Life-Threatening Arteriovenous Malformation of the Maxillomandibular Region and Treatment Outcomes

Abstract

<jats:p> 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. </jats:p><jats:p> 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 </jats:p><jats:p> 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. </jats:p>

Japanese clinical practice guidelines for vascular anomalies 2017

“…Concerning embolic agents, PVA and Gelfoam® (Pfizer, New York, NY, USA) are used for embolization as an adjuvant therapy immediately before surgery as they allow recanalization. Cyanoacrylate liquid embolic agents are considered effective for embolization performed preoperatively or alone in expectation of a long‐term occlusive effect . Coils are often used for transvenous embolization.…”

“…Cyanoacrylate liquid embolic agents are considered effective for embolization performed preoperatively or alone in expectation of a long-term occlusive effect. 64,67,68 Coils are often used for transvenous embolization. Recently, there have been reports 69,70 that favorable outcomes were obtained by TAE using Onyxâ (Medtronic, Irvine, CA, USA) a non-adhesive liquid embolic agent.…”

Japanese Clinical Practice Guidelines for Vascular Anomalies 2017

“…Cyanoacrylate liquid embolic agents are considered effective for embolization performed preoperatively or alone in expectation of a long-term occlusive effect. 64,67,68 Coils are often used for transvenous embolization. Recently, there have been reports 69,70 that favorable outcomes were obtained by TAE using Onyx â (Medtronic, Irvine, CA, USA), a non-adhesive liquid embolic agent.…”

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

“…Unfortunately, malformations of this complexity are mostly incurable with either embolization alone or post-embolization excision. 6,11 Hence, the role of palliation in the setting of acute haemorrhage cannot be overstated, as it is often the only effective modality. In emergent situations, palliations cannot always be delivered to the nidus.…”

“…10 Generally, cure of largesize facial AVMs represents a treatment challenge, even with modern endovascular and microsurgical advancements. 11 Stereotactic radiosurgery has no role in the management of this type of head and neck lesion. Unfortunately, there is still a lack of knowledge and understanding with respect to the fact that non-curative surgery or embolization should not be directed to proximally occlude arterial feeders.…”