An alternative approach to maxillofacial arteriovenous malformations with transosseous direct puncture embolization

The management of arteriovenous (AVM) malformations of the jaws is complex and requires an integrated team approach. Subspecialists, such as maxillofacial surgeons, interventional radiologists, and critical care intensivists, are commonly involved in the management of these patients. The current treatment options for maxillofacial AVMs are surgical resection combined with endovascular embolization. Surgical treatment of arteriovenous malformations has been associated with significant morbidity and mortality due to potential for massive blood loss. In the pediatric population extensive resection of the craniofacial skeleton may be associated with growth disturbance, functional compromise, and cosmetic deformity. We report a novel technique using endovascular embolization via direct transosseous puncture for a high-flow vascular malformation, obviating the need for extensive surgical resection, and review the important clinical aspects of these life-threatening lesions.     

Arteriovenous malformation of the mandible and its treatment: a case report

Arteriovenous malformations (AVMs) can be life-threatening lesions and must be considered in the differential diagnosis of most radiolucent lesions of the jaws. The clinical and radiographic presentation of an AVM of the mandible and its treatment is reported. Diagnosis of the lesion was confirmed by arteriography, and the lesion was treated surgically by enbloc resection. The bony defect was successfully grafted with a porous hydroxyapatite block.     

Two-year follow-up of osseointegration and rehabilitation in a patient with oral and maxillofacial arteriovenous malformations

The case of a patient with high-flow arteriovenous malformations (AVMs) affecting the mandible and lower face is presented. The patient had undergone surgical resection, sclerotherapy, and transcatheter embolization over the course of 16 years. As a result, all teeth except for the lower left third molar were missing, and a mass of arteriovenous malformed soft tissue covered the residual alveolar ridge. Implant placement surgery was performed in his mandible after treatment of the AVMs. Osseointegration of the implants placed in the mandible affected by the AVMs was evaluated. Rehabilitation in the absence of the alveolar ridge or keratinized gingiva was also evaluated. The implant stability quotient (ISQ) was measured before fabricating the restoration. An implant-supported partial denture was placed 4 months postoperatively. No implant failure was found; no bleeding on probing was present. The occlusion and masticatory function were satisfactory at 2-year follow-up. Osseointegration was safely achieved in the bone affected by the intraosseous AVMs that had been embolized. The success of an implant support prosthesis depends not only on the condition of the bony tissue but also on the surrounding soft tissue.     

Interdisziplinäres Konzept zur Diagnostik und Therapie gefäßreicher Fehlbildungen im Gesichts- und Halsbereich

Purpose. In patients with extended vascular anomalies in the head and neck, therapeutic decisions may pose a challenge to maxillofacial surgeons, dermatologists, and interventional radiologists. We analyzed the value of an interdisciplinary classification and treatment concept. Patients and methods. The classification distinguishes hemangiomas and vascular malformations. Whereas hemangiomas are endothelial proliferations, vascular malformations are considered to be developmental anomalies, which are further classified into high-flow or low-flow lesions and according to the vascular channels into capillary, venous, or lymphatic malformations. Since 2000 we have provided interdisciplinary consultation for patients with vascular anomalies. In patients with hemangiomas and venous malformations, the clinical diagnosis is confirmed by color-coded duplex sonography and magnetic resonance imaging; angiography is performed as part of the treatment planning for patients with arteriovenous malformations. Patients with hemangiomas are treated surgically by cryosurgery or laser surgery or conservatively according to lesion size and behavior. In patients with venous malformations, percutaneous sclerotherapy is combined with surgical reduction; patients with arteriovenous malformations undergo transarterial embolization prior to surgical excision of the nidus. Results. A total of 73 patients attended the interdisciplinary consultation. This group included 53 patients with facial hemangiomas, 7 with venous malformations, 2 with capillary malformations, 5 with lymphatic malformations, and 6 with high-flow arteriovenous malformations. Conclusions. The interdisciplinary protocol increases diagnostic accuracy and helps to establish individual treatment plans for patients with extended vascular anomalies.     

口腔颌面部软组织动静脉畸形血管构筑初探与治疗分析

目的 分析口腔颌面部软组织动静脉畸形(Arteriovenous Malformation, AVM)的血管构筑特征,探讨其治疗方法.方法 对35 例口腔颌面部软组织AVM行血管造影检查及栓塞治疗,分析所有病变的供血动脉、回流静脉及畸形血管网的分布特征.20例单纯栓塞治疗,15例行栓塞与手术治疗,随访10个月～6年,分析其疗效.结果 从血管造影表现看,口腔颌面部软组织AVM可分为4型:弥散型(15例),病变由多个动脉支供血,畸形血管呈弥散的网状结构;密集型(11例),供养动脉及畸形血管网密集分布,呈团块状;混合型(6例),病变部分较弥散分布,部分呈密集的血管团状;伴动静脉瘘型(3例),病变内含较大的动静脉瘘结构.从疗效看,35例中20例疗效良好,随访期间未见复发;13例复发需进一步治疗;2例巨大病变则进行性发展.结论 颌面部软组织AVM的血管构筑可分为4型,血管构筑的分型有助于选择适当的治疗方法,提高疗效.     

