Article Figures & Data
Figures
- Fig 1.
Patient 1.
A, Lateral projection of the left external carotid arteriogram demonstrates a periorbital arteriovenous malformation supplied by the branches of the superficial temporal (black dotted arrow) and internal maxillary arteries (white dotted arrow, middle meningeal branch: white arrow).
B, Lateral projection of the left internal carotid arteriogram showing ophthalmic artery contribution to the supply of the arteriovenous malformation.
C, Lateral projection of the left internal carotid arteriogram during second session embolization, after completion of the embolization of the external carotid supply discloses the drainage of the ophthalmic supply (marked by the tip of the hemostatic clamp). This drainage vein was selectively punctured and embolized.
D, Native image of the venous phase of a postembolization left common carotid arteriogram showing the embolic cast. The defect within the embolic cast denoted with the solid white arrow is the point of balloon inflation. Embolic agent is also noted in the vein draining the ophthalmic supply (white dotted arrow).
E, Left common arteriogram after the final session of embolization shows almost total obliteration of the lesion angiographically.
- Fig 2.
Patient 6.
A, Native radiogram of right external carotid arteriogram in lateral projection reveals a fistulous CHVM supplied by the superficial temporal artery and collateral supply by ipsilateral middle meningeal and occipital arteries.
B, The inflated HyperForm balloon is visible (white arrows) on the roadmap capture in lateral projection obtained during embolization; note the retrograde filling of the middle meningeal and occipital collateral supply.
C, Postembolization ipsilateral external carotid arteriogram in the same projection demonstrates no evidence of residual arteriovenous shunt surgery.
- Fig 3.
Patient 8.
A, Anteroposterior projection of a left external carotid arteriogram in Waters projection depicts a fistulous CHVM supplied by the superficial temporal, anterior deep temporal, and middle meningeal arteries.
B, Postembolization external carotid arteriogram in anteroposterior projection reveals total obliteration of the lesion.
- Fig 4.
Patient 9.
A, Lateral projection of the left superficial temporal arteriogram demonstrates a fistulous CHVM; there is attenuated opacification of the draining vein, which projects in between the 2 branches of the artery.
B, Floroscopic image captured during percutaneous embolization shows impediment of venous filling by the external compression over the vein with a hemostatic clamp; retrograde filling in numerous arterial pedicles is also noted.
C, Postprocedure external carotid injection in lateral projection demonstrated no evidence of a residual lesion.
D, Postembolization photograph demonstrates blackish discoloration at the injection site.
E, Photograph after resection of the cast on postoperative day 5 shows residual discoloration at the margins of the incision.
Tables
Clinical and angiographic characteristics of patients
Patient No. (Figure No.) Age/Sex Location Main Symptoms Type Access Reason to Use Onyx Assist Technique Outcome Notes 1 (Figure 1) 21/M L periorbital Painful pulsatile mass totally obstructing vision vm IA × 3 PC Anticipation of better penetration into the nidus of the malformation with IA injection and direct puncture Balloon, direct puncture of draining vein remote to fistula Total removal after 2 series of embolizations and surgeries Catheter tip retained and removed later during surgery, difficulty in balloon retrieval, supplemented with glue for cost containment purposes and also for direct puncture of draining vein 2 24/F L cheek Painful mass, cosmetic concerns vm IA × 1 Anticipation of better penetration into the nidus of the malformation with IA injection Balloon Residual AVM Incomplete treatment, patient unwilling to pursue further treatment 3 10/M At mentum of mandible Mass with intermittent bleeding vm IA × 2 Anticipation of better penetration into the nidus of the malformation with IA injection Total elimination of malformation Small AVM, bilateral facial approach, no surgery, catheter tip retained on one side 4 7/M L preauricular Enlarging PM fs IA × 1 Plan to use external compression to limit embolization to the exact point of fistula under controlled injection to avoid excessive venous filling & arterial reflux EC on both arterial and venous side of AVF Total elimination of shunt 5 9/M R angle of mandible Enlarging PM fs IA × 1 TV in session 1, PC for 2nd session Plan to use balloon assist Balloon for session 1, venous EC for both sessions Total elimination of shunt after 2 sessions of embolization Significant filling of lesion through collaterals after session 1, glue used during second session to fill in large venous pouch 6 (Figure 2) 25/F R zygoma Bruit, PM fs IA × 1 Plan to use balloon assist Balloon Total elimination of shunt 7 26/M L temple fs PC Anticipation of retrograde filling of feeders Venous EC Total elimination of shunt Surgical excision of cast 8 (Figure 3) 33/M L occipital Painful large scalp mass fs PC Anticipation of retrograde filling of feeders Venous EC Total elimination of shunt Surgical excision of cast 9 (Figure 4) 24/M L forehead Cosmetic concerns fs PC Anticipation of retrograde filling of feeders Venous EC Total elimination of shunt Surgical excision of cast, second surgery for blackish discoloration at injection site Note:—M indicates male; F, female; L, left; R, right; PM, pulsatile mass; vm or AVM, arteriovenous malformation; AVF, arteriovenous fistula; fs, fistulous lesion; IA, intra-arterial; PC, percutaneous; TV, transvenous; EC, external compression.
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