Super-selective metachronous embolization of post traumatic bilateral arterio-cavernosal fistula : case report

Objective: To report a case of high flow priapism due to post traumatic bilateral artero-cavernosal fistula treated with repeated super-selective arterial embolization with resorbable gelatin sponges. Methods: A 23-year-old man presented with a 1-day history of persistent penile tumescence following blunt perineal trauma. The suspicion of high flow priapism (HFP) was confirmed with Color Doppler US (ECDUSS), which showed a Peak Systolic Velocity (PSV) of 40 cm/sec and 35 cm/sec respectively for the right and left cavernosal arteries. Also bilateral turbulent, swirling flow patterns at the base of the penis suspicious of artero- cavernosal fistula were detected with the ECDUSS. MRI excluded tunica albuginea fracture. After an exhaustive discussion of possible complications with the patient, a selective arteriography of the hypogastric and internal pudendal artery was performed. This investigation confirmed the presence of pseudoaneurysm of the pudendal branches of the internal pudendal arteries bilaterally (right > left), causing artero-cavernosal communications and therefore a multistage super-selective embolization of right and left cavernous artery with absorbable sponges was performed. Results: After three procedures (first on the right penile branch, the second and the third on the left branch, 2 and 4 weeks later, respectively), both fistulas disappeared. No complication was noted. Four weeks after the last procedure, the patient had an IIEF score of 16. ECDUSS showed normal bilateral PSV. Conclusion: Arteriography with super-selective embolization proved to be an effective therapy for high flow priapism. In bilateral lesions multistage endovascular procedure with resorbable material is a good option.