Traumatic scalp arteriovenous fistula post capillary implantation successfully treated using PHIL embolic agent

Abstract

Background: A traumatic arteriovenous fistula of the scalp due to hair transplantation (AVFHT) is a rare fistulous communication between branches of the arteries and draining veins in the scalp's subcutaneous tissue. Its incidence is unknown and its clinical manifestations may range from a pulsatile mass to seldom epilepsy. Surgery and interventional approaches (percutaneous and endovascular embolization) using coils and embolic agents such as Onyx have been used as treatment options. The authors report a rare case of an AVFHT successfully treated through percutaneous and endovascular embolization using coils and precipitating hydrophobic injectable liquid (PHIL) embolic agent. This is possibly the first reported case using PHIL embolic agent to treat an AVFHT.

Case description: The patient presented with a painful and disabling scalp swelling in the right parieto-occipital region 2 years after a hair transplant in 2011. A computed tomography angiography showed an arteriovenous fistula between branches of the right superficial temporal artery and branches of the right occipital artery to the right superficial temporal vein that was successfully embolized using coils and PHIL. The patient was discharged after a smooth recovery and 1 month later remained healthy.

Conclusion: Percutaneous and endovascular embolization using PHIL embolic agent can be an alternative treatment for AVFHT.

Keywords: Angiography; Arteriovenous fistula; Intervention; Liquid embolic material; Precipitating hydrophobic injectable liquid.

Figure 1:

(a) Multiple subcutaneous right parieto-occipital dilated vessels (red arrows). (b) Arterial phase angiography showing feeders from the right occipital artery (purple arrow) to the arteriovenous fistula (green arrow). (c) Venous phase angiography showing the arteriovenous fistula (green arrow) and dilated right superficial temporal vein (blue arrow). (d) Volume rendering reconstruction showing the arteriovenous fistula (green arrow), superficial temporal artery (grey arrow), and dilated superficial temporal vein (blue arrow).

Figure 2:

(a) Resolution of dilated vessels on physical examination (red arrow). (b) Volume rendering reconstruction showing the embolization materials in the fistula, right occipital, and right superficial temporal arteries (green arrows).