4例儿童期颌骨动静脉畸形血管复通的再治疗

目的总结治疗儿童期上、下颌骨动静脉畸形治疗后血管复通的临床经验。方法回顾分析4例儿童期颌骨动静脉畸形（arteriovenous malformations, AVMs）患者的临床资料。所有患者均接受过至少26个月以上的颌骨AVM的多学科综合治疗,包括超选择性动脉内栓塞、颌骨骨腔内骨蜡填塞联合拔牙术,并应用计算机体层血管造影术（CTA）及数字减影血管造影术（DSA）证实AVM治疗后存在血管复通。对出现血管复通的患者,再次施以超选择性动脉内栓塞联合颌骨骨腔内骨蜡填塞及拔牙（如有必要）的综合治疗。结果4例患者随访5~14个月,平均9.5个月,均预后良好,无治疗后搏动感存在或出血。结论儿童期颌骨AVM综合治疗后,极少病例出现治疗后血管复通,再次应用超选择性动脉内栓塞联合颌骨骨腔内骨蜡填塞以及拔牙等综合治疗效果良好,值得推广应用。     

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动静脉畸形(arteriovenous malformations,AVM)为高血流血管畸形,口腔颌面部软组织内及颌骨中均可发生。主要临床表现为病变区皮色改变、皮温增高伴搏动,听诊可闻及吹风样杂音;严重者可出现明显面部畸形,并可发生溃疡及出血。治疗方法主要为血管内栓塞或硬化及手术治疗。本文介绍了栓塞治疗的方法及注意事项,并根据软组织及颌骨AVM的血管构筑特点探讨了其治疗的要点与疗效。软组织AVM的治疗应首选血管内栓塞或硬化治疗,对于存在严重面部畸形的病例可结合手术治疗。对于颌骨AVM尤其是发生大出血的病例,栓塞后行颌骨刮治术疗效确切,可有效避免复发。     

Supraclavicular flap: reconstructive strategy for massive facial arteriovenous malformations

Arteriovenous malformations (AVMs) are uncommon errors of vascular morphogenesis. Hemodynamically, they are high-flow lesions. Approximately 50% of AVMs are located in the craniofacial region. The successful treatment of vascular anomalies depends on the profound knowledge of the biologic behavior of vascular lesions and their correct classification. Vascular malformations that persist lifelong require treatment in most cases, especially when clinical symptoms occur. On the basis of individual parameters such as the diameter, location, or growth behavior, different therapeutic options such as cryotherapy, corticosteroids, laser therapy, sclerotherapy, surgical intervention, and/or embolization can be performed successfully. Subtotal excision or proximal ligation of the feeding vessel frequently results in rapid progression of the AVMs. Hence, the correct treatment consists of highly selective embolization (superselective) followed by complete resection 24 to 48 hours later. Reconstructive procedures in the head and neck region use a wide range of flaps for defect closure. The methods range from local, mostly fasciocutaneous flaps and skin grafts, to free microsurgical flaps. To ensure a satisfactory functional and aesthetic result, good texture and color of the flap are always essential. Moreover, the donor-site defect needs to be reduced, with no resulting functional or aesthetic impairment. The supraclavicular flap has been used successfully for difficult facial reconstruction cases, providing acceptable results without using microsurgical techniques. We treated 2 patients with facial AVM by this method. Both of the lesions were located within the cheek and lip. There were no procedure-related complications, and the cosmetic results were excellent.     

Malformazione arterovenosa del margine linguale somigliante a un’ulcera neoplastica: caso clinico e revisione della letteratura

ObjectivesThe purpose of this study is to describe a rare case of arteriovenous malformation (AVM) developed on the tongue of a patient aged 47 years.Materials and methodsThe lesion appeared like an ulcerated swelling on the right margin of the tongue. An incisional biopsy was performed to clarify the nature of the lesion, thought to be malignant. No bleeding was noticed during the biopsy. The lesion was diagnosed as an intramuscular AVM. Arteriogram and embolization of the right lingual artery were performed, then the lesion was totally removed under general anaesthesia.Results and ConclusionsAt 2 years after surgery there was neither clinical nor radiological evidence of recurrence. Diagnosis of AVMs is usually made from anamnesis and examination of the lesions. In this case, a biopsy was performed in order to clarify the nature of a lesion mimicking an oral carcinoma.     

