Staged, office-based multifaceted cure of a previously mismanaged, life-threatening gluteal arteriovenous malformation using venaseal cyanoacrylate for embolization

Congenital arteriovenous malformations represent high flow vascular anomalies that can lead to various degrees of venous hypertension, local edema, acral steal, local ulceration, cardiopulmonary overload, and life-threatening hemorrhage. Sacro-gluteal malformations represent a rare subset with their own challenges that can be exacerbated by nonnidal treatment. Evidence-based treatment models of these lesions are currently limited in literature. We present the case of an 86-year-old female patient with a large and rapidly expanding left gluteal arteriovenous malformation previously treated via proximal ligation of the feeding internal iliac artery followed by recurrence with extensive arterial recruitment. Imaging revealed a Yakes IIIa lesion with extensive collateral recruitment and secondary iliofemoral venous compression. The patient underwent a staged, office-based strategy utilizing cyanoacrylate embolization, intravascular ultrasound-guided venous decompression, and delayed surgical excision. The patient was able to achieve resolution of her pain, restoration of mobility, and progressive wound healing with no evidence of recurrence at 12 months of follow-up. Our approach highlights a pathophysiology- and angioarchitecture-guided treatment paradigm comprised of multistage angioembolization, correction of venous hypertension, and delayed surgical excision.