1Amrin Israrahmed,1Gaurav Chauhan

1Nedanta Medcity

Background:

To discuss the pre-procedure imaging, different modified techniques and approaches involved in the planning endovascular treatment of complex mandibular AVM lesions.

A 21 year old lady presented to the hospital with complains of severe tooth pain since 1 month. She was planned for root canal treatment. However, on the day of the procedure the dental surgeon observed areas of disproportionate bleeding from the root of left molar region. She was referred to the interventional radiology department for further management. She underwent CT angiogram of the face, which showed a left sided mandibular AVM with large ectatic dilated venous pouches. MRI angiogram was done to look for the soft tissue involvement of the lesion. Digital subtraction angiogram showed multiple feeders to the AVM from bilateral facial, internal maxillary, lingual arteries followed by a nidus and large ectatic draining veins with dominant drainage via left internal jugular vein.

Material(s) and Method(s):

To discuss pre procedure planning, various endovascular approaches, embolic agents to treat complex mandibular AVMs.

She was planned for Transarterial embolization with onyx (Ethyl vinyl alcohol copolymer). However, in the first embolization setting significant reflux of embolic material could not be achieved in the venous pouches. A second setting was planned wherein, both transarterial as well as transvenous approaches were taken

With help of micro-catheter transarterial embolization was done for all the major feeders with PVA particles and N-butyl cyanoacrylate to reduced flow into the AVM. Following this two micro catheters were placed via transvenous approach. The proximal microcathter was used for deployment of large detachable microcoils and the distal micro catheter (catheter closer to the AVM) was used to inject onyx into the large ectatic venous pouches. Thus, by a combined hybrid transarterial and transvenous approach near total embolization of the lesion was possible.

Result(s):

The patient has completed 11 months of follow up and is doing well with no evidence of any recurrence or residual lesion.

Conclusion(s):

Conservative pharmacologic treatment is not possible for mandibular AVM and surgical treatment is associated with significant functional and aesthetic deficit. Endovascular management of these mandibular AVMs is a safe and minimally invasive approach. We would like to discuss the pre-procedure imaging, different modified techniques and approaches involved in the planning endovascular treatment of these complex lesions.