Management of scalp arteriovenous malformations: a rising trend towards percutaneous direct puncture embolization technique-our experience

BACKGROUND

Scalp arteriovenous malformations (AVMs), or cirsoid aneurysms of the scalp, usually present with troublesome symptoms and cosmetic disfigurement. Endovascular/percutaneous embolization has evolved as a sole treatment method or adjunct to surgical excision in the management of scalp AVMs with an excellent outcome.

PURPOSE

To discuss minimally invasive techniques for treating scalp AVMs as well as to highlight the role of embolization before surgery.

MATERIAL AND METHODS

This is a retrospective study of 50 patients with scalp AVM who underwent embolization (percutaneous/endovascular) during 2010-2019 at a tertiary care center. n-butyl cyanoacrylate (n-BCA) was used as an embolizing agent in all the cases and the patients were followed up at three- and six-month intervals with Doppler evaluation.

RESULTS

A total of 50 patients were included in the study. The occipital region was the most common location; 82% were Schobinger class II lesions and 18% were class III lesions. Thirteen patients had small-sized AVMs and 37 patients had large-sized AVMs. Post-embolization surgery was performed in 36 patients. Of the patients, 28 underwent percutaneous embolization, 20 underwent endovascular embolization, and two underwent both to achieve complete embolization of the lesion. The number of percutaneous procedures increased in the latter half of the study period as the safety and efficacy of the technique were established. No major complications were seen in this study.

CONCLUSION

Embolization of scalp AVMs is a safe and effective technique and can be used in isolation for small lesions and as an adjunct procedure to surgery for large-sized lesions.

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.

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

PURPOSE

The aim of the present report is to describe 50 cases in the literature of mandibular arteriovenous malformations (AVMs) in which embolization was the primary treatment and to discuss details such as age, gender, materials used, outcome of embolization, time of follow-up, and intra- or postprocedure complications. An illustrative case in which reossification was noticed after embolization also is presented.

PATIENTS AND METHODS

The study was carried out in 2 steps. In the first, an electronic search without time restriction for embolization as the primary treatment for mandibular AVMs was performed on Medline through PubMed. In the second, the case of a patient with mandibular AVM and massive oral bleeding episodes is described after a long-term follow-up.

RESULTS

Clinical stability with the cessation of oral bleeding episodes was detected in 25 cases and 2 cases were planned for another embolization session. Clinical stability and reossification were detected in 23 of the 50 cases included. Complications were reported in 50% of cases, but most were minor and transient.

CONCLUSION

Currently, owing to more sophisticated imaging techniques, the diagnosis of mandibular AVMs is quicker and new, less invasive techniques that avoid surgical resection have proved effective. It should be emphasized that these techniques are not without complications and that long-term monitoring is extremely important.

Interventional Radiology and Bleeding Disorders: What the Oral and Maxillofacial Surgeon Needs to Know

Endovascular techniques are essential for controlling acute head and neck bleeding that cannot be controlled by local or systemic measures. Detailed knowledge of the head and neck vascular anatomy, advances in catheterization techniques, and the availability of new embolic materials have improved the safety, efficacy, and predictability of these procedures. To improve patient safety, the oral and maxillofacial surgeon must be familiar with these techniques.

Management of a large diffuse maxillofacial arteriovenous malformation previously treated with ligation of ipsilateral arterial supply

A 32 year-old male presented with a pulsatile facial mass with palpable thrill and audible bruit. Imaging revealed a very large diffuse left-sided facial arteriovenous malformation with extensive bilateral supply, as well as a previously ligated left external carotid artery. Endovascular treatment was required to control associated hemorrhagic events as well as for palliation and was delivered via the contralateral and ipsilateral collateral supply because of ligation of the direct route to the nidus. In addition, the patient received intravenous bevacizumab and intraarterial bleomycin therapy. Under such circumstances, endovascular embolization remains often the only option when emergent therapy for massive haemorrhage is required. Collaboration and treatment planning with head and neck surgery is imperative and should be performed from the onset, avoiding disastrous ligation of arterial feeders.

Head and neck arteriovenous malformations: results of ethanol sclerotherapy

BACKGROUND AND PURPOSE

Peripheral AVM is a locally aggressive disease with a high tendency to recur; its treatment is complex, especially in the anatomically delicate head and neck area. Here, we report results of ethanol sclerotherapy for head and neck AVM and discuss its potential use for peripheral AVM.

MATERIALS AND METHODS

We retrospectively assessed degree of AVM eradication, complications, and clinical or imaging signs of recurrence for 19 patients treated with ethanol sclerotherapy for head and neck AVM (1 intraosseous, 18 soft-tissue AVMs).

RESULTS

Of the 19 patients, 11 had complete eradication of arteriovenous shunting at DSA, with 1 recurrence (mean follow-up 15 months), and for 7 patients, treatment is ongoing. During 59 treatment sessions, 12 patients experienced 14 complications, 1 leading to permanent functional damage.

CONCLUSIONS

Ethanol sclerotherapy has potential for complete eradication of head and neck AVM with low recurrence within the first year after completion of treatment. Complete eradication may require several treatment sessions during which complications should be minimized with careful techniques.

Life-threatening arteriovenous malformation of the maxillomandibular region and treatment outcomes

We report on cases of life-threatening maxillomandibular arteriovenous malformations (AVM) whereby patients had successful endovascular treatment with good outcomes. Out of a total 93 facial AVMs treated endovascularly between 1991 and 2009, five patients (5.4%) had maxillomandibular AVMs. All presented with uncontrolled dental bleeding. Endovascular procedure was the primary treatment of choice in all cases, either transfemoral approach with arterial feeder embolization or transosseous puncture, depending on the accessible route in each patient. NBCA (glue) was the only embolic agent used. Tooth extraction and dental care were performed after bleeding was controlled. All five patients (8-18 years) with a mean age of 12.4 years presented with massive dental bleeding following loosening of teeth, dental extraction and/or cheek trauma. The plain films and CT scans of four patients with AVMs of mandibles and one of maxilla, revealed expansile osteolytic lesions. The mean follow-up period was 6.6 years (ranging between one and 19 years). Three cases developed recurrent bleeding between two weeks to three months after first embolization, resulting from residual AVM and infection. Late complications occurred in two patients from chronic localized infection and osteonecrosis, which were successfully eradicated with antibiotic therapy and bony curettage. Complications occurring in two patients which included soft tissue infection, osteomyelitis and osteonecrosis were successfully treated with antibiotics, curettage and bone resection. No patient had a recurrence of bleeding after the disease had cured Initial glue embolization is recommended as the effective treatment of dental AVMs for emergent bleeding control, with the aim to complete eradicate the intraosseous venous pouches either by means of transarterial superselection or direct transosseous puncture. Patient care by a multidisciplinary team approach is important for sustained treatment results.