INHOUSE ACHIEVEMENTS IN THE FIELD OF INTERVENTIONAL RADIOLOGY

26 INHOUSE ACHIEVEMENTS IN THE FIELD OF INTERVENTIONAL RADIOLOGY By: Rama Alawneh

You may have heard the latest commotion regarding the most recent “Worldly Medical Accomplishment” performed at the King Abdullah University Hospital (KAUH) by a team of Jordanian doctors. Well, this uproar is not out of place. It reflects the current skill and capacity of the Jordanian Doctor, and also the potential that Jordan has to offer to the medical field through its gifted medical professionals.

The paper published recently in The Journal of Craniofacial Surgery is authored by Khaled Alawneh, MD, Bashar Abuzayed, MD, Majdi Al Qawasmeh, MD, and Liqaa Raffee, MD. It proposes the use of a “novel technique of endovascular and surgical devascularization” in the removal of a scalp arteriovenous malformation.

A 26-year-old female patient presented to the emergency department at KAUH with chief complaints of an increasing headache and swelling of the left upper eyelid. The swelling was noticed to be soft and pulsatile upon examination. Consequently, a brain computed tomography (CT) scan was performed along with a brain magnetic resonance imaging (MRI) scan. Following that, brain CT angiography was performed and revealed that there was a vascular lesion. A six-vessel cerebral angiography showed that there was a left frontal scalp arteriovenous malformation (AVM).

An arteriovenous malformation of the scalp is an “abnormal fistulous connection between the feeding arteries and draining veins without an intervening capillary bed within the subcutaneous layer.” The symptoms of an AVM depends on its location. This particular AVM was supplied by the left and right superficial temporal arteries along with the left supraorbital artery. The superficial temporal arteries and the supraorbital arteries are arteries of the scalp.

“The nidus of the AVM and the direct high flow venous drainage to the superior sagittal sinus through a wide pore (See Figure 1C – black arrow) in the bone carries a high risk of passing the embolizing materials, especially since that the bony pore of the venous drainage does not collapse like the venous vessel wall when there is decreased intranidal pressure.”

In the process of her treatment, the patient was sedated and through her right femoral artery, both superficial temporal arteries were occluded using Onyx 18 – liquid embolic agent used for the occlusion of blood vessels. Post-procedure, cerebral angiography displayed regression of the nidus. There was complete cutoff of the flow from the bilateral superficial temporal arteries. Two days following this procedure, the patient was operated on through a left eyebrow incision. This operation was done in order to expose, ligate, and cut the supraorbital artery.

“The endovascular embolization of the supraorbital artery was avoided due to the high risk of ophthalmic artery occlusion and potential blindness. Therefore, instead, the external ligation of the supraorbital artery via a left eyebrow incision was done. It was a safer option. (See Figure 1B)”

With this technique, and without embolization of the nidus, total surgical excision of the AVM was feasible.

This isn’t the first medical achievement performed by doctors at KAUH. Dr. Khaled Alawneh, along with colleagues, performed a rare surgery on a 22-year-old Syrian refugee in 2017. She was referred to KAUH due to constant pain, weakness, and numbness in her right upper arm three weeks following gunshot wounds to the right chest and neck area. The patient was found to have a subclavian pseudoaneurysm – in other words, a hematoma surrounding the subclavian artery. The patient was treated via an endovascular repair by angioplastic ballooning of the stenotic region of the artery. The patient recovered and, on follow-up examination, was revealed to have significant improvement with respect to the neurological deficits previously incurred.

Such a case is considered rare and is associated with a high mortality rate; the doctors at KAUH managed to successfully treat this case. A case report was published on the 13th of June in 2017 in the Journal of Vascular and Endovascular Surgery. This case report was authored by Khaled Alawneh, MD, Liqaa Raffee, MD, and Shadi Hammouri, MD.

Progression in the field of interventional radiology has allowed the treatment of highrisk conditions with less-invasive techniques. The progression is well exemplified by the work of doctors at KAUH in Irbid, Jordan.

Figure 1. A) A schematic drawing and B) intraoperative picture showing the site of the left eye-brow incision and the cut of the left supraorbital artery (arrow). C) Intraoperative picture showing the dissection of the AVM in subperiosteal plan and exposure of the draining bony venous pore (arrow). D) Intraoperative picture showing the separation of the draining vein and occlusion of the bony venous pore with bone wax (arrow). E) Intraoperative picture showing the peri-galeal plan of the AVM dissection with noticed very minimal blood oozing from the soft tissues. F) The AVM after resection. AVM, arteriovenous malformation; OA, ophthalmic artery; SOA, supraorbital artery