Cookie Cutter Technique for Percutaneous Direct Puncture Glue Embolization of High-Flow Craniofacial Arteriovenous Malformations

Abstract Background Direct puncture embolization with glue is an effective technique for pre-operative devascularization of craniofacial arteriovenous malformations. Venous outflow and arterial inflow of the lesion need to be limited during injection of embolic material. Manual compression is the standard procedure for flow reduction, but when an AVM has multiple channels of venous drainage, achieving successful blockage of blood is technically difficult. This study demonstrates the use of a circumferential cookie cutter ring to reduce flow, with better results compared to manual compression. Design and Methods This is a retrospective study of ten patients, over a period of two years, with craniofacial arteriovenous malformations who were treated with direct percutaneous injection of glue. Pre-embolization angiography was performed to see arterial feeders and venous draining veins. Adjunctive maneuvers were used during embolization, including external compression of venous pouch with circular cookie cutter rings of different sizes varying based on lesion size. Glue cast was localized within and around the margins of circular cookie cutter ring without any distal migration. Results No neurological complications secondary to the embolization procedure were observed. The arteriovenous shunts were successfully occluded in all cases. There was partial occlusion in two cases. Total occlusion achieved in five cases when embolization was followed by surgery. Only one case required a second session to achieve total occlusion. Post embolization, there was minimal residual flow in one patient, who declined further treatment due to mitigation of symptoms. The shape of glue cast was changed in two cases after removal of cookie cutter when low concentrated glue was used. No skin necrosis was seen post embolization. Conclusions Percutaneous direct puncture embolization with glue saves time and is a safer method for superficial craniofacial AVMs with prominent venous pouch when external compression was applied with circumferential cookie cutters to reduce venous outflow.