1. Poster #: EP-106 Onyx Embolization of Facial Vascular Malformations: Treatment, Results and Follow-up
Tram Schroeder, MD, Daniel Murph, MD, Juan G Tejada, MD
Indiana University School of Medicine
Eskenazi Health

2. Disclosures
The authors have no disclosures to report.

3. Introduction
Superficial high flow vascular malformations of the face are relatively rare lesions that may present either as a small subcutaneous facial lump or a large pulsatile mass with propensity for massive hemorrhage.
Examples: AV fistulas, AVMs, aneurysms, or hemangiomas

4. Introduction
Available treatments: surgical excision, embolization, sclerotherapy, laser ablation, and electrothrombolysis.
More recently liquid embolics have been employed. Reports of results and follow up are relatively scarce in the literature.
We present our experience at a tertiary care hospital with percutaneous and transarterial embolization of facial vascular malformations with the liquid embolic Onyx.

5. Materials and Methods
Retrospective search of all patients with superficial facial vascular malformations treated with Onyx at our tertiary care institution between January 2009 and March 2015.
Data collected: age, gender, presenting symptoms, angioarchitecture of the lesion, treatment approach, and follow-up MRI/MRA and angiography results when available.

6. Results - Demographics
9 patients
6 male, 3 female
Mean age 37 +/- 12 years
14 total procedures

7. Results – Clinical Presentation
6 patients: Pulsatile mass and swelling of the face.
1 patient: Recurrent mandibulofacial AVM with episodes of intractable spontaneous bleeding.
1 patient: Enlarging jaw mass with life-threatening intra-oral bleeding.
1 patient: Incidental finding on radiographs for braces.

8. Results - Treatment
5 patients: Transarterial superselective catheterization of the arterial feeder followed by injection of Onyx-18 or -34 under continuous road-map guidance until complete resolution or substantial devascularization of the malformation was achieved
3 patients: Percutaneous embolization with direct puncture of the vascular malformations.
1 patient: Combined endovascular and percutaneous approach

9. Immediate post-treatment angiography demonstrated
Results-Outcome
Immediate post-treatment angiography demonstrated
7 patients: Complete cure of the lesion.
2 patients: Substantial devascularization of lesion.

10. Results – Follow-up
6 patients had available follow-up studies showing no recurrent or residual lesions. 1 patient lost to follow up. The other 2 patients were asymptomatic at clinic follow-up.
3 patients subsequently underwent complete surgical removal of their lesions.
No adverse effects including skin discoloration, blindness, nontarget embolization, stroke, or death occurred.
JV?

11. Case 1
31 yo male with pulsatile mass on forehead found to be a frontal AVM with fistulous components fed by bilateral ECAs and ophthalmic arteries. Treated with percutaneous injection of Onyx 34 followed by surgical resection.
A. Superficial facial lesion pre-embolization.
B. Superficial facial lesion post-embolization and surgical resection.
C. Lateral DSA of the right external carotid artery shows frontal AVM with feeders from the STA and facial artery. Feeders from the ophthalmic artery are not shown.
D. Lateral DSA of the right external carotid artery post Onyx embolization shows angiographic cure of the lesion with resolution of the AVM shunting and complete packing of the AVM nidus with Onyx.

12. Case 2 A. C. E.
29 yo male who presented with right face pulsatile mass found to be complex right facial AVM with lingual artery saccular aneurysm and AV fistula with venous varices draining to the IJV. Also saccular aneurysm at the origin of the STA with AV fistula and large venous varix, and AV fistula with supply from inferior alveolar and IMA branches. Treated in 3 stages of coiling and transarterial/percutaneous Onyx embolization. B. D. F.
A. Lateral DSA of the right external carotid artery shows lingual artery aneurysm and AV fistula.
B. Lateral DSA of the right external carotid artery post coils and Onyx embolization.
C. Lateral DSA of the right internal maxillary artery showing saccular STA aneurysm and AV fistula.
D. Lateral DSA of the right internal maxillary artery post coils and Onyx and embolization.
E. Lateral DSA of the right external carotid artery showing AV fistula.
F. Lateral DSA of the right external carotid artery post-percutaneous Onyx embolization.

13. Case 3
63 yo female with complex, nonresectable mandibulofacial AVM with related episodes of spontaneous bleeding from the oral mucosa and lower lip. She had undergone numerous procedures including surgical arterial ligations, embolizations and sclerotherapies since Stable since last intervention (18 mo prior), she presented with recent episodes of bleeding from the lower lip and left mandibular gingiva. The patient underwent continued staged transcatheter Onyx embolization and percutaneous alcohol sclerotherapy of the complex mandibulofacial AVM. A. B. C. D.
A. Lateral angiography of right common carotid artery (12 years prior) demonstrating a large complex large AVM nidus in the anterior mandibular region.
B. Lateral angiography of right external carotid artery demonstrating facial and mandibular artery feeders to the persistent AVM nidus.
C. Lateral supraselective angiography of the right facial artery during Onyx embolization shows residual AVM nidus.
D. Lateral view percutaneous sclerotherapy of the left facial artery with alcohol/ethiodol.

