Embolization of a life-threatening mandibular vascular malformation by direct percutaneous transmandibular puncture

Vascular malformations of the mandible are uncommon, but often present with significant hemorrhage. Transarterial vessel occlusion has become a valuable primary or adjunctive treatment for such lesions, as well as for most other symptomatic congenital and acquired head and neck vascular anomalies. Permanent embolic obliteration of the malformation requires placement of occlusive material directly into the nidus (core) of the lesion. Prohibitively complex proximal vasculature may prevent successful catheter positioning and lead to failure of traditional embolotherapy. Even optimal placement of arterial embolic material may fail to fully obliterate the nidus, allowing eventual restoration of flow to the lesion due to arterial recanalization. Under such circumstances it may be possible to obliterate the malformation and control lesional hemorrhage by occlusion of the malformation or its venous drainage by direct percutaneous mandibular puncture. In our case, multiple transarterial embolizations failed to sufficiently manage a symptomatic vascular malformation. Successful embolotherapy was performed via direct puncture of the venous side of the malformation through the mandibular cortex. Venous thrombosis induced concomitant occlusion of abnormal arteriovenous shunts, resulting in long-term control of life-threatening oral hemorrhage.