Treatment of a giant mandibular arteriovenous malformation with percutaneous embolization using histoacrylic glue: a case report

Obliteration of a Large Mandibular Arterio-Venous Malformation with Polymethyl Methacrylate Bone Cement

Mandibular arteriovenous malformations (AVMs) are rare and potentially life-threatening vascular lesions. Surgery, embolization, or bone cement implantation is an option for the treatment of mandibular AVMs. We present a case of huge mandibular AVM refractory to multiple embolizations of the supplying arteries, which was treated with polymethylmethacrylate (PMMA) bone cement implantation after the extraction of a molar tooth.

Gingival bleeding of a high-flow mandibular arteriovenous malformation in a child with 8-year follow-up

Intraosseous arteriovenous malformations (AVMs) in the head and neck region are uncommon. There are several types and they can have a wide range of clinical presentations. Depending on the blood flow through the AVM, the treatment may be challenging for the attending team and may lead to life-threatening hemorrhages. A clinical case report is presented. A 9-year-old girl, seen for gingival bleeding during oral hygiene, was found to have a high-flow AVM located within and around the mandible. Two-stage treatment consisted of intra-arterial embolization followed by intraoral injection of a sclerosing agent 8 weeks later. At the 8-year follow-up, imaging study showed no evidence of recurrent lesion inside or outside the bone. The final outcome is a correct occlusion with a symmetric facial result. This case shows that conservative treatment may be the first treatment option mostly in children. Arteriography and transcortical injection were enough to control the AVM.

Pediatric vascular malformations: pathophysiology, diagnosis, and the role of interventional radiology

The Mulliken and Glowacki classification (1982) differentiated vascular anomalies into two groups based on their endothelial characteristics: hemangiomas and vascular malformations. Vascular anomalies are localized defects of the vasculature that affect a limited number of vessels in a restricted area of the body. These defects are secondary to errors in vascular morphogenesis. Depending on the type of vessel involved, the vascular malformation group was subdivided into high-flow (such as arteriovenous malformation and arteriovenous fistula) and low-flow lesions (such as venous and lymphatic malformations). Depending on the type of lesion, the location and degree of involvement and the clinical effect, different types of treatment would be required. For the purpose of this review, we concentrate solely on vascular malformations: the clinical features, genetics, diagnosis, and current treatment options.

Intraosseous embolotherapy of central arteriovenous malformations in the jaw: long-term experience with 8 cases

PURPOSE

To investigate the long-term effects of direct intraosseous histoacryl embolotherapy on central arteriovenous malformations (AVMs) of the jaw.

MATERIALS AND METHODS

Eight patients with central AVMs of the jaw (3 in the maxilla and 5 in the mandible) were treated with direct intraosseous histoacryl injection. These AVMs exhibited cystic radiolucency, with (n = 5) or without (n = 3) honeycombed component. On angiography, all the AVMs exhibited a large intraosseous nidus with multiple suppliers and drainages. The intraosseous lesions were percutaneously punctured with an 18- to 20-gauge needle, and NBCA diluted 30% to 40% with iodized oil was injected during venous compression.

RESULTS

Postembolic arteriograms showed that all the AVMs were completely or nearly completely devascularized after single or multiple injections at the initial treatment. The follow-up period ranged from 3 to 8 years. Two AVMs experienced postembolic curettage and were anatomically cured. Three AVMs were anatomically cured after 1 to 3 sessions of embolotherapy. The other 3 AVMs were clinically cured after 1 (n = 2) to 4 (n = 1) sessions of embolotherapy. There were no procedure-related severe complications.

CONCLUSIONS

Direct intraosseous glue embolotherapy can be a simple and safe technique for endovascular management of central AVMs in the jaw and is particularly effective in an emergency. Complete reossification of the intraosseous nidus can be anticipated if a complete occlusion is obtained.

Treatment of arteriovenous malformations: assessment of 2 techniques--transmandibular curettage versus resection and immediate replantation

PURPOSE

This study evaluates 2 surgical methods used at our center for the treatment of mandibular arteriovenous malformations (AVMs): resection with immediate replantation and curettage via proximal transmandibular osteotomy.

