Embolization of a Complex Facial Arteriovenous Malformation, Balloon-Assisted Flow Arrest, and Controlled n-BCA Injection with Dextrose Push Technique: 2-Dimensional Operative Video

N-butyl cyanoacrylate glue (n-BCA, Cerenovus, Irvine, California) is commonly used to treat arteriovenous malformation (AVM). Even though Onyx (ethylene vinyl alcohol, Medtronic, Dublin, Ireland) presents more controlled injection, n-BCA is colorless, thus preferable for treatment of superficial facial malformations. N-BCA injection into AVM can result in premature distal migration or early precipitation and reflux into the feeder vessels. Here we describe a trans-arterial balloon assisted technique embolization of a complex facial AVM with n-BCA. A 22-yr-old female with chronic oral/gum bleeding presented with a complex facial AVM. She underwent selective transarterial n-BCA balloon assisted treatment with dextrose push. Informed written consent was obtained. A Scepter dual lumen balloon (MicroVention, Aliso Viejo, California) and a Prowler microcatheter (Cerenovus) were introduced via a 6-French Envoy guide catheter (Cerenovus) selectively into the AVM feeder. The balloon was positioned 3 cm proximal to the Prowler microcatheter tip and fully inflated to create flow arrest. Diluted 25% concentration of n-BCA in Ethiodol Oil was injected through the Prowler microcatheter. The distal migration of the n-BCA was modulated with simultaneous injection of Dextrose 5% in water via the Scepter balloon. This resulted in a controlled glue injection without early distal glue migration (because of the flow arrest) nor early proximal glue precipitation or reflux (because of the dextrose infusion), obtaining complete cure of the complex facial AVM. Glue embolization with flow arrest and dextrose push allows well controlled injection, and it represents a valid option also for high flow vascular lesions.