EMBOLIZATION OF CRANIOFACIAL ARTERIOVENOUS MALFORMATIONS. Dinah Hernandez MSN ED, PHN, RN Kaiser Permanente Los Angeles Medical Center

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1 EMBOLIZATION OF CRANIOFACIAL ARTERIOVENOUS MALFORMATIONS Dinah Hernandez MSN ED, PHN, RN Kaiser Permanente Los Angeles Medical Center

2 Background Arteriovenous malformations (AVMs) are pathological direct connections between arteries and veins that bypass normal capillaries Can occur throughout the body

3 Natural History Mostly arise during fetal development, rarely acquired after birth Presentation depends on location Symptoms can occur from spontaneous hemorrhage, compression of adjacent structures, vascular steal, pain, overgrowth of the involved body part, or changes related to decreased blood flow

4 Incidence Detection rate in the United States general population: 1.4% per 100,00 cases per year Estimated 300,000 Americans have AVMs, 12% exhibit symptoms of varying severity. Approximately fifty percent of AVMs are located in the Craniofacial region AVMs grow as the age progresses, can be affected by various stimuli: trauma, pregnancy and puberty

5 Diagnosis Clinical/physical exam Schobinger s Staging Magnetic Resonance Imaging CT Scan Angiography

6 Treatment Observation Surgical Resection Radiation Therapy Embolization Transarterial Transvenous Direct puncture Combinations of above

7 Embolization Materials Coils Glue Onyx Ethylene vinyl copolymer (EVOH), mixed in dimethyl sulfoxide (DMSO) Available in different formulations (18, 34, and 500) based on viscosity Delivered in liquid form Upon contact with blood, DMSO dissipates and copolymer precipitates into solid material that occludes vessels

8 Embolization Products Coils, Onyx and Glue

9 Kaiser Permanente diagnosis and care Consultation: Birthmark clinic which is a multidisciplinary clinic consisting of RN Case Managers and Physicians from Specialty areas: Dermatology, Plastic Surgery, Pediatrics, Interventional Radiology and Hand Plastic Surgery Physical Exam/ Case Presentation Determines best approach by multidisciplinary team Candidate for Interventional Procedure RN Case Manager follows up diagnostic imaging studies, lab results, pre procedure instructions and coordinates procedure date

10 Nursing Roles/Responsibilities Assessment Check pedal pulses Check groin and or treatment sites Comfort, control bleeding, medication Neurocheck Monitor for signs and symptoms of early complications: discoloration and ulceration Education pre and post procedure RN Case Manager: post procedure follow-up

11 Implications and Discussion Management of Craniofacial AVM is difficult Risk for adjacent tissue damage and necrosis Embolic material can cause focal tissue ischemia, skin sloughing, tissue necrosis and skin ulceration Use of tourniquet around the head and inflation of a balloon catheter in the external carotid help in the arrest or slow flow of arterial inflow

12 Case Series 6 patients with craniofacial AVMs 3 scalp 1 face 1 forehead 1 parotid region

13 Treatment Initial transarterial embolization to reduce arterial inflow Tortuosity of distal feeding arteries and abundant collaterals prevented cure by transarterial embolization alone Followed by transvenous access Via femoral vein OR Via direct puncture Coil placement into venous pouch Arrest flow through artery Tourniquet applied around head Inflation of a balloon catheter in the external carotid Onyx injected into vein to retrograde fill AVM nidus

14 Results Complete angiographic cure obtained initially in all 6 patients 2 patients had surgical removal of AVM after embolization Other patients declined surgery One year follow up angiogram available in 4 of the 6 patients All 4 remained cured with no recurrence

15 Case 1 22 year old female Presented with an enlarging pulsatile left scalp mass and disfiguring purple and blue swelling in her left forehead and orbit AVM supplied by bilateral superficial temporal and occipital arteries Underwent three stages of transarterial embolization with Onyx which occluded the major feeding arteries from bilateral superficial arteries

16 B E

17 Case 2 18 year old male with enlarging pulsatile mass in his left parietal scalp. Venous pouch receiving AV shunting was accessed with a 19 gauge needle, microcatheter was advanced, few coils were deployed. AVM embolized with Onyx 34 and 18. Arterial inflow halted by tourniquet around his head.

18 Before After

19 Case 3 59 year old woman with growing pulsatile mass in the left eyebrow. Small AVM supplied by Ophthalmic Artery, angular branch of the Facial Artery and small branches of the superficial temporal artery. Venous pouch was accessed transfemorally via facial vein, AVM embolized with Onyx 34. Post embolization angiogram showed complete obliteration of AV shunting.

20 Before After

21 Conclusion Craniofacial AVMs are typically supplied by many tortuous distal arteries limiting transarterial embolization. As a result, it is difficult to obliterate these lesions transarterially without significant risk of tissue necrosis. Adjunctive transvenous embolization is safe and effective method to treat these lesions after transient transarterial embolization.

22 References Arat, A., Cil, B. E., Vargel, I., Arat, Y. O., Turkbey, B., Canyigit, M., & Peynircioglu, B. (2007). Embolization of High Flow Craniofacial Vascular Malformation with Onyx. American Journal of Neuroradiology, 28, 1409:1414. Arteriovenous Malformation. (2011). Retrieved from Bhandari, P. S., Sadhotra, L. P., Bhargava, P., Bath, A. S., Mukherjee, M. K., & Maurya, S. (2008). Management strategy for facial arteriovenous malformation. Indian Journal of Plastic Surgery, 41, Gupta, A. K., Bansil, S., Gupta, A., & Tuli, P. (2007). Massive Arteriovenous Malformation of the Ethnomaxillofacial Region: A Case Report []. The Internet Journal of Head and Neck Surgery, 1(1). Retrieved from internet-journal-of-head-and-neck-surgery/volume1-number1/massive arteriovenous L. Feng, personal communication, December 8, Han, M. H., Seong, S. O., Kim, H. D., Chang, K. H., Yeon, K. M., & Han, M. C. (1999). Craniofacial Arteriovenous Malformation: Preoperative Embolization with Direct Puncture and Injection of n-butyl Cyanoacrylate. Radiology, 211, Koenigsberg, R., Smirniotopoulos, J., Wasserman, J., Viegman, B., & Levy, L. (2011). Brain Imaging in Arteriovenous Malformation. Retrieved from Konez, O. (n.d.). Ateriovenous Malformations (AVMs). Retrieved from NINDS Arteriovenous Malformation Page. (n.d.). Retrieved from Onyx EV3. (2012). Retrieved from Speer, A. L., Rowe, V. L., Panossian, A., & Arkader, A. (n.d.). Vascular Surgery for Arteriovenous Malformation Treatment and Management. Retrieved from Stapf, C., Mast, H., Sciacca, R., Berenstein, A., Nelson, P., Gobin, Y., Mohr, J. (2003). The New York Islands AVM Study: design, study, progress and initial results []. New York: PubMed.