Arteriovenous (AV) malformations are rare congenital vascular anomalies accounting
to approximately 0.1% of the general population.[1] They represent primitive communications between multiple arteries and draining veins
without interconnecting capillaries, and are organized into tangled system of vessels
called niduses.[2] Among the recent techniques embolization followed by surgical resection is found
to have best success rates.[3] Due to technical difficulties most often excision of the lesion is done after 24
to 48 hours of embolization.
We planned to excise a large (8 × 7 cm) high-flow arterial malformation on a 7-year-old
child ([Fig. 1]) on a single day. By 8 a.m., under general anesthesia, left superficial temporal,
internal maxillary, and lingual arteries were embolized using N-butyl-cyanoacrylate
in combination with lipidol and the facial artery was occluded using gel foam by the
interventional radiology team ([Fig. 2]). She was then shifted to the operation theater under ventilator support, and without
further delay vascular clusters were excised ([Fig. 3]). Left zygomatic and buccal branch of the facial nerves were safely dissected out.
Total duration of the whole procedure was 5 hours. Facial nerve function was found
to be normal postoperatively. She was discharged after 2 days. Suture removal was
done after 7 days. Her wound healed well ([Fig. 4]). Later, she was started on compression dressing and scar massaging.
Fig. 1 Preop image front and lateral view.
Fig. 2 Pre- and postembolization visuals.
Fig. 3 Intraoperative before and after excision image (with branches of facial nerve marked,
T, temporal; Z, zygomatic; B, buccal).
Fig. 4 Three weeks postop image front and lateral view.
Recent literatures idealize the interval between embolization and surgery to be within
1 to 3 days.[1] Few literature do emphasize on advantages of performing both embolization and excision
in a single stage,[4] but there is scarcity of data in Indian scenario and also about lesion involving
the head and neck region.
Apart from the economic benefits, early surgical excision had the advantage of very
minimal tissue reaction while operating with no bleeders or blood clots, and the surrounding
tissues appeared fresh and healthy. There was considerable reduction in local inflammatory
exudates as minimal time was given for hypoxic reaction to progress within the area
of resection. The benefit of having a virgin display of malformations without any
inflammatory reaction gives a better delineation of structures and also reduces operating
time.
By undertaking this quicker protocol, managing high-flow AV malformation by presurgical
embolization and immediate excision is more cost effective with better outcomes. Utilizing
the idea of hybrid theaters with inbuilt cath laboratory will further reduce anesthesia
and operating time.
