Combined surgical treatment of arteriovenous malformation of the lower jaw

Abstract

The objective – to presents the observation of combined treatment of a patient with arteriovenous malformation of the lower jaw.
A man, 21 years old, was hospitalized in the Scientific-Practical Center of Endovascular Neuroradiology NAMS of Ukraine with complaints of bleeding from a tooth socket after an attempt to remove the 6th tooth (first painter) of the lower jaw on the left. According to the performed survey radiography of the lower jaw, an aneurysmal bone cyst was revealed in the body of the lower jaw on the left, corresponding to the localization of bleeding. According to cerebral angiography, an arteriovenous malformation of the lower jaw was revealed on the left, the afferent arteries of which were: the right facial artery (a branch of the right external carotid artery (ECA)), the left facial artery (a branch of the left ECA), the lower alveolar artery, the superior-posterior alveolar artery (branches of the maxillary artery ‒ the terminal branch of the left ECA) with drainage into a vein, which was located in the body of the lower jaw. In order to exclude the malformation from the bloodstream and prevent bleeding, a controlled embolization of the malformation was performed using non-spherical emboli – polyvinyl alcohol (PVA) particles from Cook, USA. Using a transfemoral approach, a guide catheter was inserted into the orifice of the ECA, then a Headway 27 microcatheter (Microvention, USA) was passed through it along a Traxes 14 guide wire (Microvention, USA), the afferent arteries of the malformation were selectively cathete-rized in turn, and embolization was performed after superselective angiography. The patient was discharged in a satisfactory condition. Two weeks after the operation, the bleeding resumed. The performed control cerebral angiography revealed a relapse of the malformation with a change in its angioarchitectonics ‒ the filling of the malformation in the late arterial and venous phases of cerebral blood flow was noted. Re-embolization was performed using PVA emboli (Cook), which was supplemented by transcutaneous puncture of the drainage vein in the mandible and its embolization with histoacryl (B. Braun, Germany) and lipiodol (Guerbet, France) in a 1 : 1 ratio.
Results. As a result of using this technique, it was possible to turn off the malformation completely. For 6 months from the moment of surgery, no bleeding was noted, and subsequently the patient had a tooth removed without complications.
Conclusions. The proposed method for treating arteriovenous malformation of the lower jaw, proposed in this case, showed the effectiveness of a combination of endovascular embolization in combination with transcutaneous embolization of the draining vein and can be successfully used to treat this pathology.