Transcript Poster #: EP-106 Onyx Embolization of Facial

Poster #: EP-106
Onyx Embolization of Facial
Vascular Malformations:
Treatment, Results and Follow-up
Tram Schroeder, MD, Daniel Murph, MD, Juan G Tejada, MD
Indiana University School of Medicine
Eskenazi Health
Disclosures
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The authors have no disclosures to
report.
Introduction
Superficial high flow vascular
malformations of the face are relatively
rare lesions that may present either as
a small subcutaneous facial lump or a
large pulsatile mass with propensity for
massive hemorrhage.
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Examples: AV fistulas, AVMs, aneurysms,
or hemangiomas
Introduction
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Available treatments: surgical excision,
embolization, sclerotherapy, laser ablation,
and electrothrombolysis.
More recently liquid embolics have been
employed. Reports of results and follow up
are relatively scarce in the literature.
We present our experience at a tertiary care
hospital with percutaneous and transarterial
embolization of facial vascular
malformations with the liquid embolic Onyx.
Materials and Methods
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Retrospective search of all patients
with superficial facial vascular
malformations treated with Onyx at our
tertiary care institution between
January 2009 and March 2015.
Data collected: age, gender,
presenting symptoms,
angioarchitecture of the lesion,
treatment approach, and follow-up
MRI/MRA and angiography results
when available.
Results - Demographics
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9 patients
6 male, 3 female
Mean age 37 +/- 12 years
14 total procedures
Results – Clinical Presentation
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6 patients: Pulsatile mass and swelling
of the face.
1 patient: Recurrent mandibulofacial
AVM with episodes of intractable
spontaneous bleeding.
1 patient: Enlarging jaw mass with lifethreatening intra-oral bleeding.
1 patient: Incidental finding on
radiographs for braces.
Results - Treatment
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5 patients: Transarterial superselective
catheterization of the arterial feeder
followed by injection of Onyx-18 or -34
under continuous road-map guidance until
complete resolution or substantial
devascularization of the malformation was
achieved
3 patients: Percutaneous embolization with
direct puncture of the vascular
malformations.
1 patient: Combined endovascular and
percutaneous approach
Results-Outcome
Immediate post-treatment angiography
demonstrated
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7 patients: Complete cure of the lesion.
2 patients: Substantial devascularization of
lesion.
Results – Follow-up
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6 patients had available follow-up studies
showing no recurrent or residual lesions.
1 patient lost to follow up. The other 2
patients were asymptomatic at clinic
follow-up.
3 patients subsequently underwent
complete surgical removal of their
lesions.
No adverse effects including skin
discoloration, blindness, nontarget
embolization, stroke, or death occurred.
Case 1
31 yo male with
pulsatile mass on
forehead found to
be a frontal AVM
with fistulous
components fed by
bilateral ECAs and
ophthalmic arteries.
Treated with
percutaneous
injection of Onyx 34
followed by surgical
resection.
A. Superficial facial lesion pre-embolization.
B. Superficial facial lesion post-embolization and surgical resection.
C. Lateral DSA of the right external carotid artery shows frontal AVM with feeders
from the STA and facial artery. Feeders from the ophthalmic artery are not
shown.
D. Lateral DSA of the right external carotid artery post Onyx embolization shows
angiographic cure of the lesion with resolution of the AVM shunting and complete
packing of the AVM nidus with Onyx.
Case 2
29 yo male who presented
with right face pulsatile
mass found to be complex
right facial AVM with lingual
artery saccular aneurysm
and AV fistula with venous
varices draining to the IJV.
Also saccular aneurysm at
the origin of the STA with
AV fistula and large venous
varix, and AV fistula with
supply from inferior alveolar
and IMA branches. Treated
in 3 stages of coiling and
transarterial/percutaneous
Onyx-18 -34 embolization.
A.
C.
E.
B.
D.
F.
A. Lateral DSA of the right external carotid artery shows lingual artery aneurysm
and AV fistula.
B. Lateral DSA of the right external carotid artery post coils and Onyx embolization.
C. Lateral DSA of the right internal maxillary artery showing saccular STA
aneurysm and AV fistula.
D. Lateral DSA of the right internal maxillary artery post coils and Onyx and
embolization.
E. Lateral DSA of the right external carotid artery showing AV fistula.
F. Lateral DSA of the right external carotid artery post-percutaneous Onyx
embolization.
Case 3
63 yo female with complex, nonresectable
mandibulofacial AVM with related episodes of
spontaneous bleeding from the oral mucosa and
lower lip. She had undergone numerous
procedures including surgical arterial ligations,
embolizations and sclerotherapies since 1991.
Stable since last intervention (18 mo prior), she
presented with recent episodes of bleeding from
the lower lip and left mandibular gingiva. The
patient underwent continued staged
transcatheter Onyx embolization and
percutaneous alcohol sclerotherapy of the
complex mandibulofacial AVM.
A. Lateral angiography of right common carotid
artery (12 years prior) demonstrating a large
complex large AVM nidus in the anterior
mandibular region.
B. Lateral angiography of right external carotid
artery demonstrating facial and mandibular
artery feeders to the persistent AVM nidus.
