E-005 Super-selective pre-operative embolization of juvenile angiofibromas

Purpose Juvenile angiofibromas (JNAs) are hypervascular, locally destructive tumors best treated by complete surgical resection. They occur predominantly in teenage boys and originate at the posterior pedicle of the middle turbinate at the posterolateral nasal wall near the sphenopalatine foramen. They fill and often obstruct the ipsilateral nasal cavity, leading to headaches, facial pain, swelling, and sinus obstruction. CT, MRI, and angiography are useful in the diagnosis, pre-operative planning, and detection of residual disease. The primary blood supply of JNAs is usually the ipsilateral internal maxillary artery; however, alternative blood supplies are possible, especially in recurrent disease. In addition, small-vessel anastomoses and variant anatomy may exist which may lead to hazardous connections between the tumor and surrounding structures, such as the eyes or the brain. Non-target embolization of these may cause stroke or blindness. The purpose of this report is to illustrate the role of super-selective embolization of JNAs prior to surgical resection. We recommend bilateral pre-embolization angiography followed by super-selective embolization prior to surgical resection to minimize the risk of life-threatening epistaxis and to improve visualization of the operation field during surgical resection in the operating room (OR). Materials and Methods We discuss three consecutive young, active duty male patients with the clinical history and imaging findings characteristic for JNA who were treated at NMCSD. Case 1 is a 20-year-old Caucasian male sailor with a past medical history significant for JNA surgically treated 5 years ago who presented to his primary care physician with a 4-month history of right-sided facial pain and recurrent heavy epistaxis. Case 2 is a 26-year-old Caucasian male sailor with no significant past medical history who presented to his primary care physician with a 7-month history of left-sided facial pain and left nasal airway obstruction with recurrent sinusitis and epistaxis. Case 3 is a 25-year-old Caucasian male marine with no significant past medical history who was being worked-up by otolaryngology for bilateral tympanic membrane perforation secondary to IED blast trauma when an incidental, multipendunculated, and expansile vascular nasal mass was discovered on MRI which originated at the sphenopalatine foramen and extended through the right posterior nasal cavity and medial maxillary fissure. All patients underwent both CT and MRI to confirm the diagnosis, followed by bilateral carotid angiography. Each had super-selective pre-operative embolization done by the senior author with 50–150 micron-sized particles, 2–4 days prior to surgical resection in the OR. Result In each case, pre-operative super-selective embolization of the primary arterial feeders was successfully accomplished with a shaped microcatheter and wire combination plus pretreatment with topical nitropaste and intraarterial nicardipine to avoid vasospasm in these potentially highly spastic distal vessels. This resulted in short operative times and minimal blood loss (25 cc, 20 cc, and 20 cc, respectively) in the OR. Conclusion Pre-operative super-selective embolization of JNAs in the short interval prior to surgical resection improves outcomes by shortening operative times and minimizing blood loss while improving visualization of the operative field. Such treatment reduces the risk of life-threatening epistaxis and decreases the need for blood transfusions.