Case report: Combined transarterial and direct approaches for embolization of a large mandibular arteriovenous malformation

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.

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.