Combined Endovascular and Surgical Treatment of Cervicofacial Arteriovenous Malformations

Abstract

Objectives: Arteriovenous malformations (AVMs) often cause disfigurement and severe functional disturbances. An improper approach can unlock an explosive growth in the AVM and present a very high risk of relapse. Recurrent AVMs are much harder to cure. Intraoperative massive bleeding is a tangible risk if AVMs are treated surgically without preparatory endovascular embolization. The study’s aims were: (1) Recognize and clearly diagnose a cervicofacial AVM. (2) Describe the indications and techniques to treat cervicofacial AVMs. (3) Analyze the critical importance of a combined endovascular and surgical approach. Methods: The most accepted indications and techniques concerning head and neck AVMs are gathered from a review of the literature and compared with the personal experience of the authors with 10 AVMs of the soft tissues of the head and neck and 4 AVMs of the facial bones. All patients underwent preoperative endovascular embolization with n-butyl cyanoacrylate followed by surgical removal of the malformation within 48 hours of the procedure. Results: One early case of AVM of the maxilla was complicated by massive intraoperative hemorrhage despite preoperative embolization. One maxillo-mandibular AVM recurred 2 years after the treatment. In all patients an improvement in cosmetic appearance was documented. Smaller AVMs were easier to manage and had the best results. Conclusions: An aggressive combined endovascular-surgical treatment seems to be the only “curing” strategy for head and neck AVMs. A thoughtful preoperative balance must be made within a multidisciplinary team and clearly discussed with the patient.