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Technical Note

Internal Maxillary Artery Preoperative Embolization Using n-Butyl Cyanoacrylate and

Pushable Coils for Temporomandibular Joint Ankylosis Surgery
Yazan J. Alderazi1,2, Darshan Shastri1, John Wessel3, Melvin Mathew1, Tareq Kass-Hout1,4, Shahid R. Aziz3, Charles
J. Prestigiacomo1, Chirag D. Gandhi1

- BACKGROUND: Temporomandibular joint (TMJ) anky- - CONCLUSIONS: Preoperative IMAX embolization before
losis causes disability through impaired digestion, masti- TMJ ankylosis surgery is technically feasible with
cation, speech, and appearance. Surgical treatment encouraging preliminary safety. There were no complica-
increases range of motion with resultant functional tions from the embolization procedures and surgeries
improvement. However, substantial perioperative blood loss occurred with low volumes of blood loss.
can occur (up to 3 L) if the internal maxillary artery (IMAX) is
injured as it traverses the ankylotic mass. Achieving hemo-
stasis is difficult because of limited proximal IMAX access
and poor visualization. Our aim is to investigate the technical
feasibility and preliminary safety of preoperative IMAX INTRODUCTION
embolization in patients undergoing TMJ ankylosis surgery.
- METHODS: Case series using chart reviews of 2 patients
who underwent preoperative embolization before TMJ
ankylosis surgery.
T emporomandibular joint (TMJ) ankylosis causes disability
through impaired digestion, mastication, speech, and
appearance.1,2 Surgical treatment increases range of
motion. This allows improvement in chewing, swallowing, and
pronunciation.1 Current literature suggests that postoperative
complications are uncommon, with rates of 1.7%e10.3%.1,3
- RESULTS: Both patients were women (28 and 51 years old) However, perioperative blood loss can be substantial, with vol-
who had severely restricted mouth opening. Embolization umes as high as 3 L of blood loss after damage to the internal
was performed using general anesthesia with nasal intuba- maxillary artery (IMAX).4-6 Most often, injury to this artery occurs
tion on the same day of TMJ surgery. Both patients underwent during total TMJ replacement.7 In addition, the anatomy can be
bilateral IMAX embolization using pushable coils (Vortex, challenging in the setting of severe ankylosis that impairs
Boston Scientific) of distal IMAX followed by n-butyl- visualization and in cases where the internal maxillary artery
traverses the ankylotic mass.6 After damage to the vessel, it is
cyanoacrylate (Trufill, Cordis) embolization from coil mass up
difficult to control the hemorrhage due to limited access and
to proximal IMAX. There were no complications from the poor visualization of the IMAX.5 There is currently no
embolization procedures. Both patients had normal neuro- high-quality evidence to support or refute the practice of IMAX
logic examination results. TMJ surgery occurred with mini- embolization before TMJ surgery.6
mal operative blood loss (300 mL for each surgery). Our aim is to investigate the technical feasibility of using a
Maximum postoperative mouth opening was 35 mm and combination of pushable coils and n-butyl-cyanoacrylate (nBCA)
34 mm, respectively. One patient had a postoperative TMJ for preoperative IMAX embolization before TMJ surgery; and to
wound infection that was managed with antibiotics. describe the preliminary safety.

Key words Neurointerventional Surgery, Department of Neurology, Texas Tech University Health
- Embolization Sciences Center School of Medicine, Lubbock, Texas; 3Department of Oral and Maxillofacial
- Internal maxillary artery Surgery, Rutgers School of Dental Medicine, Newark, New Jersey; and 4Department of
- Preoperative embolization Surgery, Rochester Regional Health System, Rochester, New York, USA
- Temporomandibular joint ankylosis To whom correspondence should be addressed: Yazan J. Alderazi, M.B., B.Ch.
- Temporomandibular joint surgery [E-mail:]
Citation: World Neurosurg. (2017) 101:254-258.
Abbreviations and Acronyms
IMAX: Internal maxillary artery
Journal homepage:
nBCA: n-Butyl-cyanoacrylate
TMJ: Temporomandibular joint Available online:
1878-8750/$ - see front matter 2017 Elsevier Inc. All rights reserved.
From the 1Division of Endovascular Neurosurgery, Department of Neurological Surgery,
Rutgers University, New Jersey Medical School, Newark, New Jersey; 2Division of



Figure 1. A 28-year-old woman with preoperative angiograms of the (C) left and (D) right internal maxillary
bilateral internal maxillary artery embolization for arteries demonstrating no residual flow between the
temporomandibular joint arthroplasty. Preembolization push-coils distally (arrow) and the n-butyl-cyanoacrylate
angiograms, lateral views, of the (A) left and (B) right (double arrows) casts proximally.
internal maxillary arteries. Postembolization

