Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 244-246

Iatrogenic preauricular arteriovenous fistula in underlying slow-flow venous malformation and its endovascular management

Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission20-Jun-2020
Date of Acceptance09-Oct-2020
Date of Web Publication6-Jul-2021

Correspondence Address:
Sarbesh Tiwari
Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_85_20

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Arteriovenous fistula (AVF) is direct abnormal communication with the shunting of blood from an artery to a vein without intervening capillary network. AVF in preauricular location is uncommon, and most of the cases are posttraumatic or iatrogenic. The endovascular route is the preferred approach for treating such a lesion with better cosmetic outcome, however surgical excision may be required for complex cases.

Keywords: Arteriovenous fistula, superficial temporal artery, venous malformation

How to cite this article:
Garg PK, Khera PS, Pathvardhan P, Tiwari S, Yadav T, Sureka B. Iatrogenic preauricular arteriovenous fistula in underlying slow-flow venous malformation and its endovascular management. Indian J Vasc Endovasc Surg 2021;8:244-6

How to cite this URL:
Garg PK, Khera PS, Pathvardhan P, Tiwari S, Yadav T, Sureka B. Iatrogenic preauricular arteriovenous fistula in underlying slow-flow venous malformation and its endovascular management. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jul 26];8:244-6. Available from:

  Introduction Top

Vascular malformations (VaMs) are among the common causes of congenital facial swelling.[1] Inadvertent cytology/biopsy from such a lesion without prior imaging can lead to certain complications such as bleeding or development of arteriovenous fistula (AVF) which warrants surgical or endovascular management. Here, we describe one such case of iatrogenic AVF in preexisting slow-flow venous malformation (VM) of the face and its successful endovascular management.

  Case Report Top

18-year-old female presented with a right preauricular swelling and tinnitus. She had painless swelling in the face over the right parotid region since childhood. Fine-needle aspiration cytology (FNAC) from the lesion without imaging guidance or prior imaging was attempted 4 years back at a local hospital which yielded only bloody aspirate. Post FNAC, she developed gradual increase in the size of the swelling and pulse-synchronous tinnitus of the right ear [Figure 1]a and [Figure 1]b. Her general physical examination and vitals were within normal limits. On local examination, the swelling was located at the right preauricular region, soft in consistency, and had a palpable thrill over it. The temporary stoppage of the tinnitus was noted on compression of the swelling.
Figure 1: Clinical images of the patient. (a) Preprocedure image showing swelling in the right preauricular region (in the red box). (b) On postembolization day 2, the swelling has decreased significantly

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High-resolution ultrasound of the swelling showed the lesion within the right parotid gland, which had compressible anechoic spaces with multiple phleboliths [Figure 2]a. Color and spectral Doppler showed predominantly venous flow within the spaces; a prominent vascular space with arterial flow was noted at the superior aspect of the lesion [Figure 2]b. The facial vein also showing arterialized flow. Magnetic resonance (MR) imaging face with dynamic contrast enhancement angiogram showed T2 hyperintense lesion in the preauricular region, with few phleboliths features consistent with slow-flow VM [Figure 2]c and [Figure 2]d. The superior component of the lesion showed early contrast opacification, compared to the rest of the lesion, supplied by the right superficial temporal artery (STA), and early opacification of adjacent veins in the arterial phase suggestive of concomitant AVM and slow-flow VM.
Figure 2: Ultrasound image (a) of the swelling showing a heteroechoic soft-tissue lesion with phlebolith (white arrow). (b) Color and spectral Doppler demonstrate high arterial flow with low resistance pattern in one of the flow voids. Axial (c) and coronal (d) fat-saturated magnetic resonance images showing a hyperintense lesion with phleboliths (black arrow), suggestive of slow-flow venous malformation

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Further, digital subtraction angiogram (DSA) of the right external carotid artery revealed a fistulous communication between the right STA and the right maxillary vein draining through the right angular vein, facial vein, and finally into the right internal jugular vein [Figure 3]a and [Figure 3]b. The fistula was located only at the superior aspect, with the rest of the swelling showing no angiographic blush.
Figure 3: Digital subtraction angiogram of the right STA, lateral (a) and anteroposterior (b) views showing the site of fistula (black arrow) between the right STA and dilated right maxillary vein

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Endovascular embolization was planned considering the cosmetic concerns and persistent tinnitus. Under conscious sedation and local anesthesia, the right external carotid artery was cannulated and a super-selective injection of the right STA was performed to understand the angioarchitecture of the fistula. It was a moderate- to high-flow fistula, hence it was embolized using 60% of 1 mL N-Butyl Cyanoacrylate (NBCA)–lipiodol mixture taking care not to allow significant venous reflux [Figure 4]a. Check angiogram revealed nonopacification of the fistulous communication [Figure 4]b and [Figure 4]c.
Figure 4: Post embolization, nonsubtracted anteroposterior image (a) showing radio-opaque glue cast filling the site of fistula, extending along the draining vein (red arrows), also seen the phleboliths (blue arrow). Check angiogram through right external carotid artery lateral (b) and anteroposterior (c) views does not reveal the opacification of the fistula or early draining veins

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The patient was shifted to the ward with complete disappearance of pain and tinnitus within 1 day with a significant decrease in the size of swelling. Follow-up ultrasound Doppler showed no detectable arterial color flow within the lesion. The patient was followed up for 3 months with no recurrence.