射频消融技术联合DSA引导下无水乙醇介入治疗口腔颌面部难治性动静脉畸形的疗效观察

目的 探讨射频消融技术联合数字减影血管造影（digital subtraction angiography,DSA）引导下无水乙醇介入治疗难治性口腔颌面部动静脉畸形的可行性,评价其临床疗效及安全性。方法 2014年3月—2016年4月,应用射频消融技术联合DSA引导下无水乙醇介入栓塞治疗7例口腔颌面部动静脉畸形患者（男4例,女3例）,密切随访,根据患者的临床症状、不良反应、并发症以及影像学资料的变化进行疗效观察及评价。结果 6例有效,1例无效,治疗有效率为85.7%。未观察到严重并发症发生。结论 射频消融技术联合DSA下无水乙醇介入栓塞治疗难治性口腔颌面部动静脉畸形的近期疗效及安全性良好,可能成为其重要的治疗方式。     

颌面部先天性动静脉畸形的PVA栓塞治疗

目的 评价颌面部先天性动静脉畸形行聚乙烯醇泡沫微粒（PVA）永久性栓塞的治疗效果。方法 8例颌面部先天性动静脉畸形（男3例,女5例）进行了PVA永久性栓塞治疗。数字减影的颈动脉造影在PHILIPS V3000下完成,PVA颗粒（250－500μm）,栓塞用导管4F或3F。结果 5例患者仅行单次栓塞,3例患者行双次栓塞。栓塞后造影,异常血管团消失,均达到影像治愈;搏动、杂音栓塞后消失;4例肿胀得到改善。栓塞后1－6月,未发现有口腔内渗血或出血。栓塞后反应主要表现为肿胀、疼痛、发热,一般持续3－7d。结论 颌面部动静脉畸形的PVA栓塞治疗安全、有效,但远期效果还有待长期观察。     

口颌面部动静脉畸形诊治指南

动静脉畸形(arteriovenous malformations,AVMs)是由于胚胎期脉管系统发育异常而导致动、静脉直接吻合所形成的血管团块,内含不成熟的动脉和静脉,而且血管团块中没有毛细血管,动静脉之间存在不同程度的直接交通.在血管瘤与血管畸形中,动静脉畸形相对少见,仅占1.5%左右,口腔颌面部是最好发的部位,占...     

Direct-puncture embolization of intraosseous arteriovenous malformation of jaws.

PURPOSE: Our goal was to report our experience with direct-puncture embolization of intraosseous arteriovenous malformations (AVMs). PATIENTS AND METHODS: Three cases of AVM in the mandible and 2 cases of AVM in the maxilla comprised this study group. The patients were embolized with fiber coils through direct puncture, and the coils were placed directly into the center of the intraosseous lesion, in some cases in conjunction with polyvinyl alcohol foam and N-butyl-2-cyanoacrylate through vascular access. RESULTS: The acute arterial bleeding was controllable in 3 patients. The other 2 patients had pericoronal oozing bleeding and a warm soft pulsative mass on the left face, respectively; their symptoms and signs improved greatly. The pericoronal oozing of blood in all patients disappeared during a 3- to 13-month follow-up, and new bone formation was found on the follow-up radiography. CONCLUSIONS: The embolization of the AVM of jaws by direct percutaneous puncture in conjunction with endovascular therapy is effective and safe, but longer follow-up is required to determine the true efficacy of this method of treatment.     

Comparative study of clinical manifestation,plain-film radiography,and computed tomographic scan in arteriovenous malformations of the jaws

OBJECTIVE: The purpose of this study was to summarize the clinical manifestation, plain-film radiography, and computed tomographic (CT) scan features of arteriovenous malformations (AVMs) of the jaws on the basis of a series of 12 patients. STUDY DESIGN: This study group comprised twelve patients with AVM of the jaws from February 1996 to February 2001. Seven cases were located in the mandible, and 5 in the maxilla. Both plain-film radiography and CT scan were available for all cases. For the patients with lesions in the mandible, panoramic, posterioanterior, and lateral mandibular views were applied. Waters' position view and panoramic radiography were indicated for AVMs of the maxilla. RESULTS: Each patient with AVM of the maxillary bone had involvement of adjacent soft tissues. Various radiographic signs were noted, including erosion, coarse trabeculae, and apparent lack of any radiographic change, and CT scans featured cystic expansion of alveolar process with broken cortex. The radiographic signs and CT scan features of AVMs in the mandible were related to involvement of surrounding soft tissues. If involvement of the adjacent soft tissues was found, "soap bubble" radiolucency was shown radiographically and osteolytic expansion with perforation of cortex was present on CT scan. In cases without surrounding soft tissue involvement, the various radiographic signs included multilocular or unilocular radiolucency or coarse trabeculae; osteolytic expansions with intact cortex were found on CT scan. CONCLUSION: AVMs of the jaws showed intraosseous osteolytic expansion on CT scan but had variable appearance on plain-film radiographs.     