METHODS navigated to the left internal carotid artery. Control angiography to

This is a case series of patients undergoing preoperative IMAX assess for potential dangerous anastomosis was performed. The
catheter was then repositioned into the left external carotid artery.
embolization before surgery for TMJ ankylosis. The patients
There the IMAX and occipital artery were visualized, but the su-
were admitted to the hospital between January 1, 2013, and
perficial temporal artery was not visualized, most likely because of
June 30, 2014. We reviewed the charts and imaging of each
prior ligation during surgery. A Prowler Select Plus microcatheter
patients hospital record. The institutional review board gran-
(Cordis) was advanced over a Transend-14 floppy microwire
ted exemption approval for the study and for the request for a (Stryker, Kalamazoo, Michigan, USA) using a roadmap technique
waiver of informed consent for our research. into the distal internal maxillary artery. A 4  3.7-mm pushable
Vortex Coil was then deployed in the distal IMAX. Next, nBCA
RESULTS (Trufill; 50% concentration, 1 mL) was slowly injected into the
IMAX. The target of embolization was the segment of the IMAX
This case series consists of 2 patients.
medial and deep to the ramus of the mandible. The microcatheter
was positioned to achieve embolization from the coil mass distally
Patient 1 to the proximal IMAX distal to the origin of the superficial temporal
A 28-year-old woman with a significant medical history of rheu- artery. The distal coil mass was used to prevent nBCA from distal
matoid arthritis was seen for the treatment of bilateral TMJ bony embolization and proximal reflux safety was ensured by posi-
ankylosis. She had previously undergone 7 treatments for TMJ tioning of the microcatheter. nBCA was not allowed to reflux onto
ankylosis, including most recently a bilateral gap arthroplasty the microcatheter. Control angiography of the external carotid
with Derma Matrix interpositional graft (Synthesis CMF, West artery demonstrated complete occlusion of the IMAX from the
Chester, Pennsylvania, USA) for severe degenerative joint nBCA cast proximally to the coil distally. There was distal recon-
disease. Clinical examination demonstrated a mouth opening of stitution of the internal maxillary artery through the facial artery and
less than 15 mm with persistent pain. A decision was made to ethmoidal branches. Control angiography of the left internal
proceed with total joint replacement of the right and left TMJs carotid artery showed no evidence of thromboembolic complica-
with preoperative bilateral IMAX embolization to decrease the tions. The same procedure with 0.8 mL nBCA (50% concentration)
risk of hemorrhagic complications during surgery. was used for embolization of the right IMAX with similar results
(Figure 1). The level of anesthesia was reduced, and the results of a
The procedure was performed using general anesthesia after the
neurologic examination while the patient remained intubated were
patient had been electively intubated nasally in the operating
normal. The procedure took 1.5 hours and was completed without
room. The patient was transferred to the neurointerventional suite
any complications.
for bilateral IMAX embolization. Right femoral access was used. A
6-French Envoy MPD (Codman and Shurtleff, Inc., Raynham, The patient was then transferred to the operating room for
Massachusetts, USA) was advanced into the aortic arch and bilateral TMJ arthroplasty and coronoidectomies followed by total

WORLD NEUROSURGERY 101: 254-258, MAY 2017 255


Figure 2. A 51-year-old woman with bilateral internal Postembolization angiograms of the (C) left and (D)
maxillary artery embolization before right internal maxillary arteries demonstrating no
temporomandibular joint replacement. Pre- residual flow between the push coils distally (arrow)
embolization angiograms, lateral views, of the (A) left and the n-butyl-cyanoacrylate casts proximally (double
and (B) right internal maxillary arteries (dashed arrows). arrows).

joint replacement. The estimated blood loss during surgery was bilateral TMJ Silastic splitter followed by a second procedure to
300 mL. Maximum mouth opening at the end of surgery before remove the Silastic splitters and to insert a custom alloplastic
extubation was 35 mm. Postoperative complications included prosthesis (TMJ Concepts, Ventura, California, USA). Bilateral
pain and emesis, which were effectively controlled with medi- IMAX embolization was completed before the first surgery.
cation. The patient was discharged home neurologically intact;
The procedure was performed using general anesthesia after the
however, she returned 10 days later with pain and swelling at the
patient was electively intubated nasally in the operating room.
left incision site. Computed tomographic scans revealed a com-
The patient was transferred to the neurointerventional suite for
plex abscess around the TMJ arthroplasty. The patient under-
bilateral IMAX embolization. Through a 6-French short right
went incision and drainage of the left submandibular abscess
femoral artery access sheath, a 6-French Envoy MPD (Codman
with minimal blood loss.
and Shurtleff) was advanced into the aortic arch and navigated to
the right external carotid artery after control angiography of the
Patient 2 right internal carotid artery. There was a focal stenosis of the
A 51-year-old woman was seen with progressive trismus caused external carotid artery just distal to the origin of the facial artery.
by bilateral TMJ ankylosis. She was unable to open her mouth. A Prowler select plus microcatheter (Cordis) was advanced over
Initial computed tomographic scans showed bilateral TMJ anky- a Synchro 2 soft microwire (Stryker) using a roadmap technique
losis with joint space narrowing, subchondral sclerosis, and into the distal IMAX. Intravenous heparin was given to maintain
articular bony erosion. A decision was made on a 2-stage surgery activated coagulation time at 200e300 seconds. The microwire
for reconstruction of the TMJ joint. This included a bilateral TMJ was removed followed by sequential placement of 2 Vortex coils
gap arthroplasty and coronoidectomies with insertions of a measuring 6  6.7 mm and 5  5.5 mm into the distal IMAX.



