CT Angiography of a Gonadal Artery Collateral from an Inferior Accessory Right Renal Artery

stay was unremarkable, without any recurrence of bleeding. To date, the patient has not had any therapeutic complications or recurrent bleeding. The small intestine presents a challenge when bleeding occurs as a result of its approximate length of 5 meters, which limits endoscopic imaging. Several treatment options exist for the treatment of small-bowel AV malformations. Endovascular methods include localized vasopressin injection, coil embolization, and polyvinyl alcohol embolization. Before the development of embolization treatments, medical treatments with vasopressin and/or subsequent resection were the gold-standard treatment methods. The use of vasopressin to induce vasoconstriction and thereby arrest bleeding was found to be as low as 36% effective (1), and the incidence of recurrent bleeding was as high as 71% (1). Therefore, vasopressin is used temporarily for stabilization and preparation for surgery, and has been replaced in most institutions with superselective embolization of mesenteric vessels. The aim of embolization of AV malformations is to completely obliterate the entire network of abnormal vasculature comprising the malformation, as partial treatment may allow recurrence (2).The use of NBCA adhesive, a liquid monomeric agent that polymerizes and solidifies when in contact with blood, has been shown to be effective in the management of AV malformations in the cranium. It has a low viscosity and can therefore be delivered through microcatheters within diminutive vessels. NBCA has been used to treat acute arterial hemorrhage from gastrointestinal and other pathologic processes (3). Kish et al (3) used NBCA in one of 16 patients for treatment of a rectal carcinoma pseudoaneurysm. NBCA has been shown to be successful in the treatment of gastrointestinal bleeding from a jejunal artery pseudoaneurysm secondary to intestinal tuberculosis (4). Additionally, the combination of microcoils and cyanoacrylate glue has been used to embolize an AV malformation of the superior pancreaticoduodenal artery supplying the duodenum (5).The difficulties associated with the use of NBCA include nontarget delivery, failure to satisfactorily obliterate the nidus, and catheter adhesion and subsequent retention. These difficulties are reduced with careful procedural technique (2). In summary, this case demonstrates a novel use of glue embolization for successful treatment of an AV malformation in the distal SMA presenting with massive lower intestinal bleeding and hypovolemic shock. Future studies are necessary to examine long-term safety and efficacy of glue embolization in the mesenteric arterial system, including the incidences of recurrent bleeding and bowel ischemia.