忌行供血动脉阻塞治疗颅面部动静脉畸形

颅面部动静脉畸形虽然临床少见,但处理十分棘手。本文论述了颅面部动静脉畸形的临床表现、血管构筑、自然发展病程以及正确的治疗策略,从理论上探讨了单纯供血动脉栓塞或结扎不仅不能治疗动静脉畸形,还会加速病变的发展,为进一步血管内超选择治疗带来困难。为了取得良好的治疗效果,严禁行颈外动脉或供血动脉的结扎或堵塞治疗颅面部动静脉畸形。     

球囊临时阻断联合经皮穿刺硬化治疗颌面部动静脉畸形初探

为探讨采用动脉球囊临时阻断联合经皮穿刺硬化方式治疗颌面部动静脉畸形(arteriovenous malformation,AVM)的疗效和安全性,本研究回顾性分析2012年12月至2019年12月就诊于香港大学深圳医院介入科门诊的20例颌面部AVM患者的资料。患者年龄(26.8±3.0)岁(18~36岁),均经数字减影血管造影诊断为AVM,并按照外周AVM的Yakes分类进行分型,介入术中采用球囊临时阻断责任动脉主干,使高流量AVM变为低流量静脉畸形,再经皮穿刺畸形血管注射聚桂醇泡沫硬化进行治疗。比较患者治疗前后的症状及影像学变化,参照Achauer标准评价疗效。其中Ⅱa型AVM占60%(12/20),且治疗均有效;Ⅲb型和Ⅳ型患者的治疗效果较差。20例患者治疗的临床有效率为85%(17/20),临床治愈率为50%(10/20),无皮肤坏死、器官功能受损等严重并发症。存在主要责任供血动脉的颌面部AVM病例适合用球囊临时阻断对应责任动脉主干,再用经皮穿刺硬化治疗处理,此种方法安全有效。     

Imaging characteristics of arteriovenous malformations simulating vascular tumors of the temporalis muscle: a report of two cases

Arteriovenous malformations (AVMs) of the temporalis muscle are an extremely rare subgroup of head and neck AVMs. The authors report two cases presenting with temporal fossa tumor-like lesions. MRI demonstrated enlargement of the temporalis muscle with hypointensity on T1, hyperintensity on T2 and moderate contrast enhancement. Angiography shows slow arteriovenous shunting with a dense capillary blush of the entire muscle before draining into facial veins. The arterial supply is characteristic of being restricted to the temporalis muscle.     

彩色多普勒超声在颌面部血管畸形诊断、分类及疗效评价中的应用

目的：评价彩色多普勒超声在颌面部血管畸形诊断、分类及疗效评价中的作用。方法：对110例颌面部血管畸形进行二维及彩色多普勒超声检查,根据超声特点,将其分为高流速病变和低流速病变。对DSA检查证实为高流速血管畸形者,常规行供血动脉栓塞治疗。所有数据采用SPSS10.0软件包进行t检验和χ2检验。结果：110例血管畸形中,67例二维显示形态不规则的网格状混合性回声,部分伴强回声静脉石,多谱勒显示彩色血流稀少或较丰富,动脉收缩峰血流速度（PSV）平均为（28.53±8.1）cm/s,超声诊断为低流速血管畸形。43例显示72条供血动脉增粗,病变内血流信号极丰富,PSV平均为（144.53±38.9）cm/s,呈低阻动脉型频谱,超声诊断为高流速血管畸形。经DSA检查或术后病理证实,高流速和低流速病变的超声诊断正确率分别为100%和97.02%。43例高流速血管畸形的供血动脉全部行栓塞治疗,栓塞前、后的PSV分别为（144.53±38.9）cm/s和（86.2±36.3）cm/s,阻力指数（RI）分别为（0.55±0.04）和（0.80±0.05）（P均〈0.01）。结论：彩色多普勒超声检查能对血管畸形病变做出较正确的诊断和分类,对临床选择合理的治疗方案及动脉栓塞术后疗效评价均具有重要的指导意义。     

CT angiography of the head and neck: A report of 5 cases

We report on five cases in which patients were examined with CT angiography (CTA). In two cases of facial arteriovenous malformation (AVM), the dilated vascular structure was clearly visible. Moreover, three-dimensional reconstruction allowed observation of the relationship to the bone and comparison with the skin surface. The maximum intensity projection (MIP) image was useful for understanding the spatial relationship between the embolic material and the residual AVM. We also constructed three-dimensional subtraction images. In these images, only the blood vessels and lesion site were visible as bright areas, making it easy to determine the volume of the lesion. CT angiography can be used as a screening method for observing blood vessels and is useful for detailed examination of the relationship between lesions and blood vessels, and for examination of hypervascular lesions.