Absolute Ethanol Embolisation of Mandibular Arteriovenous Malformations Following Direct Percutaneous Puncture and Release of Coils via a Microcatheter

Ethanol embolotherapy of mandibular arteriovenous malformation-induced acute oral hemorrhage after tooth extraction

BACKGROUND

Mandibular arteriovenous malformation (AVM) is rare. Our work aims to introduce the ethanol embolization of a patient suffering from acute oral hemorrhage induced by mandibular AVM.

METHODS

A 35-year-old woman without coagulopathy underwent tooth extraction, and the acute oral bleeding occurred intraoperatively. Imaging examinations indicated the enhancement of vascular mass with bone destruction inside the mandible. Angiography finally confirmed the high blood flow nature and the diagnosis of AVM.

RESULTS

During the interventional procedure, the coils were first applied into the dilated outflowing vein to slow down the blood flow rate of mandibular AVM. Absolute ethanol was injected in a multi-bolus modality to destroy the nidus of AVM. Her mandibular lesion had been stable in the 12-month re-examined angiography, no further bleeding occurred during the period.

CONCLUSIONS

Ethanol embolotherapy was a less invasive, more precise, and quick-action approach managing AVM of the jaw and related emergency medicine.

Ethanol Embolotherapy for Cutaneous Erythema of High-Flow Vascular Malformations in the Head and Neck

BACKGROUND

Cutaneous erythema is one of the most common signs of arteriovenous malformations (AVMs) in the head and neck region, influencing aesthetic appearance. Surgical resection of AVMs may lead to cicatrization of the skin or aggravation of the lesion. Laser treatment, although effective in improving superficial vascular lesions, cannot prevent deep AVMs from further development.

OBJECTIVE

The authors propose an absolute ethanol embolization therapy that can effectively and safely eradicate the nidus with a favorable aesthetic outcome.

METHODS

The authors conducted a retrospective observational study of 14 AVM patients with distinct cutaneous erythema in the head and neck region undergoing embolotherapy in a single primary care center. Symptoms before and after treatment, complications, and degree of devascularization were recorded and assessed. Changes in cutaneous redness were evaluated using a previously reported quantitative measurement.

RESULTS

Complete symptomatic relief was observed in 5 patients, and major improvement was observed in 9 patients. The mean Δ a * value of the color change had a significant reduction of 6.50 ± 4.04, p < .001, indicating a remarkable remission of cutaneous erythema.

CONCLUSION

Ethanol embolization is an effective and safe treatment for head and neck AVMs with excellent aesthetic outcomes and might become a potential treatment method for other superficial vascular anomalies.

Overview of peripheral arteriovenous malformations: From diagnosis to treatment methods

Based on the latest classification by the International Society for the Study of Vascular Anomalies in 2018, vascular malformations (VMs) can be categorized into simple, combined VMs of major named vessels, and VMs associated with other anomalies. Simple VMs include lymphatic, venous, capillary, and arteriovenous malformations (AVMs). AVMs represent disorders of direct arteriovenous shunts caused by the absence of a capillary bed between the involved arteries and veins. This abnormal vascular communication causes arterial blood to accumulate in the venous vessels, thus resulting in venous hypertension and characteristic clinical manifestations, such as pulsation, tremors, and elevated temperature. AVMs can occur sporadically or as manifestations of syndromic lesions and are considered among the most complex and challenging VMs. The diagnosis and treatment of AVMs can vary depending on the lesion location and associated clinical symptoms, thus complicating their management. Herein, we discuss peripheral AVMs in terms of their clinical manifestations, imaging examinations, and staging systems to provide a comprehensive reference for the treatment, evaluation methods, and follow-up procedures for this vascular anomaly.

Angiographic Types of Palpebral Arteriovenous Malformations and Relevant Therapeutic Options Based on Ethanol Embolization: A Multicenter Study

PURPOSE

The present work aimed to determine the different angio-architectural types of palpebral arteriovenous malformations (pAVMs) and appropriate ethanol embolotherapy for each type.

MATERIALS AND METHODS

This was a multi-center comparative effectiveness research retrospectively conducted from November 2012 to October 2021. A total of 70 patients with pAVMs were included, which was classified into cystic pAVMs (n=29) and diffuse pAVMs (n=41) based on the angio-architecture. Of the included patients, 17 with cystic pAVMs and 13 with diffuse pAVMs underwent ethanol embolization combined with coils (CE). The remaining participants underwent no-coil ethanol embolization (NCE). Participants had undergone 60 months of follow-up. Normality of data was tested by the D'Agostino and Pearson test. Correlation was tested by the Pearson χ2 test. Deterioration-free survival (DFS) rate was estimated using the Kaplan-Meier survival analysis. Multivariate Cox regression models included variables that were significant at a p value<0.05 in the univariate analysis to screen the prognostic factor.

