Angioembolization of Scrotal AVM, A Mis-diagnosed Case Treated as Varicocele

doi:10.21203/rs.3.rs-3411939/v1

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Angioembolization of Scrotal AVM, A Mis-diagnosed Case Treated as Varicocele

https://doi.org/10.21203/rs.3.rs-3411939/v1

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Scrotal Artero-venus malformation (AVM) is a rare congenital vascular anomaly which is demonstrated as swelling, heaviness, pain and bleeding in inguinal and scrotal area and in some cases may result in azoospermia and infertility. Therefore, this can be misdiagnosed with other usual pathologies of scrotum such as hernia and varicocele. Here we present a case of scrotal AVM which was misdiagnosed as varicocele followed by unnecessary varicocelectomy. Finally, diagnostic angiography confirmed the diagnosis and successful angioembolization was performed for the patient.

Scrotal swelling

varicocele

AVM

angiography

angioembolization

Scrotal swelling is a common medical condition. The causes can be benign or malignant such as mass lesions, metastasis, infections or vascular anomalies. Among the vascular etiologies, varicocele is the most common event while arteriovenous malformation (AVM) is the least one [1]. AVM is a congenital anomaly that is produced by changes in morphologies of vessels with gradual increase in size by child growth and is characterized by hyper-vascularity and excessive arteriovenous connections at the level of nidus [2, 3].

The usual sites for AVM are throat, extremities, trunk, intra- and extra-cranial regions of head and neck with the rarest location at scrotal area [4, 5, 6]. AVM often has an audible or tangible bruit and in sonography high systolic blood flow with low Resistive Index (RI) and arterialization of venous flow are detectable. MRI can show extension of AVM into adjacent organs. Angiography demonstrates a rapid shunt of contrast material from feeder arteries to dilated veins through non-developed vascular bed plexus [4].

The patients with scrotal AVM usually refer to health centers by complaining of scrotal swelling, feeling mass, scrotal heaviness, pain and bleeding. In some severe cases azoospermia with infertility, heart failure and even critical hemorrhage are noted [1].

Here we present a case of AVM which was wrongly diagnosed and treated as varicocele and then, after accurate diagnosis successful angioembolization was done.

A 34-year-old man with chief complaints of pain, dysuria, erectile dysfunction and scrotal swelling that increased in size during standing and walking was referred to vascular surgery department. According to patients’ explanation and previous medical records, he was first diagnosed as varicocele and treated by varicocelectomy. He was well for a while but again the signs and symptoms relapsed and even scrotal ulcers were developed. The patient had undergone second operation of varicocelectomy, hydrocelectomy and scrotoplasty. After these operations still the patient had pain that was more severe than before with increase in scrotal secretions and swelling. The third operation of sclerotherapy was performed. After this procedure the pain increased, erectile dysfunction and libido were good at the beginning but later they became worse.

In physical examination, bulging was noted in left inguinal and scrotal area with varices at scrotum and base of penis (Fig. 1). Thrill was also palpated in scrotum, left inguinal canal and left lower quadrant. The patient was highly suspected for AVM of scrotum and was referred to interventional Radiology Department for angiography and angioembolization. The angiography and angioembolization procedures were done in two separated sessions.

The first session was diagnostic angiography. After prep and drape and local anesthesia of the right inguinal area, the right common femoral artery was punctured and a 5F arterial sheet was inserted. Then by a 5F cobra catheter the internal and external left iliac arteries were catheterized separately. During angiography artero-venous malformation was observed in scrotum and base of penis. The AVM had multiple feeders from left internal and external iliac arteries, left internal pudendal, left inferior vesical, scrotal and left perineal arteries. (Fig. 2–4)

After a week, the angioembolization was performed under aseptic condition by insertion of a 6F sheet into the right common femoral artery. Each mentioned feeder of arterial branches of the scrotal AVM were catheterized by micro guide wire (Tenor) and Micro-catheter (Mastero) and were embolized by glue and lipiodole (50%-50% suspension). No significant reflux of the glue was detected into normal arteries during the operation. The procedure was successfully done with no complication. (Fig. 5–6)

After two days of hospitalization, the swelling of the scrotum and penis base were diminished and patient got free of pain. Follow up examination after 6 months showed mild swelling in left inguinal region however no swelling and dilated veins were noted in the scrotal area. Patient did not complain of pain and was satisfied (Fig. 7).

The usual vascular lesion in the scrotum is varicocele while other vascular pathologies like lymphangioma, hemangioma and AVM are very rare [7].

Scrotal AVM accounts for less than 1% of all vascular malformations which can be precisely diagnosed by angiography to demonstrate the feeding arteries, nidus and drainage veins [8].

In the AVM, the high flow diversion of blood from the tissue can cause various degrees of ischemia and pain [9]. However, there are also painless cases which present as para-testicular mass or incidental finding during checkup for infertility and sometimes as combination of swelling and infertility [10]. The increased temperature due to high blood flow may have deleterious effects on spermatogenesis and results in oligo- to azospermia which will get improved following surgery [11].

The treatments are embolization, sclerotherapy, surgical excision or a combination of them [4, 12]. Sclerotherapy is performed to reduce the nidus size and embolization is done before surgical resection in order to decline bleeding risk [7] however embolization can also be utilized as permanent treatment [6]. Infertility and impotence are major complications as consequences of poor procedural management [7].

The common clinical findings are swelling and palpable mass in scrotal area with pain, hemorrhage and ulceration [13, 14, 15]. Few cases can present with infertility [16, 17]. The diagnosis can be done by Doppler ultrasound followed by digital subtraction angiography [13, 14, 16]. Sometimes MRI and CT angiography are also used for the diagnosis of scrotal AVM however they are not very effective for establishment and management of the disease [18, 19]. In the treatment of low flow vascular malformations, variable embolization materials such as coil, gelatin, sponge, polyvinyl alcohol particles, onyx, and suspension of butyl cyanoacrylate and lipidol can be used. The choice of these material depends on the size of target vessels, flow velocity and embolization duration (temporary and permanent). The possible complications for embolization procedure are necrosis of skin, bladder or other intra-abdominal organs, arterial perforation and impotence in case of bilateral internal pudendal artery embolization. In cases of skin necrosis, surgery is required to remove the necrotic tissue [20].

The complications following sclerosant injections are hemolysis which may eventuate to hemoglobinuria, allergy reaction to contrast media and sclerotherapy agents, acute kidney injury in cases of high usage of contrast media. Hematoma and pseudo-aneurysm are considered as local complications in the insertion artery [21]. No specific complication is noted in our case up to date.

AVM should be taken in differential diagnosis of patients with scrotal swelling, spontaneous bleeding and scrotal pain. Doppler ultrasound, MRI and CT angiography can be used as diagnostic tools while digital subtraction angiography is the gold standard imaging modality for definitive diagnosis. Embolization of venous compartment of the AVM prior to surgery or alone is considered a good treatment option.

The authors declare no conflict of interests at this case report.

All three authors contributed equally in writing, editing and providing the material of this case report.

The authors declare no conflict of interests in this case report. The patient provided written informed consent for the procedure and publication.

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Angioembolization of Scrotal AVM, A Mis-diagnosed Case Treated as Varicocele

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