Shoulder Pain Associated With Multiple Arteriovenous Malformations Successfully Treated With Embolization

Abstract

A 44-year-old male presented with left upper extremity and shoulder pain with worsening functional impairment after years of repetitive use, overtraining, and multiple injuries from weightlifting and mixed martial arts. Imaging showed no obvious injury or ligamentous deformity other than mild osteoarthritis (OA) of the left glenohumeral joint. Duplex ultrasonography (US) revealed four arteriovenous malformations (AVMs) surrounding the shoulder joint and left upper extremity. The vasculature was mapped via angiography through a transradial approach. Initial treatment included transarterial embolization of two AVMs off the axillary artery and branching anterior circumflex humeral artery. Secondary treatment included embolization of two lesions months later via direct puncture, one through a transvenous approach and the second through direct transmalformation cannulation, via the nidus, near the clavicle and posterior scapular lateral border. Treatment resulted in significant improvement in pain and range of motion. Follow-up assessments revealed improvement in overall symptoms, recovered function, and return to exercise and competitive mixed martial arts. This case highlights the value of duplex ultrasonography, embolization, and transarterial and transvenous approaches for the treatment of AVM-associated extremity or joint pain.

Keywords: arteriovenous malformations; capillary venous malformation; gelfoam; transarterial embolization; transvenous embolization; traumatic avm; vascular embolization.

Figure 1. Transarterial Arteriovenous Malformation (AVM) Embolization

A. Fluoroscopic imaging of the left upper extremity with visualization of an AVM off the anterior circumflex humeral artery cannulated transarterially from the radial artery. B. Post embolization, improved flow can be seen to the anterior circumflex humeral artery and complete cessation of flow to the AVM.

Figure 2. Transarterial Arteriovenous Malformation (AVM) Embolization

A. Fluoroscopic imaging of the left upper extremity with visualization of an AVM off an aberrant malformation off the axillary artery cannulated transarterially from the radial artery. B. Post embolization, trace improvement was seen with improved blushing but no cessation of flow to the identifiable vessels.

Figure 3. Supraclavicular Transvenous Arteriovenous Malformation (AVM) Embolization

A. Fluoroscopic imaging of the AVM off the subclavian vein proximal to the bifurcation of the cephalic vein transvenously cannulated. B. Fluoroscopic imaging of the feeding tributaries feeding the venous supply. C-D. Post embolization, patent flow of the feeding vasculature with improved flow from the cephalic tributaries. Overall improvement was seen with improved blushing but no cessation of flow to the identifiable vessels.

Figure 4. Posterior Transmalformation Arteriovenous Malformation (AVM) Embolization

A. Fluoroscopic imaging of the AVM. B. Post embolization, patent flow of the feeding vessel with improved blushing and cessation of flow to the AVM.