usually require embolization. At times, surgical intervention of vascular malformations or medical management of lymphatic malformations has been implemented in a multidisciplinary approach to patient care. This review presents an overview of vascular malformations of the female pelvis, their clinical course, diagnostic studies, and treatment options.

Keywords: arteriovenous malformation; interventional radiology; lymphatic malformation; sclerotherapy; vascular malformation; venous malformation.

Fig. 1

Pelvic lymphatic malformation (PLM). ( a–c ) Coronal, sagittal and axial T2-weighted MR images. Arrows point to the diffuse macro- and microcystic lymphatic malformation of the buttocks with extension into the pelvis adjacent to the bladder. Arrowhead shows a fluid-fluid level within a larger cyst as a result of infection and/or hemorrhage. ( d ) Percutaneous sclerotherapy of the lymphatic malformation with doxycycline. The point of access is at the buttocks and the lymphatic malformation communicates with deeper components within the pelvis resulting in a larger intrapelvic treatment via a percutaneous approach.

Fig. 2

Pelvic venous malformation (PVM). ( a ) MRI images show extensive venous malformation of the right lower extremity extending into the pelvis and alongside the bladder, uterus, and rectum. ( b ) The capacious vein along the lateral aspect of the right lower extremity (arrow) is the lateral marginal vein, a pathognomonic finding in patients with Klippel–Trenaunay syndrome. ( c ) Arrow points to the lateral marginal vein at time of treatment. Preembolization digital subtraction images demonstrate a relatively straight lateral marginal vein with multiple abnormal tributaries along the lateral aspect of the right thigh. ( d ) Treatment involved coil embolization of the lateral marginal vein at its drainage point into the femoral vein followed by endovenous laser ablation of the remainder of the vein. Posttreatment venogram shows no further filling of the lateral marginal vein (arrow).

Fig. 3

Pelvic arteriovenous malformation (PAVM). ( a ) Color Doppler images show markedly increased vascularity of the uterus. There is a larger ovoid area within the uterus with multidirectional flow concerning for a uterine arteriovenous malformation. ( b ) Coronal MR images of the pelvis shows a large tangle of vessels (arrow) in the pelvis as well as rapid opacification of the internal iliac vein, common iliac vein, and inferior vena cava suggesting arteriovenous malformation. ( c ) Digital subtraction angiography from the right uterine artery illustrates the abnormal collection of arterial vessels with rapid drainage into the ipsilateral internal iliac vein. The arrow demonstrates the nidus of the arteriovenous malformation.