Transhepatic embolization of a pancreatico-duodenal arteriovenous malformation: Application of retrograde pressure cooker technique with ethylene-vinyl alcohol copolymer

Pancreatic arteriovenous malformations are rare vascular anomalies that may present with gastrointestinal bleeding, abdominal pain, or portal hypertension. Their management is challenging, with surgical resection carrying a significant risk of morbidity. Endovascular embolization offers a less invasive alternative; however, success is often limited in cases with multiple arterial feeders. We present a 65-year-old woman with cirrhosis and upper gastrointestinal hemorrhage from a Yakes type III pancreatic arteriovenous malformation. Given her poor surgical candidacy and complex arterial inflow, transvenous retrograde embolization via a transhepatic approach was performed using a modified pressure-cooker technique with coils and Onyx. Complete nidus obliteration was achieved following staged interventions. This represents the first reported successful use of a retrograde pressure-cooker technique with Onyx in a pancreatic arteriovenous malformation.