RESULTS

The local symptoms of pAVMs, including pulsation, warmth, red plaque, blepharoptosis, bleeding, and visual blurring, along with the devascularizational grade of angiography were recorded before and after the respective procedures. Post-treatment complications were either evaluated at the 3-month routine follow-up or were self-reported by patients. Cystic pAVMs presented with significantly different clinical and angiographic features compared with diffuse pAVMs. With CE, patients with cystic pAVMs obtained a higher devascularizational grade (p<0.0001) and better clinical outcomes (p=0.0009) than those with diffuse pAVMs. Contrarily, with NCE, patients with diffuse pAVM had better outcomes than those with cystic pAVMs (p=0.0248). Moreover, the overall DFS rate was higher in patients with cystic pAVMs (p=0.0006). Finally, the angio-architecture of pAVMs was found to independently influence its prognosis (p=0.02).

CONCLUSIONS

In pAVMs, the angio-architectural type was associated with the relative prognostic status. Ethanol embolization combined with coils was an effective method to treat cystic pAVMs, whereas NCE was more suitable for the diffuse type, further emphasizing the importance of a type-based therapeutic strategy for pAVMs.

CLINICAL IMPACT

Palpebral arteriovenous malformations (pAVMs) are rare and tricky in clinical practices. The present study has divided the pAVMs into cystic and diffuse types according to their angiographic characteristics. Ethanol embolization with (CE) or without coils (NCE) was performed on both types. CE was suitable for cystic pAVMs; whereas NCE was a better choice for diffuse pAVMs. The five-year survival analyses provided evidence of the safety and efficacy of ethanol application in pAVMs. Finally, our work demonstrated that both the short- and long-term clinical outcomes of diffuse pAVMs were poor compared to those of cystic pAVM.

Inhibition of angiotensin II type 1 receptor partially prevents acute elevation of pulmonary arterial pressure induced by endovascular ethanol injection

This study aimed to examine whether the administration of losartan can prevent acute elevation of pulmonary arterial pressure (AEPAP) induced by endovascular ethanol injection and to assess its related mechanisms. Male swine were selected and performed with absolute ethanol endovascular injection. Saline was used as the negative control. Losartan was administered preoperatively. Pulmonary arterial pressure (PAP), femoral arterial pressure (FAP) and heart rate (HR) were monitored during operations. Venous plasma and pulmonary artery (PA) tissue were harvested for analyses. Protein level was detected by Western blotting and ELISA, whereas qRT-PCR was used in mRNA detection. H & E staining and immunohistochemistry were conducted to evaluate histopathology. Ethanol injection elevated PAP in swine. The concentration of RAS ligands was elevated in plasma (all P < 0.0001) but not in PA. The level of oxidative stress increased in both plasma and PA. MRNA level of AT1R (P < 0.01, 95% CI: 0.251-1.006), not AT2R increased in PA. Losartan failed to inhibit AEPAP after all sessions of ethanol injection, and partially reversed the ethanol-induced PA remodeling. The P38 MAPK was activated after ethanol injection and could be inhibited by losartan (P < 0.01, 95% CI: -0.391 to -0.164). Ethanol also promoted the translocation of the P40-PHOX/P47-PHOX/P67-PHOX complex and the activation of NOX, which was independent from RAS. Endovascular ethanol injection can induce AEPAP mainly by activating RAS and P38 MAPK signaling. Losartan can partially prevent AEPAP and vascular remodeling owing to the promotion of NOX activity by ethanol. Mechanism diagram of endovascular ethanol injection-induced acute elevation of pulmonary arterial pressure (AEPAP) partially prevented by losartan. RAS: Renin-angiotensin system; AGT: angiotensinogen; Ang I: angiotensin I; ACE: angiotensin I converting enzyme; Ang II: angiotensin II. AT1R: angiotensin II type 1 receptor. NOX2: NADPH oxidase 2. PA: pulmonary artery.

Interventional embolization combined with surgical resection for treatment of extracranial AVM of the head and neck: A monocentric retrospective analysis

Objectives

The aim of this study was to demonstrate the efficacy and feasibility of treating patients with extracranial arteriovenous malformations (AVM) of the head and neck with interventional embolization followed by surgical resection.

Methods

We reviewed the charts of all patients between 2012 and 2021 with extracranial AVM of the head and neck scheduled for interdisciplinary treatment according to University Hospital RWTH Aachen’s protocol and conducted standardized interviews using a newly developed questionnaire. Interview results, as well as clinical examination and radiographic outcome results were analyzed to help determine the efficacy of our treatment approach.

