Percutaneous sclerotherapy of a bleeding nasal arteriovenous malformation

A 24-year-old female presented with a right nasal mass causing recurrent epistaxis since infancy. After her pregnancy (and 2 years prior to presentation), her epistaxis became frequent and debilitating. Multiple surgical debridements and ligations failed to improve her symptoms. Contrast-enhanced MRI head demonstrated intravenous contrast revealed a right nasal ala arteriovenous malformation (AVM)(Fig. 83.1). Transradial cerebral angiography demonstrated AMV supply by branches of both external and internal carotid arteries, the right internal maxillary artery (Fig. 83.2), and the ophthalmic artery (Fig. 83.3). Given the dual supply to the nidus, we decided to treat it percutaneously. A 21-gauge angiocath needle was used to access the nidus under fluoroscopic guidance. Contrast injection demonstrated filling of the nidus with a late draining vein (Fig. 83.4). Sclerotherapy was performed using a foam sclerosant consisting of a mixture of air, Ethiodol and 3% Sotradecol in a 3:2:1 ratio. The nidus was accessed at several sites and the sclerosant was injected with care to prevent reflux into the arterial system. A completion external carotid arteriogram demonstrated markedly decreased enhancement of the AVM nidus (Fig. 83.5). The patient was discharged with no adverse sequela. At 1-year follow-up, she remained symptom free.