Peripheral arteriovenous malformations (AVM) are the formation of abnormal shunts between arteries and veins. These tangles of multiple dysplastic, irregular blood vessels form a nidus –the center of the AVM. We present a case of a 70-year old woman with an extensive network of multiple discreet AVMs in her right upper limb and right chest wall. She had previously undergone a mid-forearm amputation due to a bleeding fungating ulcer from an AVM on the dorsum of her right hand. The multiple AVMs on her stump, shoulder and chest wall were also beginning to ulcerate and bleed.
Duplex ultrasound (DU) was the preferred imaging modality in view of the patient’s underlying chronic kidney disease. Real-time duplex investigation of the right upper limb was performed. The feeding arteries, the nidi and the draining veins of the discrete AVMs were identified. Waveform patterns and flow velocities were analyzed. The depth of the nidi from the skin surface as well as the anatomical position was measured for planning for potential surgical intervention.
DU findings demonstrated intertwining arterial and venous channels in the AVMs with no identifiable solid cutaneous mass. Hemodynamics was demonstrated as high-velocity flow in all arterial segments with arterialized flow patterns in the nidi and venous segments, indicating high-flow AVMs. A clear pattern of the anatomical architecture of the discrete AVMs was mapped out by detailed DU.
In this case, the use of detailed color flow, spectral Doppler and gray scale imaging allowed the determination of the architecture, extent, complexity and anatomical locations of the malformations. DU was of significant benefit in definitively differentiating the high-flow AVMs from other vascular malformations.
Emmanuel Pelingon, Vascular Technologist, National University Health System – Ng Teng Fong General Hospital
Emmanuel Pelingon, Vascular Technologist, National University Health System - Ng Teng Fong General Hospital