PERCUTANEOUS EMBOLIZATION AND LAPAROSCOPIC LIGATION

Thank you for this opportunity to present our case of laparoscopic ligation of a congenital umbilical arteriovenous malformation. A 3 day old female twin who was born at 37 weeks was transferred to our facility with increasing oxygen requirement as well as a palpable abdominal thrill and audible bruy. A chest X-ray was performed and revealed cardiomegaly. An ultrasound found a mass of vessels in the anterior abdominal wall. An MRA of the abdomen and pelvis demonstrated umbilical and inferior epigastric arteries bilaterally feeding a large arteriovenous malformation drained by the umbilical vein. Angiography through the left inferior epigastric artery exhibited a complex plexus of vessels fed by the inferior epigastric and umbilical arteries and drained by the umbilical vein. Interventional radiology placed coils in the umbilical vein, however, there was still persistent flow. Consequently, they placed coils into the left epigastric artery, but flow continued. They then placed coils into the right epigastric artery, and overall flow decreased but did not cease. Follow up ultrasound showed persistent but decreased flow through the AVM. Echocardiography showed continued pulsatile flow through the ductus venosum, right heart dilation, significant pulmonary hypertension, and continued bowing of the intraventricular septum from the right to the left. We decided to pursue laparoscopic ligation of the arteriovenous malformation. Lateral entry to the peritoneal cavity was obtained. The umbilical arteries and vein were noted to communicate with the arteriovenous malformation. The coils were noted as well as continuous pulsatile flow. An additional port was placed in the left upper quadrant, and a suture was passed through the abdominal wall to control the vessel. The umbilical arteries were dissected away from the abdominal wall, and a 3 millimeter Maryland vessel sealer was used to seal and ligate the vessels. A window was made in the fusciform and the vessel sealer was used to attempt to close the vane. However, the coils interfered with the function of the instrument. An additional port was inserted and clips were used to occlude the umbilical vein. Once the vein was closed, the transfascial abdominal suture was adjusted and tied, and no further bleeding was found. Postoperative ultrasound showed no further flow through the arteriovenous malformation. Post-operative echocardiogram showed significantly improved right heart and pulmonary pressures as well as resolution of right heart dilation and improved function. Laparoscopic ligation of congenital umbilical arteriovenous malformations has only been reported once in the literature. Endovascular embolization, if attempted, may not be completely successful despite extensive coiling, although it may be useful preoperatively to avoid complications associated with dramatic and immediate reduction of preload. Test clamping the vessels is another option to assess the cardiovascular impact of cessation of flow prior to definitive ligation. Thoughtful coil placement to allow for a clear segment for future surgical ligation as well as careful placement of laparoscopic energy devices to avoid interference from coils can be helpful. Laparoscopic ligation is safe and effective and may be used as a primary or secondary method for closure of congenital umbilical arteriovenous malformations. Thank you for this opportunity to present our case.