Arteriovenous fistula after superficial temporal artery biopsy
Mikhael MPGC Janssen, department of vascular surgery, university hospital Leuven, Belgium
Johan Vaninbroukx, department of radiology, university hospital Leuven, Belgium
Inge Fourneau, department of vascular surgery, university hospital Leuven, Belgium
Corresponding author:
Inge Fourneau
Departement of Vascular Surgery
University Hospital Leuven
Herestraat 49
B- 3000 Leuven, Belgium
Tel: 00 32 16 34 68 50
Fax: 00 32 16 34 68 52
E-mail:
Abstract
An arteriovenous fistula of the superficial temporal artery is quite rare. If it occurs, it is most often caused by trauma to the temporal region where the artery is very superficial to the skin. We present the first reported case ever of an arteriovenous fistula after temporal artery biopsy and review the literature on pathophysiology, diagnosis and treatment.
Introduction
Arteriovenous fistulae (AVF) of the superficial temporal artery (STA) can occur spontaneously, after trauma or due to iatrogenic injury. The STA lies very superficially in close contact to the accompanying vein making it a site of predilection of fistula formation on the scalp.We present an interesting case of a patient with an AVF after STA biopsy for suspected giant cell arteritis and review the literature on pathophysiology, diagnosis and treatment.
Case report
A 61-year old male presented with an annoying tinnitus on the right pre-auricular and temporal region. His medical history revealed auto-immune pancreatitis, diagnosed after duodenopancreatectomy, ulcerative colitis, diabetes and recurrent episodes of unexplained fever. Four months before presentation, he underwent a temporal artery biopsy on the right side. Giant cell arteritis was suspected as explanation for arthralgia and recurrent fever. Almost instantly after the biopsy he gradually developed a tinnitus. At the end the noise was more disturbing than the noise produced by the patient’s continuous positive airflow pressure apparatus he used for obstructive sleep apnea during the night. On physical examination a strong thrill was palpable and a loud bruit could be heard over de right pre-auricular region. The murmur diminished after compression. An arteriovenous fistula secondary to the temporal artery biopsy was suspected. A diagnostic selective arteriography confirmed the diagnosis. The artery stump connects with a tortuous vein draining in the retromandibular vein. (Fig 1)
Through retrograde femoral artery puncture, the right external carotid artery was catheterized. Superselective catheterization of the superficial temporal artery revealed the arteriovenous fistula which was subsequently coiled with three Nester® coils 3/70 (Cook Medical). (Fig 2)
After the coiling no residual arteriovenous fistula remained (Fig 3)and immediately the patient was relieved of his disturbing tinnitus. The patient was discharged the next day and only felt some tenderness over the right temporal region. Six weeks later our patient was completely asymptomatic.
Discussion
STA biopsy is still considered the gold standard in the diagnosis of giant cell arteritis. (1) The biopsy technique has been well described in the literature (2). In our hospital STA biopsy is done in ambulant setting under local anesthesia. A pre auricular incision is used and the artery is clipped. Complications include incorrect or inadequate tissue sampling, bleeding, hematoma formation, scarring, infection, wound dehiscence, and rarely cerebral ischemia after the biopsy when the temporal artery provides essential collateral circulation in the case of severe ipsilateral carotid disease.(3) Damage to the frontal branch of the facial nerve has been reported in a few reports. (3,4,5) Our case report adds a new complication to this list. To the best of our knowledge, it has never been reported.
AVF of the STA is rare. A pubmed search with ‘arteriovenous fistula AND temporal artery’ yielded 173 hits. Looking closely at these reports, 58 cases of a superficial temporal artery fistula are reported. Another Pubmed search with ‘cirsoid aneurysm’ yielded 175 results with at least 30 cases of AVF of the STA. The term ‘cirsoid aneurysm’ is less often used and derived from the Greek word ‘kirsos’ meaning varix because of the variceal aspect of the draining vein.
An arteriovenous fistula is a direct connection between a feeding artery and a draining vein without an intervening capillary bed. A potential mechanism of fistula formation is that simultaneous laceration of the artery and the accompanying vein results in a single fistula. Another mechanism is that endothelial cells of the disrupted vasa vasorum of the arterial wall proliferate into the hematoma forming several small channels to adjacent veins. (6)
These AVF can be congenital, spontaneous, posttraumatic or by iatrogenic cause. Nagasaka et al speculates that some fistula might be present but non-functional before injury and become functional after the trigger of injury. (7) Only 20 cases with an AVF of the STA as postoperative complications have been reported so far. (tableI) Nine cases occurred after hair transplantation; 6 after temporomandibular joint arthroscopy, 3 after craniotomy, one 3 months after surgical repair of trauma and one after reduction of a temporomandibular joint dislocation. The last two reports might be considered as a traumatic cause.
The most predominant clinical manifestation is a pulsating mass with a bruit and tinnitus. Headache, local pain, dizziness, hemorrhage and even skin necrosis are described. Typically the palpable thrill decreases or disappears when compression is applied to the proximal STA.
