Patient: In late December 2007, I was found to have a “left internal iliac arteriovenous fistula” by ultrasound examination at a local hospital because I had a sensation of a rise in my left lower abdomen for more than half a month. (I had a total hysterectomy at the local hospital on November 27, 1999. The bleeding started on the eighth day after the operation and stopped only after half a month.) Ultrasound examination on December 26, 2007, ultrasound description: a large number of tortuous and dilated anechoic duct structures were seen in the posterior side of the pelvic bladder, with a range of 13x5cm, thin wall, thickest internal diameter of 4.5cm, no obvious thrombus attached to the wall, no obvious pulsation of the duct wall, CDFI: it was filled with red and blue colored blood flow signals, PW measured arterial and venous blood flow spectrum, the highest flow velocity Vmax=89.1 The maximum flow velocity Vmax=89.1 cm/s and the lower flow velocity V=28.4 cm/s. The capsular anechoic structure was associated with the left common iliac. The left internal iliac artery was dilated with an internal diameter of 1.1 cm and a flow velocity of V=84.3 cm/s. A ductal structure with a width of about 0.6 cm was seen in the left posterior wall of the sacculated anechoic structure, which was connected to the sacculated structure. s, RI=0.60, the internal diameter of the traffic port was about 0.6 cm, the flow velocity Vmax=84.2/s. The bilateral attachments were not clear. Ultrasound suggests: 1. Giant vascular lesion in the left posterior aspect of the pelvic bladder: Consider an arteriovenous fistula, the involved artery is from the left internal iliac artery branch. 2. Hysterectomy is absent and both adnexa are not visible. The answer we got from several hospitals in my family’s case was: 1. to perform interventional surgery, put a spring steel ring to embolize and then put a vascular stent to isolate the fistula; 2. to perform open surgery to ligate. I would like to ask the experts: 1. which surgical option should I choose? 2. Is it necessary to put a vascular stent after embolization with a spring coil? Thank you! A: The clinical information and examination provided are not comprehensive enough. Further imaging examinations such as CT, MRI and if necessary DSA arteriography should be done in order to establish the diagnosis and clarify the scope of the lesion and the location of the arteriovenous fistula before considering the treatment options. If the above diagnosis is established, both interventional and open surgery can be chosen. The former is less invasive but more expensive, while the latter is more invasive but relatively less expensive. If the patient is suffering from congenital vascular malformation, you should be prepared that the symptoms may be improved by treatment, but not necessarily cured. Patient: Thank you very much for your patience in answering my question in your busy schedule. I had a DSA angiogram at the local hospital a month ago, and this is what the doctor wrote in my medical record at that time: 1. placed a tube in the left internal iliac artery, and performed a DSA angiogram at 6 ml/sX2. (inferior gluteal artery) arteriovenous fistula, fistula area 5X4 cm, direction of return: to the right iliac vein back to the heart. A seldinger technique was considered for superselective placement of a tube distal to the uterine artery, and COOK MWCE-35-5-5.38-5-8 and 38-5-12 spring-loaded steel coils were placed in the left superior gluteal. COOK MWCE35-5-5.35-5-8 was applied to the inferior gluteal and left internal iliac arteries. The left internal iliac artery was twisted. Dilatation of 1.0 cm requires isolation of the internal iliac artery opening with a membrane stent. 2. Placement of a tube in the left external iliac artery with 5 ml/sX2 DSA angiography shows the left deep spinocranial artery associated with the fistula area. Consider applying COOK MWCE38-3-3 embolization spring steel ring for embolization, and if embolization is incomplete, consider applying TALENT TM LPS L1XW12B68 with membrane stent along the super rigid guidewire stent positioned at the upper edge of the lumbar 4 conus. The local doctor said that in my case, at least 12 packs of spring steel coils (said to cost more than $1,300 per pack) should be placed to embolize the fistula, and then a vascular stent (said to cost more than $28,000) should be placed to isolate the fistula, costing about $60,000 to $70,000. Do you think it is necessary to put in a stent after I have had a spring coil placed? I can’t imagine the cost of such a treatment for an ordinary working class person. If I have this kind of surgery at your hospital, is it the same treatment plan? How much will it cost? Thank you! A: I have not seen the patient’s DSA film, the patient’s specific choice of treatment should be your own choice. But from the imaging report, the patient’s arteriovenous fistula is relatively extensive, and interventional treatment can be considered and should be the first choice (after placing the spring coil, a laminated stent should be placed to seal the opening of the left internal iliac artery). The cost is more expensive and probably the overall cost of treatment in our hospital is estimated to be more than in your local hospital. The cost of surgical treatment will be less. We also need to remind you again that the disease is not easily cured completely, so be prepared to spend money but the results are not satisfactory.