Transhepatic embolization of a pancreatico-duodenal arteriovenous malformation: Application of retrograde pressure cooker technique with ethylene-vinyl alcohol copolymer

TL;DR

A rare pancreatic arteriovenous malformation was successfully treated using a new embolization technique with coils and Onyx in a high-risk patient.

Contribution

First successful application of retrograde pressure-cooker embolization with Onyx for a pancreatic arteriovenous malformation.

Findings

Transvenous retrograde embolization via transhepatic approach achieved complete nidus obliteration.

Modified pressure-cooker technique with coils and Onyx was effective in a complex, surgically unsuitable case.

Staged interventions led to successful treatment of a Yakes type III arteriovenous malformation.

Abstract

Pancreatic arteriovenous malformations are rare vascular anomalies that may present with gastrointestinal bleeding, abdominal pain, or portal hypertension. Their management is challenging, with surgical resection carrying a significant risk of morbidity. Endovascular embolization offers a less invasive alternative; however, success is often limited in cases with multiple arterial feeders. We present a 65-year-old woman with cirrhosis and upper gastrointestinal hemorrhage from a Yakes type III pancreatic arteriovenous malformation. Given her poor surgical candidacy and complex arterial inflow, transvenous retrograde embolization via a transhepatic approach was performed using a modified pressure-cooker technique with coils and Onyx. Complete nidus obliteration was achieved following staged interventions. This represents the first reported successful use of a retrograde pressure-cooker technique with Onyx in a pancreatic arteriovenous malformation.

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