PATIENTS AND METHODS

Patients with AVMs of the mandible who were treated during a 17-year period between 1992 and 2008 at our department were assessed. Two surgical techniques were used for treatment: 1) resection of the segment, curettage of the intrabony lesion, extraction of involved teeth, and immediate replantation and 2) proximal osteotomy curettage of the lesion within the bone and extraction of involved teeth. In the replantation group the resected segment of the mandible was replanted after the contents were scraped out and the involved teeth removed. In contrast, in the proximal osteotomy group this was done without removal of the bone segment. In both techniques the cortical bone of the mandible was maintained. However, in the transmandibular curettage group the periosteum was not entirely stripped off because curettage was done via proximal osteotomy without removal of the segment. The entire intrabony lesion and a margin of cancellous bone related to the lesion were excised in both groups. The bone was fixed with titanium plates in all cases. All patients were followed up annually for a period of 1 to 17 years (mean, 9.5 years).

RESULTS

We treated 12 patients with mandibular AVMs (2 male and 10 female patients). Their ages ranged from 7 to 17 years. Preoperative angiography showed high-flow central vascular lesions in all patients. Of the lesions, 7 (58%) were treated via resection with immediate replantation and 5 (42%) were treated via transmandibular curettage. Embolization was performed in 4 cases 48 hours before surgery. However, blood loss was not significantly decreased by embolization. The lesions were categorized as multilocular (58.3%) or unicystic (41.7%) based on the radiographic findings and were located in the mandibular body (66.7%) or ramus (33.3%). Blood loss averaged 1.60 L in the group undergoing resection and immediate replantation and 1.30 L in the transmandibular curettage group. During the follow-up period, no recurrences were encountered in either group via clinical, radiographic, or computed tomography scan assessment, and none of the patients had facial deformities develop.

CONCLUSIONS

The results suggest that transmandibular curettage via proximal osteotomy without complete resection is an effective less invasive method with which to treat AVMs of the mandible provided that the lesion is small, is confined within the bone, and has not invaded the soft tissues. Less blood loss, preservation of the bone, more favorable postoperative esthetics, and better function are among the advantages of this technique. In more extensive cases and those involving both hard and soft tissues, resection with immediate replantation is recommended. Both techniques obviated the need for bone graft reconstruction. This technique is better than resection and discarding of the segment.

A preliminary study of angiographic classification and its correlation to treatment of central arteriovenous malformation in the jaw

OBJECTIVE

To elaborate on the classification of central arteriovenous malformations (AVMs) in the jaw based on angioarchitecture and to evaluate the correlation of this classification with treatment options.

STUDY DESIGN

X-ray films and digital subtraction angiograms (DSA) of 25 cases with AVMs in the jaw were retrospectively reviewed to evaluate the appearance of bone resorption, feeding arteries, nidus of the malformations, and draining veins. Based on the findings a classification of angioarchitecture was recommended. Furthermore, the treatment results of these cases were reviewed to assess the correlation of this classification system with treatment options.

RESULTS

The angiographic pictures of 25 cases with central AVMs could be divided into 5 types: Type I (n = 5) had diffused microarteriovenous fistulas (AVFs); type II (n = 8) had 1 large venous pouch with all the feeding arteries draining into it; type III (n = 7) had a large venous pouch as well as diffused microAVFs (I+II); type IV (n = 2) had multiple venous pouches; and type V (n = 3) had multiple venous pouches and diffused microAVFs (I + IV). The angioarchitecture corresponded well to the x-ray appearance in all cases except 1 (96%). With respect to the treatment outcomes, type II, III, and IV AVMs gained clinical cure in 100% of the cases, whereas type I and type V AVMs obtained clinical cure only in 60% and 33.3% of the cases, respectively.

CONCLUSIONS

Central AVMs in the jaw contained variant patterns of angioarchitecture and could be divided into 5 types. This angiographic classification was helpful for decision making about appropriate therapy.

N-Butyl Cyanoacrylate Glue Embolization of Splenic Artery Aneurysms

A patient with Polyarteritis Nodosa presented with abdominal pain and low hematocrit level. Abdominal computed tomography (CT) depicted the presence of free blood and CT angiography revealed two aneurysms in the inferior branch of the splenic artery that were subsequently treated by endovascular transarterial embolization with N-Butyl Cyanoacrylate. Post embolization splenic arteriography demonstrated complete embolization of both aneurysms, including the inflow and outflow vessels.