  Discussion Top

AVFs are abnormal communications with shunting of blood from an artery to a vein that mainly involve the peripheral vascular system but can affect virtually any organ or system in the body.[2] The fistulas can be either congenital or acquired. Congenital fistulas may present at birth or remain asymptomatic until adulthood. The acquired causes include traumatic, iatrogenic, and sporadic nontraumatic.[3]

Iatrogenic AVF is described extensively in literature and can involve different arteries. Iatrogenic AVF may develop post coronary intervention, pacemaker placement, dialysis catheter insertion, lumbar discectomy, post hip/knee arthroplasty, etc.[4]

In the head-and-neck region, the preauricular region is the commonly affected area for AVF. STA is particularly vulnerable to trauma due to its long and relatively exposed course in the scalp, hence prone to AVF.[5] The clinical features of AVF include swelling, pain, bleeding, and tinnitus.

Iatrogenic AVF of STA had been described after manual reduction of temporomandibular joint dislocation, after reduction malarplasty, and after maxillo-facial surgery.[6],[7] Rarely, AVF is also described after STA biopsy for vasculitis.[8]

The development of AVF in preexisting slow-flow VM is not described in the literature. In this case, the patient had initially parotid-region swelling due to VM. She inadvertently underwent FNAC from VM without prior imaging. This possibly leads to injury to the STA and adjacent veins and the formation of AVF.

The clinical features of AVF include swelling, pain, bleeding, and tinnitus. Doppler ultrasound shows the low-resistance flow in the supplying artery, the arterialized high-velocity waveform in the draining vein, and turbulence at the site of the fistula. Dynamic computed tomography and MR angiography demonstrate early opacification of the draining vein during the arterial phase. DSA is the gold standard for diagnosis and helps in the evaluation of angioarchitecture and planning endovascular management.[2]

The goal of AVF treatment is to remove the abnormal connections between the artery and vein. The treatment options include conservative, surgery, endovascular embolization, or a combination. Conservative management includes manual compression of the fistula which leads to gradual thrombosis. Surgical excision consists of ligation of the feeding artery and excision of the fistula, although associated with less recurrence but more invasive and difficult in deeply situated AVF. Furthermore, there is a risk of potential nerve injuries, especially facial and parotid nerves.[9] Partial treatment or proximal ligation of the feeding artery will lead to recurrence as the facial region has a rich collateral circulation.

The endovascular route is the preferred alternative to surgery as it is minimally invasive, offers quick recovery, and is cosmetically more compatible. The chances of recurrence are less when the size of the fistula is small and when there is presence of a single arterial feeder. Transarterial embolization is the most widely chosen route, however transvenous approach or even direct puncture technique may be used based on anatomy.[5] Embolizing agents that have been used include microcoils, liquid embolic agents such as NBCA (glue) or Onyx, and absolute alcohol.[10] In the present case, the embolization was carried out with NBCA as the fistula was of moderate flow and sufficient safety margin for venous reflux was present. Preoperative embolization followed by direct surgery may be considered in complex high-flow AVFs with an aim to decrease the flow of fistula and achieve a permanent cure.

  Conclusion Top

The present case report discusses AVF as a complication secondary to an inadvertent attempt of needling in a congenital slow-flow VM. Prior imaging must be performed in every suspected case of VaM and tissue sampling should be avoided. For any other lesion, especially in the head-and-neck region, tissue sampling should be performed under ultrasound guidance to avoid complications. DSA may be required for accurate delineation of feeding vessels and preoperative planning. Endovascular treatment has the advantage of minimal invasive nature and cosmetic advantage.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Khanna G, Sato Y, Smith RJ, Bauman NM, Nerad J. Causes of facial swelling in pediatric patients: Correlation of clinical and radiologic findings. Radiographics 2006;26:157-71.  Back to cited text no. 1
González SB, Busquets JC, Figueiras RG, Martín CV, Pose CS, de Alegría AM, et al. Imaging arteriovenous fistulas. Am J Roentgenol 2009;193:1425-33.  Back to cited text no. 2
Biegaj E, Rutkowska-Zimirska J, Radzymińska-Maliszewska M, Zaremba A, Pniewski J. Arteriovenous fistula of superficial temporal vessels case report. Folia Morphol (Warsz) 2019;78:879-82.  Back to cited text no. 3
Yan GW, Li HW, Yang GQ, Bhetuwal A, Liu JP, Li Y, et al. Iatrogenic arteriovenous fistula of the iliac artery after lumbar discectomy surgery: A systematic review of the last 18 years. Quant Imaging Med Surg 2019;9:1163-75.  Back to cited text no. 4
Li F, Zhu S, Liu Y, Chen Y, Chi L, Chen G, et al. Traumatic arteriovenous fistula of the superficial temporal artery. J Clin Neurosci 2007;14:595-600.  Back to cited text no. 5
Takeuchi S, Takasato Y. Iatrogenic arteriovenous fistula of the superficial temporal artery after manual reduction of temporomandibular joint dislocation. J Craniofac Surg 2011;22:1959-61.  Back to cited text no. 6
Kim JH, Yoon SM, Choi HJ. Iatrogenic arteriovenous fistula of the superficial temporal artery after reduction malarplasty. J Craniofac Surg 2015;26:e50-1.  Back to cited text no. 7
Janssen M, Vaninbroukx J, Fourneau I. Arteriovenous fistula after superficial temporal artery biopsy. Ann Vasc Surg 2013;27:500.e1-5.  Back to cited text no. 8
Cvetic VZ, Radmili O, Lukic B, Colic M, Davidovic L. Endovascular treatment of traumatic pseudoaneurysm of the superficial temporal artery. Vasc Endovascular Surg 2016;50:171-4.  Back to cited text no. 9
Zheng J, Guo Z, Zhang X, Sun X. Intravascular embolization versus surgical resection for patients with scalp arteriovenous fistula. Chin Neurosurg J 2019;5:3.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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