Embolization of Head and Neck Vascular Malformations using Serial Arterial Embolization Followed by Dominant Arterial Embolization with Two Microcatheter Technique.

PURPOSE: Head and neck arteriovenous malformation (AVM) and fistulae treatment without reflux and with nidal penetration are challenging. We describe a case series including adult and pediatric patients utilizing a specific two-microcatheter technique using Onyx with strategic embolization of small feeding branches prior to dominant branch embolization. We aim to demonstrate the safety and efficacy of this technique. PATIENT SELECTION: Head and neck vascular malformation cases were reviewed from 2010 to 2017. 11 patients between 2010 and 2017 were treated with serial embolization along with Onyx embolization utilizing a two-microcatheter technique. Five patients had cerebral AVMs, three had dural arteriovenous fistulae, two had mandibular AVMs, and one had a posterior neck AVM. Vascular anatomy, location, and procedural details were recorded. TECHNIQUE: During procedures 1-4, smaller arterial feeders were embolized first to maximally decrease the intranidal pressure at the time of the embolization of the major residual feeder. The dominant residual feeder was then embolized using two catheters. Coils followed by Onyx were initially deployed through the proximal catheter to form a dense plug. The plug was allowed to solidify for 30 min. Aggressive embolization of the nidus was then performed through the distal catheter. RESULTS: All 11 patients had excellent treatment results with complete (6) or near-complete (5) obliteration of the vascular malformation nidus. No procedural complications were noted, specifically no strokes, hemorrhages, or unintentionally retained catheter fragments occurred. CONCLUSION: AVMs and fistulae are challenging to treat. A two-microcatheter technique for Onyx embolization with prior embolization of smaller arterial feeders is a safe and efficacious treatment option. This technique allows for maximal nidus penetration while minimizing the risk of nontarget embolization/reflux. In all cases, we achieved excellent results with complete or near-complete obliteration of the vascular malformation nidus.