Results

We included 10 patients (8 female, 2 male), with a mean age of 33.5 (11–61) years who were scheduled for treatment of the AVM with interventional embolization followed by surgical resection. In 6 of the 10 patients (60%) the lesion was located in extracranial soft tissue only. In one patient (10%), the lesion was located in bone tissue only. A combined intraosseous and oral soft tissue lesion was seen in the remaining 3 patients (30%). Radiographic resolution was achieved in 62.5% of cases and a significant decrease of symptoms was identified (p = 0.002). None of the patients reported dissatisfaction and no major complications occurred.

Conclusion

An interdisciplinary treatment approach combining neuroradiological interventions with surgical resection appears to be an effective treatment with an acceptable complication rate. Patients treated according to our protocol showed a high satisfaction rate, regardless of the radiographic outcome. Standardized follow-up allows for early detection of recurrences and helps with subjective patient satisfaction.

Interventional therapy of extracranial arteriovenous malformations of the head and neck—A systematic review

Objectives

The primary aim of this study was to conduct a meta-analysis of the literature on interventional treatment for patients with extracranial AVM of the head and neck to identify a superior treatment. The secondary aim was to evaluate the methodological quality of associated articles published between 2000–2020.

Methods

The literature search was conducted on PubMed, Embase, the Cochrane Library, and scholar.google.com. Studies, meeting the acceptable reference standard underwent meta-analysis. All identified literature underwent methodological quality analysis.

Results

Of 1560 screened articles, 56 were included in the literature review. Appropriate diagnostic tests were reported in 98% of included articles. 13% of included articles did not specify the embolization agent. Outcome analysis varied throughout. 45% of the authors used radiographic imaging for follow-up. 77% specified the span of follow-up of their entire patient collective. Two articles met the inclusion criteria for meta-analysis. Curing rate of transarterial ethanol embolization for intraosseous AVM was 83% with a complication rate of 58%. Curing rate of ethanol combined with NBCA or Onyx in soft tissue AVM was 18% with a complication rate of 87%.

Conclusion

Our literature review revealed an absence of treatment or reporting standards for extracranial AVM of the head and neck. The meta-analysis is comprised of two articles and methodological quality is heterogeneous. We recommend implementing consistent reporting standards to facilitate comparability of studies and to provide robust data for the development of an evidence-based treatment strategy.

Advances in knowledge

Meta-analysis showed a favorable radiological outcome for intraosseous AVM when treated with intraarterial ethanol embolization. Our analysis demonstrated that the published data on extracranial AVMs of the head and neck is lacking in consistency and quality, prompting agreement for the need of standardized reporting on AVM treatments.

Systematic review of pediatric mandibular arteriovenous malformations

OBJECTIVES

The management of arteriovenous malformations (AVMs) can be challenging in the pediatric population. It is of utmost importance to keep in mind various management options as these lesions can have disastrous outcomes. This is a systematic review of the treatment AVMs describing the current practices so that practitioners can be aware of what is currently reported in the literature. The challenges of AVM management can be mitigated when approaching these patients through a multidisciplinary team-based approach.

METHODS

A systematic review of the literature was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to gain insight into pediatric mandibular AVMs. Demographics, arterial involvement, clinical symptoms, imaging, treatment, complications, follow-up, and outcomes were reviewed.

RESULTS

63 articles were included in the systematic review with 106 distinct cases. The age range was from 3 to 17 years with a mean of 12 years. 51% of the patients were female. The most common clinical presentation was emergency hemorrhage (37.4%), swelling or edema (33.0%), and persistent bleeding (31.9%). The most common CT findings were osteolytic changes and radiolucencies (60.8%). With regards to treatment, 56.6% of patients had embolization alone and 34.9% were treated with embolization in combination with other surgical treatments. Of the patients who had surgical resection of the lesion, 50% had resection followed by reconstruction, 23.7% had curettage of the lesion, and 13.2% had resection/curettage then immediate reimplantation of the mandible segment. The most common complications after intervention included bleeding in 17.9% of patients and infection in 8.3% of patients. 89.5% of patients were clinically cured without recurrence at follow-up.

CONCLUSION

Diagnosing AVMs can be difficult as they have variable clinical and radiographical presentations. Although rare, because of risk of massive hemorrhage, it is important for healthcare professionals to be aware of this pathology. Many surgical techniques, routes of embolization, embolic material, and other experimental therapies have been described and this review shows that the most cases had embolization as a part of the treatment. The role of therapies targeted at the molecular level still needs to be further explored.

