Chapter 42

### PATIENT STORY

A 35-year-old Caucasian man with a pulsating painful flank mass was referred for further evaluation and treatment. The mass had been present for over 15 years and had enlarged over the past year along the right lower back and flank in an area underlying a birth mark (Figure 42-1). Examination confirmed a 15-cm tender mass with overlying erythematous skin changes. A thrill was palpable over the mass, and a continuous bruit was present on auscultation.

###### FIGURE 42-1

An arteriovenous malformation presenting as a pulsating back or flank mass. A 35-year-old Caucasian man shown with a pulsating mass on his back and right flank. The mass had been present for over 15 years and had enlarged over the past year. The mass was associated with pain and developed in an area underlying a birth mark.

The lesion was confirmed to be a localized arteriovenous malformation (AVM) with minimal involvement of the surrounding tissues, as demonstrated on abdominal computed tomography (CT) scanning with angiography including three-dimensional (3D) reconstruction (Figure 42-2).

###### FIGURE 42-2

Abdominal computed tomography (CT) demonstrating an arteriovenous malformation (AVM) of the right back and flank. The AVM lesion was confined to the superficial tissues. Conventional CT scanning with intravenous contrast (A) with three-dimensional (3D) reconstruction (B) was performed.

Conventional angiography (Figure 42-3) confirmed the presence of an extensive AVM lesion with multiple feeding arteries. The massively dilated venous outflow due to the fistulous lesion producing a hemodynamically advanced condition.

###### FIGURE 42-3

Angiography of an arteriovenous malformation (AVM) of the right back and flank. Note the extensive AVM lesion with multiple feeding arteries and massively dilated venous outflow.

Direct puncture, transvenous embolization utilizing 0.035 Bentsen wires was performed preoperatively for subsequent open resection of the lesion to reduce intraoperative bleeding. Complete excision of the lesion filled with the coils was performed safely (Figure 42-4), leaving a minor residual lesion that was treated with conventional sclerotherapy (Figure 42-5). Follow-up CT angiography and 3D reconstruction demonstrated an excellent result (Figure 42-6).

###### FIGURE 42-4

Surgical resection of an arteriovenous malformation (AVM) of the right back and flank. Direct puncture, transvenous embolization utilizing 0.035 Bentsen wires was performed prior to open resection of the lesion to reduce intraoperative bleeding. The Bentsen wires are seen protruding from the lesion.

###### FIGURE 42-5

Postoperative angiography after surgical resection of an arteriovenous malformation (AVM) of the right back and flank. Note the minor residual lesion, which was treated with conventional sclerotherapy.

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