A refractory lower extremity variceal ulcer associated with perimedullary arteriovenous fistula

A 16-year-old male presented with a 3-year history of bilateral lower limb paresthesia and a refractory ulcer next to the swollen right medial malleolus (figure 1A). Lumbar MRI revealed a spinal vascular malformation (figure 2A). Digital subtraction angiography demonstrated a giant perimedullary arteriovenous fistula (PMAVF)1 originating from an anterior spinal artery at T10-11, draining into the inferior vena cava, and a few vascular malformations involving the right ankle (figure 2, B–F). Combination surgery and embolization was successfully performed for the PMAVF. Of note, the ulcer resolved without any direct treatment within 7 days (figure 1B).