A 24-year-old man was referred for further management of a large arteriovenous malformation
(AVM) in the second part of his duodenum ([Fig. 1]). He had a long history of refractory anemia requiring regular iron infusions and
recurrent episodes of gastrointestinal bleeding necessitating hospital admission.
Gastroscopy at his local hospital had shown a large duodenal AVM and computed tomography
angiograms performed during bleeding episodes failed to identify a vessel amenable
to embolization. The patient was keen to avoid surgical resection and was referred
for consideration of endoscopic management.
Fig. 1 A large duodenal arteriovenous malformation in the second part of the duodenum.
After discussion at our multidisciplinary team meeting, the option of an over-the-scope
clip (OTSC) was considered most appropriate because it is minimally invasive and the
lesion was endoscopically easily accessible. At gastroscopy the duodenal AVM was identified
and the borders of the lesion were marked with argon plasma coagulation (APC) ([Fig. 2]). An OTSC (Ovesco Endoscopy, Tubingen, Germany) was then deployed ([Fig. 3], [Video 1]) with no immediate complications. The patient has since not reported any further
bleeding episodes and has remained stable with no requirement for iron infusions during
a 10-month follow-up period.
Fig. 2 Application of argon plasma coagulation to mark the borders of the lesion.
Fig. 3 Placement of an over-the-scope clip to treat the duodenal arteriovenous malformation.
Video 1 Endoscopic-guided placement of over-the-scope clip to treat the duodenal arteriovenous
malformation.
Large duodenal AVMs are rare and previous case reports have described successful management
of bleeding lesions with angiographic embolization [1]
[2] although this approach has not been universally effective [3], nor has laparoscopic ligation of the feeding branch of the gastroduodenal artery
[3]. Band ligation has not been previously described but carries the risk of delayed
bleeding from post-ligation ulcer development and glue injection has only provided
temporary hemostasis in another case report [3]. The role of endoscopic ultrasound for lesion delineation and therapy requires consideration,
but in our case, the lesion was macroscopically visible, so this was not performed.
Surgical resection has been used for definitive management of large AVMs but carries
substantial risk in the setting of active bleeding.