The diagnosis is primarily clinical. In general, MR imaging is the most valuable modality in the classification of vascular malformations. Doppler ultrasound also can be used for follow up. (8).
Intra-arterial angiography is still the gold standard for many authors (9,10,11 ) as it helps in planning the eventual treatment, certainly when endovascular treatment becomes treatment of choice.
Surgical (en bloc) excision or ligation used to be the gold standard. Ligation alone however is often followed by recurrence because of the development of collaterals and also precludes endovascular intervention. (12) The largest series of AVF (congenital and posttraumatic origin) of the STA show good success rates after surgical excision with no recurrence. (12, 13). They conclude that surgical resection is the preferred treatment for the majority of AVF’s. Fisher-Jeffes reports recurrence in 2 patients out of 13 with AFV in STA (14)
In the above mentioned large series preferring surgery, partial scalp necrosis occurred in 9-19% of the cases involving STA.
In 1986 Berenstein et al. used percutaneous embolization in 17 patients with various scalp AVF’s with only one recurrence. (15) Since then endovascular techniques are used alone or in combination with surgery.Endovascular treatment can be done by transarterial, transvenous of percutaneous access. The latter can be used if superselective catheterization is not possible. Gupta et al. used percutaneous puncture successfully in combination with pressure of the draining vein during the embolization with a cyanoacrylate-lipiodol mixture. (16) Embolization can be done with absolute alcohol, gel foam, glue or thrombogenic coils.
In older literature there is still scepticism about endovascular treatment with reports of skin necrosis, necessity for surgical excision of the swelling for cosmetic unacceptable result after percutaneous embolization or recurrence. (12, 17) Some authors see embolization as a bridge to surgery in order to reduce flow and facilitate excision. (14, 18) Miekisiak et al. recently chose surgical excision over endovascular treatment because of the cost and extensive lesion. (9)
However we believe together with other authors (11, 16) that endovascular treatment is safe and the preferred treatment over surgery. Endovascular treatment avoids cosmetically unacceptable scar, massive bleeding complication and can be done under local anesthesia.
Conclusion
An arteriovenous fistula of the superficial temporal artery is a rare complication after temporal artery biopsy. The typical clinical presentation is a palpable thrill over the temporal region. Surgical excision and/or endovascular embolization are good treatment options. However we believe endovascular treatment is superior with similar recurrence rates but superior aesthetic outcome and will still improve with technical advances in endovascular techniques.
List of figures
Figure 1. Selective catheterization of the external carotid artery at the level of the maxillary artery (thick arrow) with the fistula draining into the retromandibular vein towards the internal jugular vein (arrowhead). The operative clips show the resected STA (thin arrows)
Figure 2. Superselective catheterization of the STA stump showing contrast in the fistula, draining in the retromandibular vein.
Figure 3. Result after successful coiling of the arterial stump showing no more opacification of the fistula and draining vein.
Table I. List of all reports of iatrogenic AVF of STA. * no full text or abstract was retrieved
Author / Etiology / Treatment / OutcomeBernstein 2011 (19)
Takeuchi 2011 (20)
Dogan 2008(11)
Miekisiak 2008 (9)
Amlashi 2004 (21)
Martin-Ganizo 2004 (22)
Tokunaga 2000 (23)
Calwell 1999 (24)
Davies 1997 (17)
Fukuta 1997 (25)
Scholl 1997(26)
Carls 1996 (27)
Tornambe 1994 (28)
Preisler 1991 (29)
Kadota 1990 (30)
Moses 1990 (31)
Semashko 1989 (32)
Lanzieri 1985 (33)
Barros 1978 (34)
Souder 1970 (35) / Hair transplantation
Reduction of temporo-mandibular joint dislocation
Hair transplantation
Scalp wound suture after trauma
Craniotomy for intracranial aneurysm
Temporomandibular joint arthroscopy
Craniotomy for abcess
Temporomandibular joint arthroscopy
Hair transplantation
Hair transplantation
Temporomandibular joint arthroscopy
Temporomandibular joint arthroscopy
Hair transplantation
Temporomandibular joint arthroscopy
Craniotomy
Temporomandibular joint arthroscopy
Hair transplantation
Hair transplantation
Hair transplantation
Hair transplantation / No treatment
Endovascular (coils)
Endovascular (n-butylcyanoacrylate)
Surgical excision
Surgical ligation
Endovascular (coils)
Percutaneous embolization (n-butyl cyanoacrylate and lipiodol)
Initial ligation, followed by balloon embolization
Endovascular (polyvinyl alcohol microparticles + coils) and excision
Excision
Endovascular
Endovascular
Surgical ligation
Balloon embolization and subsequent surgery
Surgical ligation
Surgical ligation
*
*
Surgical excision
Surgical excision / Lost to follow up
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good
Good
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