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case_images: Transvaginal Ultrasound showing doppler findings (A) and spatial measurements of echogenic mass (B) Features suggestive of an increased vascular component that is indistinguishable whether it is located in the endmetrium or the myometrium.
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case_images: Her OBGYN reviewed the benign pathology of the previously removed products of conception (POC) and performed TVUS, which showed multiple small cysts as well as an echogenic mass with increased blood flow measuring 2.1 x 1.8 x 1.6 cm (Fig. 1).
case_images: MRI - Axial Fat suppressed T2WI A), Coronal T2WI (B), Sagittal delayed postcontrast T1WI (C), and Axial Digital Subtraction Imaging (D). Features of serpiginous low T2 hypointense structures through the myometrium suggestive of myometrial vasculature pointing towards uterine AVM in concordance with hypervascular Doppler signal (A and B). Supporting this is the finding of incompletely maintained endometrialMyometrial interface on the posterior aspect (C). However, appearance of a high T1 signal mass in pre- and postcontrast images with enhancing components on subtraction imaging would favor the diagnosis of RPOC. Note: MRI, Magnetic resonance imaging; T2WI, T2-weighted imaging; T1WI, T1-weighted Imaging; AVM, Arteriovenous malformation; RPOC, Retained products of conception.
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case_images: She was admitted, and an expedited MRI of the pelvis revealed a mixed signal endometrial mass with solid enhancement, an indistinct endometrial-myometrial interface in the posterior uterine body along with serpiginous low T2 signal through the myometrium - features suggestive of both RPOC (mass) and uterine AVM (dilated abnormal vessels in the myometrium; Fig. 2).
case_images: CTA in coronal (A) and axial (B) views. Clear visualization and comparisons with the prior MRI pelvis favor towards an AVM due to the early filling of the cluster of vessels that appeared to be predominantly located in the myometrium. Views also suggest that both left, and right uterine arteries are involved. Note: CTA, Computer tomography angiography; MRI, Magnetic resonance imaging; AVM, Arteriovenous malformation.
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case_images: Due to the indeterminate findings, an urgent computed tomography angiography (CTA) of the pelvis was performed and revealed 2.3 x 2.1 cm vessel cluster within the myometrium, supplied by both uterine arteries, with early venous filling, favoring a diagnosis of uterine AVM over RPOC (Fig. 3).
case_images: Selective angiograms of right (A and C) and left (B and D). Postembolization imaging (C and D) shows a remarkable reduction in blood flow through the AVM. Although previous imaging was able to narrow down on the diagnosis of AVM, it was mentioned that both the left and right uterine arteries likely contributed to the AVM. The above imaging clearly reveals that only the left uterine artery acted as a feeder. Embolization yielded excellent results. Note: AVM, Arteriovenous malformation.
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case_images: Braun Medical Inc., Bethlehem, PA) catheter, or RenegadeTM microcatheter (Boston Scientific, Marlborough, MA) on various arteries (Fig. 4).
case_images: CTA images 6 weeks postembolization. As expected, when compared to CTA images shown in Fig. 3, there is no significant vascular ectasia withing the uterine parenchyma. There are no further complications such as arteriovenous fistulae or pseudoaneurysm because of the transarterial catheterization. Note: CTA, Computer tomography angiography.
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case_images: A 6-week follow-up CTA (Fig. 5) of the pelvis revealed no residual AVM nidus, fistula, or pseudoaneurysm, with patent bilateral internal iliac, uterine, and ovarian arteries.