Direct sac puncture and N-butyl cyanoacrylate embolization of medial canthal arteriovenous malformation supplied by the external carotid artery and the internal carotid artery branches RV Phadke, H Diwakar, S Mohan, A Parihar and T Singh Department of Radiodiagnosis and Imaging, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India SUMMARY We report a periorbital arteriovenous fistula that was treated with direct sac puncture N-butyl cyanoacrylate embol- ization under controlled inflow and outflow. The efficacy of this technique in a periorbital lesion is discussed. Key words: arteriovenous fistula; arteriovenous malformation; embolization; medial canthal; N-butyl cyanoacrylate. INTRODUCTION Arteriovenous malformation (AVM) of the face or scalp is an abnormal fistulous communication between arteries and vein known as arteriovenous fistula (AVF) without intervening capil- laries. Lying in the subcutaneous tissue, they cause cosmetic deformity with a significant risk of massive bleeding on surgery or trauma. 1 In the past, treatment of such AVF was mainly surgical, with either excision or ligation of feeding arteries. Surgical excision was associated with significant bleeding and ligation was a troublesome procedure because of the mul- tiple feeders. Because of complex vascular anatomy with mul- tiple arterial feeders and draining veins, there is always a risk of torrential intraoperative haemorrhage. To avoid this, presur- gical devascularization of the lesion is preferred. 2 Periorbital lesions pose many difficulties in the form of complex supply and drainage. Apart from multiple feeders including the oph- thalmic artery, these lesions may drain into cavernous sinus through ophthalmic veins. We report the use of N-butyl cyano- acrylate (NBCA) injection in a patient with an AVF near the medial canthus of the eye with good results. CASE HISTORY A 28-year-old man presented with a pulsatile swelling on the bridge of the nose near the medial canthus of the left eye of 2 months duration, measuring 1.5 cm · 2 cm. There was no history of trauma. On physical examination, the swelling was seen to be soft, boggy and pulsatile with normal overlying skin and bruit. Diagnostic cranial angiogram showed an AVF with a venous sac in the region of the medial canthus of the left eye with tor- tuous feeding arterial branches from the left facial artery, the internal maxillary artery, the superficial temporal artery and the ophthalmic artery (Fig 1a,b). There was appreciable collateral circulation between facial and internal maxillary arteries. The lesion was drained by bilateral superior ophthalmic veins into cavernous sinuses and by angular veins draining into facial veins bilaterally. Detailed clinical examination showed reduction in the pulsa- tility of the sac after applying manual compression over the ipsilateral common carotid artery (CCA), suggestive of reduc- tion of flow to AVF. RV Phadke MD; H Diwakar MD; S Mohan MD; A Parihar MD; T Singh MD. Correspondence: Rajendra V Phadke, Consultant Radiologist (Neurointervention), Royal Preston Hospital (Lancashire Teaching Hospitals NHS Foundation Trust), Preston PR2 9HT, UK. Email: rajendra.phadke@lthtr.nhs.uk Submitted 6 September 2005; accepted 16 February 2006. doi: 10.1111/j.1440-1673.2006.01608.x Case Report Australasian Radiology (2006) 50, 389–391 ª 2006 The Authors Journal compilation ª 2006 Royal Australian and New Zealand College of Radiologists