A rare case of a giant arterio-venous fistula (AVF) following metastatic choriocarcinoma conditioning pulmonary embolism: multimodal transcatheter embolization using a simultaneous transarterial and transvenous approach

Abstract

Background: Choriocarcinoma is a highly malignant tumor but with a good prognosis due to the valid response to systemic chemotherapy. We present a case of a young woman affected by a giant pelvic arterio-venous fistula following a metastatic gestational choriocarcinoma, conditioning metrorrhagia and pulmonary embolism, successfully treated by multimodal transcatheter embolization, using a simultaneous transarterial and transvenous approach.

Case presentation: In a young patient affected by choriocarcinoma and metrorrhagia, a computed tomography showed a giant arterio-venous fistula, pulmonary metastases and embolism. A transfemoral diagnostic arteriography showed a giant arterio-venous fistula sustained by right and left hypogastric arteries with early opacification of the right gonadal vein and of the inferior vena cava. A transarterial embolization of the distal branches of hypogastric arteries with poly-vinyl-alcohol particles, coils and Squid was performed. A transfemoral phlebography of the right gonadal vein showed multiple thrombi, responsible of the pulmonary embolism. An Amplatzer plug via trans-jugular was finally placed at the confluence of the gonadal vein in the vena cava, to reduce arterio-venous fistula out-flow and to occlude the vein, preventing further episodes of pulmonary embolism. Metrorrhagia progressively disappeared. A second transarterial embolization combined with a complete response to systemic chemotherapy determined arterio-venous fistula resolution.

Conclusions: This was a very rare case of a giant pelvic arterio-venous fistula following choriocarcinoma in a patient symptomatic for metrorrhagia with an accidental finding of pulmonary embolism at computed tomography. A transcatheter embolization was successfully performed with different embolic materials, using a simultaneous transarterial and transvenous approach: the goal was not only to obtain metrorrhagia resolution but also to avoid a massive pulmonary embolism, a potential life threatening condition, in a young woman affected by a highly malignant tumor but with a good prognosis.

Keywords: Amplatzer vascular plug; Arteriovenous fistula; Choriocarcinoma metastases; Embolic agents; Embolization; Pulmonary embolism.

Fig. 1

Contrast-enhanced MDCT shows (a) a suspicious giant pelvic AVF (arrows), (b) confirmed by Color Doppler

Fig. 2

Diagnostic arteriography from the right hypogastric artery shows (a) a giant AVF with early opacification of the right gonadal vein and the inferior vena cava. DSA performed with a microcatheter shows peripheral arterial branches sustaining the fistula (b), embolized using coils (c) and PVA particles (d)

Fig. 3

DSA shows branches of the left hypogastric artery sustaining the AVF (a), embolized also using Squid (arrow) (b)

Fig. 4

Diagnostic phlebography via trans-femoral of the right gonadal vein shows (a) multiple thrombi (arrows). Amplatzer plug placement (arrows) via trans-jugular to occlude the right gonadal vein (b) to simultaneously reduce AVF-outflow and avoid pulmonary embolism. Contrast-enhanced MDCT after 24 h confirms (c) the correct placement of the plug (arrows)

Fig. 5

After the second arterial embolization performed 6 months later, the final aortography shows the complete AVF occlusion