C. Lateral supraselective angiography of the right
facial artery during Onyx embolization shows
residual AVM nidus.
D. Lateral view percutaneous sclerotherapy of the
left facial artery with alcohol/ethiodol.
A.
B.
C.
D.
Case 4
14 yo male presented with
three week history of
enlarging jaw mass, acute
pain and bleeding. Intra-oral
bleeding led to anemia (Hb
7.6), syncope, dizziness.
Angiography demonstrated
no evidence of tumor blush or
AVM nidus. Subtle AV
shunting and contrast pooling
was demonstrated in the left
mandibular lesion.
Percutaneous onyx
embolization was performed
and the lesion was surgically
resected. Final pathology
report was consistent with
hemangioma.
A. Axial CT of the neck with IV contrast demonstrates an expansile, lytic lesion in
the body of the left mandible with evidence of contrast pooling.
B. Coronal MRI of the neck with contrast demonstrates enhancement with
surrounding inflammatory changes.
C. Lateral left ECA angiography and D. left internal maxillary artery angiography
demonstrated subtle AV shunting with very slow flow and contrast pooling.
E.-F. Representative subtracted and nonsubtracted images of percutaneous Onyx
embolization procedure.
Case 5
52 yo male with
pulsatile mass in
right temporal
area found to
have 5 mm
pseudoaneurysm
of the main trunk
of the STA.
Treated with
transarterial
embolization with
Onyx-34.
A.
B.
A. Angiography of right external carotid artery preembolization shows pseudoaneurysm.
B. Angiography of right external carotid artery postembolization shows angiographic cure of lesion.
Case 6
45 yo male with
pulsatile mass on
left scalp found to
have AV fistula from
left STA to left EJV
and facial vein with
venous aneurysm
inferiorly. Treated
A. Lateral angiography of the left superior temporal
with transarterial
artery pre-embolization shows AV fistula and venous
varix.
embolization with
Lateral angiography of left superior temporal artery
Onyx-18 and -34. B. post-embolization
shows angiographic cure of the
lesion.
Case 7
15 yo male presented with
intra-oral vascular mass
identified incidentally during a
dental procedure. Subsequent
CT angiography and doppler
ultrasonography revealed an
intraosseous AVM with large
venous varix within the right
mandibular body. Shortly after
diagnosis, the patient
developed acute intraoral
hemorrhage requiring
emergent embolization.
Resection and reconstruction
was performed by maxillofacial
and plastic surgery.
A. and B. Axial CT and MRI demonstrate a lytic , enhancing vascular mass in the
right mandibular body.
C. Doppler US demonstrates an AVM in the right mandibular body draining into a
dilated varix.
D. Lateral Right ECA angiography demonstrates the AVM supplied by branches of
the facial and internal maxillary artery with venous drainage predominantly to
the right external jugular vein.
E. and F. Post-embolization lateral right ECA angiography demonstrates occlusion
of approximately 80% of the mandibular AVM.
Case 8
47 yo female
presented with right
temporal pulsatile
mass. Angiography
demonstrated a right
pre-auricular AV
fistula with venous
varix. The lesion
was embolized with
Onyx 34.
A.
B.
C.
A. Lateral right external carotid artery angiogram demonstrates an
arteriovenous venous fistula, arising from the superficial temporal artery,
which appears enlarged. A saccular venous varix is seen immediately distal
to the shunt, with venous drainage to the superficial temporal vein.
B. Lateral supraselective STA DSA for Onyx 34 injection
C. Right external carotid artery angiogram demonstrating occlusion of the
arteriovenous fistula and venous varix. The STA remains patent.
Case 9
45 y/o female presented with
enlarging pulsatile right
periorbital mass in the
medial canthus. Catheter
angiography demonstrated
an AVM with feeders from
the right ophthalmic artery,
the right IMA and the right
facial artery. The lesion was
treated with percutaneous
embolization with Onyx 18
and 34 . Complete
angiographic cure of the
lesion was achieved. The
lesion was then surgically
removed by oculoplastics.
A.
C.
E.
B.
D.
F.
A.-B. Lateral and AP CCA angiography demonstrates right periorbital AVM with
feeders from the ophthalmic, facial and IMA arteries.
C.-D. Lateral and AP DSA images show percutaneous contrast injection with 22
gauge 1.5 inch needles in the AVM nidus and Onyx cast.
E.-F. Lateral and AP CCA artery angiogram at the end of the case shows
angiographic cure of the lesion with resolution of the shunting and complete
filling of the AVM nidus with Onyx.
Conclusion
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In our small case series transarterial
and percutaneous Onyx embolization
of facial vascular malformations is safe
and effective resulting in complete
cure of the malformations, substantial
decrease in peri-operative surgical
bleeding risk, successful control of
life -threatening hemorrhages, and
palliative care of intractable lesions.
References
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Arat A, Cil BE et al. Embolization of
High Flow Craniofacial Vascular
Malformations with Onyx. AJNR
2007:28:1409-1414
Spiotta AM, Miranpuri AS et al.
Balloon augmented Onyx embolization
utilizing a dual lumen balloon catheter:
utility in the treatment of a variety of
head and neck lesions.
J NeuroIntervent Surg 2014:6:547-5.