14. Case 4
14 yo male presented with three week history of enlarging jaw mass, acute pain and bleeding. Intra-oral bleeding led to anemia (Hb 7.6), syncope, dizziness.
Angiography demonstrated no evidence of tumor blush or AVM nidus. Subtle AV shunting and contrast pooling was demonstrated in the left mandibular lesion. Percutaneous onyx embolization was performed and the lesion was surgically resected. Final pathology report was consistent with hemangioma.
Axial CT of the neck with IV contrast demonstrates an expansile, lytic lesion in the body of the left mandible with evidence of contrast pooling.
Coronal MRI of the neck with contrast demonstrates enhancement with surrounding inflammatory changes.
Lateral left ECA angiography and D. left internal maxillary artery angiography demonstrated subtle AV shunting with very slow flow and contrast pooling.
-F. Representative subtracted and nonsubtracted images of percutaneous Onyx embolization procedure.

15. Case 5
52 yo male with pulsatile mass in right temporal area found to have 5 mm pseudoaneurysm of the main trunk of the STA. Treated with transarterial embolization with Onyx-34. A. B.
A. Angiography of right external carotid artery pre-embolization shows pseudoaneurysm.
B. Angiography of right external carotid artery post- embolization shows angiographic cure of lesion.

16. Case 6
45 yo male with pulsatile mass on left scalp found to have AV fistula from left STA to left EJV and facial vein with venous aneurysm inferiorly. Treated with transarterial embolization with Onyx-18 and -34.
A. Lateral angiography of the left superior temporal artery pre-embolization shows AV fistula and venous varix.
B. Lateral angiography of left superior temporal artery post-embolization shows angiographic cure of the lesion.

17. Case 7
15 yo male presented with intra-oral vascular mass identified incidentally during a dental procedure. Subsequent CT angiography and doppler ultrasonography revealed an intraosseous AVM with large venous varix within the right mandibular body. Shortly after diagnosis, the patient developed acute intraoral hemorrhage requiring emergent embolization. Resection and reconstruction was performed by maxillofacial and plastic surgery.
A. and B. Axial CT and MRI demonstrate a lytic , enhancing vascular mass in the right mandibular body.
C. Doppler US demonstrates an AVM in the right mandibular body draining into a dilated varix.
D. Lateral Right ECA angiography demonstrates the AVM supplied by branches of the facial and internal maxillary artery with venous drainage predominantly to the right external jugular vein.
E. and F. Post-embolization lateral right ECA angiography demonstrates occlusion of approximately 80% of the mandibular AVM.

18. Case 8
47 yo female presented with right temporal pulsatile mass. Angiography demonstrated a right pre-auricular AV fistula with venous varix. The lesion was embolized with Onyx 34. A. B. C.
Lateral right external carotid artery angiogram demonstrates an arteriovenous venous fistula, arising from the superficial temporal artery, which appears enlarged. A saccular venous varix is seen immediately distal to the shunt, with venous drainage to the superficial temporal vein.
Lateral supraselective STA DSA for Onyx 34 injection
Right external carotid artery angiogram demonstrating occlusion of the arteriovenous fistula and venous varix. The STA remains patent.

19. Case 9
45 y/o female presented with enlarging pulsatile right periorbital mass in the medial canthus. Catheter angiography demonstrated an AVM with feeders from the right ophthalmic artery, the right IMA and the right facial artery. The lesion was treated with percutaneous embolization with Onyx 18 and 34 . Complete angiographic cure of the lesion was achieved. The lesion was then surgically removed by oculoplastics. A. C. E. B. D. F.
A.-B. Lateral and AP CCA angiography demonstrates right periorbital AVM with feeders from the ophthalmic, facial and IMA arteries.
C.-D. Lateral and AP DSA images show percutaneous contrast injection with 22 gauge 1.5 inch needles in the AVM nidus and Onyx cast.
E.-F. Lateral and AP CCA artery angiogram at the end of the case shows angiographic cure of the lesion with resolution of the shunting and complete filling of the AVM nidus with Onyx.

20. Conclusion
In our small case series transarterial and percutaneous Onyx embolization of facial vascular malformations is safe and effective resulting in complete cure of the malformations, substantial decrease in peri-operative surgical bleeding risk, successful control of
life -threatening hemorrhages, and palliative care of intractable lesions.

21. References
Arat A, Cil BE et al. Embolization of High Flow Craniofacial Vascular Malformations with Onyx. AJNR 2007:28:
Spiotta AM, Miranpuri AS et al. Balloon augmented Onyx embolization utilizing a dual lumen balloon catheter: utility in the treatment of a variety of head and neck lesions.
J NeuroIntervent Surg 2014:6:547-5.