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● Abstract● Objective: The Amplatzer vascular plug (AVP) is a new embolic device with advantages in embolization of high-flow vessels. We report a case involving implantation of an AVP into the retromandibular vein and coil-embolization of an arteriovenous fistula (AVF). Case presentation: We present the case of a 31-year-old woman with an external carotid artery (ECA)-retromandibular vein AVF. She complained of pulsatile tinnitus after a sagittal split-ramus osteotomy. The high-flow left ECAretromandibular vein AVF was depicted in the arterial phase using selective external carotid angiography (ECAG). Endovascular embolization treatment of the fistula using an AVP and coils was planned. We initially intended to introduce the AVP into the fistula via a transvenous route through the left external jugular vein, but could not pass the 5-Fr guiding catheter round the hairpin curve between the fistula and ECA. We therefore changed treatment strategy, placing an 8 mm AVP into the retromandibular vein. Fistula closure was almost obtained after implantation, but shunt flow from a narrow channel remained. We then embolized the fistula using coils, from the AVP to the fistula inlet. The fistula was occluded using five coils. Conclusion: We treated the patient with implantation of an AVP in the retromandibular vein and coil-embolization of the AVF. Advantages of the AVP are its stability for high-flow vessel occlusion and its cost-effectiveness when compared with coils. However, this device has disadvantages in the ease of its delivery to distal vessels. Therefore, using this device in craniofacial lesions needs technical refinement.

Endovascular embolization of an external carotid-retromandibular arteriovenous fistula using the Amplatzer vascular plug