Embolization as the Primary Treatment for Mandibular Arteriovenous Malformations: An Analysis of 50 Literature Reports and of an Illustrative Case

Head and Neck Arteriovenous Malformations: Clinical Manifestations and Endovascular Treatments

Arteriovenous malformations (AVMs) are vascular malformations that present high-flow direct communication between the arteries and veins, not involving the capillary beds. They can be progressive and lead to various manifestations, including abnormal skin or mucosal findings, ischemia, hemorrhage, and high-output heart failure in severe cases. AVMs often involve the head and neck region. Head and neck AVMs can present region-specific clinical manifestations, angioarchitecture, and complications, especially in cosmetic appearance and ingestion, respiratory, and neuronal functions. Therefore, when planning endovascular treatment of head and neck AVMs, physicians should consider not only the treatment strategy but also the preservation of the cosmetic appearance and critical functions. Knowledge of the functional vascular anatomy as well as treatment techniques should facilitate a successful management. This review summarizes AVMs' clinical manifestations, imaging findings, treatment strategy, and complications.

Endovascular embolisation of a complex mandibular AVM: a hybrid transarterial and transvenous approach

Mandibular arteriovenous malformations (AVMs) are rare lesions which can present with life-threatening haemorrhage. Endovascular embolisation can be life saving for these patients. We discuss a patient of mandibular AVM, who initially presented with reports of massive oral bleeding. The lesion was only partially embolised via transarterial route, as the nidus could not be penetrated completely. In view of rebleeding within 72 hours from the same site, a second embolisation procedure was done via combined, transarterial and transvenous approaches. Coils and onyx were used as embolising agents. Complete embolisation was achieved via combined approach. No further bleeding episodes were seen at 1-year follow-up. Endovascular embolisation of mandibular AVMs can be technically challenging and, hence, a sound knowledge of the anatomy as well as the possible modification of technique is essential to achieve complete obliteration of the lesion and to maximise the benefit of embolisation and to avoid major radical surgery.

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.

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.