Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 47, Num. 1, 2001, pp. 33-34

Journal of Postgraduate Medicine, Vol. 47, Issue 1, 2001 pp. 33-34

Angioembolisation in Vaginal Vascular Malformation

Srivastava DN, Saxena AK, Kriplani A*, Agarwal N*

Departments of Radiodiagnosis, Obstetrics and Gynaecology*, All India Institute of Medical Sciences, New Delhi, India.

Code Number: jp01008

Abstract

Vaginal arteriovenous malformations are rare entities and their most common presentation is vaginal haemorrhage. This case report describes a 22-year-old woman presented at 20 weeks of gestation with slow growing soft and tender swelling at anterior vaginal wall. Diagnosis was confirmed as vaginal vascular malformation on contrast enhanced magnetic resonance imaging. The mass did not subside after delivery and patient developed dyspareunia. It was successfully treated by angioembolisation using polyvinyl alcohol particles. Angioembolisation being safe and effective should be the treatment of first choice in the treatment of symptomatic vaginal vascular malformation.

Vaginal vascular malformations are and can lead to life threatening complications. We report one such case whose diagnosis was made on magnetic resonance imaging (MRI) and was treated successfully by angio-embolisation.

Case History

A 22-year old multiparous woman (one full term normal delivery and two abortions) developed a slow growing soft and tender swelling at anterior vaginal wall at 20 weeks of gestation. The clinical diagnosis was arterio-venous malformation (AVM) which was confirmed on MRI. The contrast enhanced image showed a vascular mass (Figure 1).

This mass kept on increasing in size and by the end of pregnancy it was very tender. There was no history of trauma. Antepartum embolisation was not considered for this patient. Large, palpable, pulsatile vaginal mass on clinical examination at 36 weeks prompted the decision of elective caesarean section to avoid possible rupture during vaginal delivery. No spontaneous regression occurred in post partum period and the patient developed dyspareunia and difficulty in micturition three months after delivery. Angio-graphic embolisation of the mass was done through right internal iliac panch by using 3 Fr infusion catheters (Tracker 325 Target Therapeutics, Fremont, CA, USA) and polyvinyl alcohol particles (Figures 2 and 3). The lesion disappeared in subsequent follow-up examinations and patient is symptom free on her last follow-up two years after embolisation.

Discussion

Vaginal vascular malformations can present with vaginal haemorrhage, congestive heart failure, postmenopausal bleeding and an asymptomatic mass. These lesions can be congenital or acquired.(1) The acquired lesions are believed to follow trauma or may arise after choriocarcinoma or other gynaecologic malignancies.(2) The incidence of vaginal AVM is so uncommon that only case reports are available.(3)

The diagnosis can rapidly be made and and extent of the lesion noted by showing vascular mass on transvaginal colour doppler ultrasound, angiography, computerised tomography or MRI. MRI findings which may be useful for differentiating AVM from other hypervascular tumours have recently been described and include phase shift artefact, paradoxical enhancement and enhanced flow voids.(3) Pelvic arteriography is helpful in delineating the main blood supply, the presence of collateral vessels, and venous shunting and pooling.

Symptomatic AVM needs treatment while asymptomatic AVM may be followed up with noninvasive sonography. However, it is important to correctly diagnose them since they may bleed during an unrelated procedure like uterine curettage. Angio-embolisation should be the treatment of choice in these symptomatic lesions as it appears to be safe and effective.(3) Recently a case of an empyonic cervical pregnancy diagnosed at ten weeks and associated with a large arteriovenous malformation treated with selective uterine artery embolisation has been reported. The mass had disappeared by the time of follow-up four months later.(4) Since there is a paucity of data on vaginal AVM and long-term follow up data is not available, it is difficult to assess long term benefits of embolisation therapy. Palmaz et al(5) in their review of one uterine AVM and four pelvic malformations with long term follow up, discovered that there is initially great success in treating congenital AVM. However, these lesions will often reccur, because they usually have excellent collateral circulation.

In our case, diagnosis was made on MRI and treated with angioembolisation. The patient continues to be asymptomatic after two years of follow up, emphasising the potential of angioembolisation as an alternative to surgery.

References

1. Sholapurkar SL, Malhotra S, Dhall K, Kochhar S. Multiple congenital arteriovenous malformations with involvement of the vagina and profuse hemorrhage from vaginal ulcer. Gynecol Obstet Invest 1992; 33:126-128. MEDLINE
2. Hoffman MK, Meilstrup JW, Shackelford DP, Kaminski PF. Arterivenous malformations of the uterus: An uncommon cause of vaginal bleeding. Obstet Gynecol Surv 1997; 52:736-740. MEDLINE
3. Matsumoto K, Kurachi H, Murakami T, Narumi Y, Tsuda K, Yoshino K, et al. Vaginal arterivenous malformations:” MR imaging. Abdom Imaging 1996; 21:554-556. MEDLINE
4. Su YN, Shih JC, Chiu WH, Lee CN, Cheng WF, Hsieh FJ. Cervical pregnancy: assessment with three dimensional power doppler imaging and successful management with selective uterine artery embolization. Ultrasound Obstet Gynecol 1999; 14:284-287. MEDLINE
5. Palmaz JC, Newton TH, Reuter SR, Bookstein JJ. Particulate intraarterial embolization in pelvic arteriovenous malformations. AJR Am J Roentgenology 1981; 137:117-122. MEDLINE

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