Arteriovenous malformation on the sole of the foot treated successfully by embolization

Abstract

Arteriovenous malformations of the sole of the foot are rare and can cause disturbances in normal living activities. We report a case of a plantar arteriovenous malformation in a 24-year-old male with pain and difficulty in walking. The arteriovenous malformation was complex, with a large and poorly marginated nidus, so we considered that with surgical resection, walking disabilities would be inevitable. When surgical removal of vascular mass is difficult, embolization alone can be effective. Therefore, he was treated with 4 therapeutic embolization procedures. Transvenous approaches to the venous sac and direct punctures of the nidus was performed. The nidus was successfully eradicated by embolization using alcohol, resulting in the disappearance of associated symptoms. Appropriate imaging is essential for diagnosis and evaluation of treatment. We were successful in achieving improved quality of life and satisfaction for a rare and difficult case by percutaneous embolization and sclerotherapy.

Keywords: AA, Arterial Aneurysm; AVF, Arteriovenous Fistula; AVM, Arteriovenous Malformation; Arteriovenous malformation; CT, Computed Tomography; CTA, Computed Tomography Angiography; DSA, Digital Subtraction Angiography; ECT, Enhanced Computed Tomography; EO, Ethanolamine Oleate; Embolization; Extremity; Foot; HHT, Hereditary hemorrhagic telangiectasia; MRA, Magnetic Resonance Angiography; MRI, Magnetic Resonance Imaging; Peripheral; Sclerotherapy; Sole.

Fig. 1

A throbbing painful mass on the left sole of the foot at first visit. A pulsating 5-cm diameter mass was observed in the first metatarsal phalangeal joint. The epidermal color and texture were within normal range.

Fig. 2

Enhanced computed tomography scan with volume rendering. The medial planter and dorsal pedis arteries, thickened and tortuous, shunting randomly with surrounding veins. The draining veins were visualized earlier through the nidus, as abnormal wiry vessels, and as venous sacs around the first and second proximal phalangeal area.

Fig. 3

Digital substraction angiography before treatment, (a) showing multiple fine afferent arteries (small arrow) originating from the medial plantar (large arrow) and dorsal pedis artery (small arrowhead), shunting to the venous sac (large arrowhead) (type II). (b) Multiple fine arteries connected directly to fine veins (arrow) (type III).

Fig. 4

The first procedure and its complications. (a) Digital subtraction angiography in arterial phase. Contrast agent diluted into the distal part of medial plantar artery (arrow). (b) Sclerosant injected into the nidus under balloon inflation (arrow). (c) Blisters and purpura emerged at 2 postoperative days. (d) The ulcer showed complete epithelialization after 5 postoperative months.

Fig. 5

DSA and photograph after all 4 procedures. (a) Venous sac embolized with coils, followed by alcohol and/or NBCA injection. (b) Direct puncture of the type III component (arrow), followed by alcohol injection. (c) Final DSA showing complete eradication of the nidus. (d) Three years from the fourth session. The pulsation disappeared, and the mass shrunk and is painless and soft. He was able to wear shoes and walk freely with no symptoms.