E-027 high volume dual lumen balloon catheter onyx embolization of a large mandibular venous lake associated with a hemorrhagic intraosseous mandibular arteriovenous malformation

Abstract

Introduction Mandibular venous lakes associated with intraosseous mandibular arteriovenous malformations (AVM) can lead to catastrophic, life-threatening hemorrhage. Dual lumen balloon catheter Onyx embolization may play a significant role in prevention of hemorrhage, lesion obliteration and supporting a multidisciplinary treatment plan for these rare and difficult lesions, whose large size may necessitate unusually high volume Onyx injection. This report demonstrates the feasibility of this approach. Methods Case report and review of the literature. Case report A 16-year-male with a history of a “birthmark” on his right lower face and jaw presented with right mandibular molar tooth loosening, facial swelling and two spontaneous episodes of bleeding from the mouth soaking his pillow at night. Dental panoramic examination demonstrated an expansile lucent lesion in the right mandible. Biopsy was aborted after a small needle aspirate was composed of 100% blood. A lingual tilt of the affected teeth, gum redness and a palpable thrill over the right lower jaw were noted. CT angiography revealed a large intraosseous mandibular AVM. Catheter angiography demonstrated both superficial and intraosseous mandibular components. A large right mandibular venous varix or “venous lake” predominated the intraosseous component and measured up to 5.8 cm in size, surrounding the roots of several mandibular molars. Embolization was performed to reduce bleeding risk and support multidisciplinary treatment after discussion with oral surgery. Two facial artery branches supplying extraosseous components were embolized with PVA particles (355–500 um) to reduce flow into the malformation and aid Onyx penetration. A 4 mm × 10 mm Scepter C balloon allowed injection of approximately 34.5 cc of a combination of Onyx 34 and Onyx 18 into a branch supplying the intraosseous varix over 103 min with total output air kerma of 1458 mGy, resulting in complete obliteration of the venous lake. Residual superficial extraosseous AVM component fed by distal facial and lingual arteries drained to superficial veins. Transient right facial tenderness and swelling was experienced as well as mild numbness of the right lower lip and tongue. He returned to school two days after embolization. No further bleeding occurred. Multidisciplinary treatment with further embolization followed by mandibular surgical reconstruction is planned. Discussion Embolization comprises an important adjunctive or primary treatment modality for intraosseous mandibular AVM. While multiple embolic agents have been used in transarterial, transvenous or percutaneous approaches, the slow, controlled delivery of Onyx confers particular advantage in the setting of rapid shunting into large mandibular venous lakes. From the transarterial approach, dual lumen balloon catheter flow control enables high volume injection of Onyx across fistulous connections to occlude even large lesions, theoretically dramatically reducing bleeding risk. The volume of Onyx injected into the mandibular venous lake in our case of approximately 34cc, while exceeding generally recommended maximum injection guidelines of 1cc DMSO/10lbs pt. weight, was tolerated without significant adverse effect, allowing lesion obliteration as the first stage of a multidisciplinary treatment plan. High volume Onyx embolization of intraosseous mandibular AVMs using dual lumen balloon catheters is well tolerated and represents an important treatment option for these difficult lesions. Disclosures M. Fiesta: None. B. Atchie: None. N. Mehta: None. J. Barr: 2; C; Microvention. 4; C; Medtronic. R. Novakovic: None. B. Welch: 5; C; Covidien, clinical proctor. J. White: None. K. Rickert: None. M. Zide: None. P. Tiwana: None. G. Pride: 2; C; Sequent Medical.