Endodontic implications of a patient with arteriovenous malformation: a case report and literature review

AIM

To present the endodontic management of a patient diagnosed with a high-flow arteriovenous malformation (AVM) requiring root canal treatment and to discuss the relevant endodontic literature for this rare but significant problem.

SUMMARY

AVM is a complex communication of an artery and a vein in which the oxygenated blood is forced away from the intended tissue. The incidence of its occurrence in the face and neck is rare, and when present, the most common sign is gingival bleeding. Arteriovenous malformation is both a diagnostic and therapeutic challenge for dentists. Also, there is ambiguity regarding the precautions to be taken whilst doing endodontic procedures in such cases. Hence, there is a need to understand the disease process and its implications in order to prevent life-threatening complications during treatment. This case report highlights the successful endodontic management of a cariously exposed right maxillary second premolar in a patient diagnosed with high-flow AVM. On an orthopantomogram, the AVM was spreading in the left submandibular space involving the left ramus area. The clinical findings of limited mouth opening with inter-appointment swelling and trismus during treatment made the case unusual and challenging. This paper addresses the current understanding of the classification, diagnosis, clinical features and endodontic management, together with specific guidelines and recommendations whilst performing endodontic procedures in AVM cases.

KEY LEARNING POINTS

The classification and oral manifestations of AVM must be known and understood. Practitioners should be aware of the radiographic appearance of AVM. Recommended precautions should be taken when carrying out restorative and endodontic procedures in a patient with AVM. Antibiotic prophylaxis may be considered before endodontic treatment in a patient with AVM. Multidisciplinary treatment planning may be required.

Clinical and imaging features of intraosseous arteriovenous malformations in jaws: a 15-year experience of single centre

Intraosseous arteriovenous malformations in jaws (j-AVMs) are rare congenital high-flow vascular anomalies with a high tendency of life-threatening haemorrhage and are regarded as one of the most dangerous haemorrhagic diseases in maxillofacial region. Pre-treatment clinical and imaging evaluations serve as the most important diagnostic modalities. A retrospective study involved 211 patients with j-AVMs from November 2003 to November 2017 was performed. The male-to-female ratio of j-AVMs was approximately 4:3. The mean age of the patients with j-AVMs is 21.86. Bleeding was the main complaint associated with j-AVMs. J-AVMs occurred in the mandible more often than in the maxilla (64.93% and 32.23%, respectively). Most j-AVMs (95.26%) occurred in the posterior teeth region. Classical imaging features of j-AVMs included: an unclear maxillary sinus with a mild ground-glass appearance (maxillary j-AVMs) and a clear oval or irregular lucency that is mostly centred on the root of the first molar (mandibular j-AVMs) on OPGs, enhancement in the cancellous bone on contrast-enhanced CTs. Other atypical features of j-AVMs were also concluded. A comprehensive diagnose system based on clinical and imaging features of j-AVMs could provide valuable reference data for clinical management of j-AVMs and help avoid improper iatrogenic trauma or delayed treatment.

Intraosseous Arteriovenous Malformations in the Extremities Managed with Coils and Absolute Ethanol Treatment

BACKGROUND

The extremity intraosseous arteriovenous malformations (AVMs) are rare high flow vascular lesions for which the treatment remains challenging. The aim of the study wasto assess treatment methods, interim results, and complications of coils and absolute ethanol in managing extremity intraosseous AVMs via direct puncture approach.

METHODS

From 2009 to 2017, 12 patients (mean age, 27.5 years; range, 3-54 years) with extremity intraosseous AVMs underwent staged coils and absolute ethanol treatment via the direct puncture approach. All patients were symptomatic before the procedure as per the Schobinger staging system. The mechanical detachable coils and undetachable coils were used first followed by the injection of absolute ethanol used as a sclerosant agent via a direct puncture approach. Follow-up evaluation (6 to 72 months; mean, 23.5 months), including imaging and symptoms and signs, was performed in all patients.

RESULTS

Twenty-seven absolute alcohol procedures were performed for patients with intravascular sclerosis (range: 1-3, mean: 2) with one procedure required per patient (n = 2), 2 per patient (n = 5), or 3 per patient (n = 5). The average stretched length of the total coils per patient was 843.33 cm. The amount of absolute ethanol used ranged from 10 mL to 45 mL (mean, 25.69 mL) in a single session. Nine of twelve patients (75%) exhibited complete responses, and 3 patients (25%) exhibited partial responses. One patient experienced minor complication of transient motor nerve injury and completely recovered half a month later. No major complications occurred.

CONCLUSIONS

The study provides strong evidence, suggesting that direct puncture and coils with absolute ethanol approach is an effective and safe treatment in patients with extremity intraosseous AVMs, yielding minor complications and good results.