Next, 0.05 mL nBCA (50% concentration) was injected under because of rich anastomosis of the preserved external carotid
fluoroscopy to achieve embolization from the coil mass distally to artery branches supplying the extracranial structures. Of note,
the proximal IMAX distal to the origin of the superficial temporal as the technique described in our case series uses liquid
artery. Control angiography of the external carotid artery after embolic agents, careful knowledge and assessment of
embolization demonstrated complete occlusion of the IMAX from extracranial-to-intracranial anastomosis is prudent. Baseline an-
the nBCA cast proximally to the coils distally (Figure 2). Using the giograms of the internal and external carotid arteries are
same technique, the right IMAX was embolized using two Vortex mandatory before embolization to assess for potential dangerous
coils measuring 6  6.7 mm and 4  3.7 mm, followed by 0.7 mL anastomoses. These potential dangers include the various mid-
nBCA glue (50% concentration). The procedure was completed in dle meningeal artery and inferolateral trunk variants with anas-
1.5 hours and without thromboembolic complication (Figure 2). tomosis with the retina and internal carotid artery respectively.
For this reason, 50% concentration of nBCA was used because it
The patient then underwent the first stage of TMJ replacement.
is less likely to flow distally. In addition, adequate positioning of
Intraoperative blood loss was 300 mL. A maximal mouth opening
the microcatheter in a non-wedged position and gentle injection
of 46 mm was checked during surgery. Radiography of the
were used to avoid opening of an anastomosis that may have
mandible showed embolization coils overlying the condylar re-
been initially invisible angiographically. The technical advantages
gions of each mandible and embolization nBCA cast, overlying
of the present technique are a rapid and complete occlusion of
the subchondral region of the left mandible as well. The results of
the desired segment with the use of a few relatively inexpensive
a neurologic examination were normal after extubation. There
coils and 1 vial of nBCA. The technical limitations are lack of
were no postoperative complications. The patient later returned
complete control of nBCA liquid embolic agent, potential embo-
for the second stage of TMJ replacement, in which the intra-
lization through unopacified anastomosis, and the inability to
operative blood loss was 250 mL. The procedure was completed
reposition either the coils or nBCA.
without any intraoperative or postoperative hemorrhagic com-
plications, and the patient was discharged home. A follow-up
appointment 4 months later showed a maximum mouth open- Safety of Internal Maxillary Artery Embolization
ing of 34 mm. Traditionally, preoperative embolization has been used in the
treatment of hypervascular tumors, such as juvenile nasophar-
yngioma, meningioma, paraganglioma, and in the treatment of
DISCUSSION epistaxis.9-11 By occluding the feeding arteries, blood flow to the
tumor is decreased, allowing for decreased intraoperative blood
Technical Discussion loss and a more precise surgical resection.12 A retrospective
The present case series demonstrates the technical feasibility review of 100 patients with preoperative embolization for head,
and preliminary safety of preoperative embolization of the IMAX neck, and spine tumors reported no mortality or major
before TMJ ankylosis surgery to reduce hemorrhagic complica- complications associated with the procedure.13 In addition,
tions. There were no complications from the embolization. more than 72% of patients had an intraoperative blood loss of
Furthermore, the results suggest that preoperative embolization less than 500 mL.
may help to reduce intraoperative blood loss and postoperative
hemorrhagic complications. The subsequent TMJ surgeries Epistaxis is a relatively common condition, controlled by
occurred with minimal blood loss (300 mL). Damage to the IMAX applying pressure or anterior nasal packing, and electrocautery,
during TMJ total joint replacement is uncommon, it but can cause yet some cases of recurrent idiopathic and traumatic forms of
significant intraoperative blood loss.6,8 Selective IMAX emboli- epistaxis require surgical or endovascular intervention.14
zation has been described to control iatrogenic injury to the artery Because of the complex anatomy and rich vascular supply of
during these procedures.4 There is limited literature regarding the nasal cavity, multiple arteries are usually embolized,
preoperative embolization of IMAX for TMJ ankylosis almost always including bilateral IMAX branches.9 Successful
surgerymainly by deploying detachable platinum coils in the control of epistaxis through embolization of IMAX and other
segment that passes through the ankylosis.7 The cases in our external carotid artery branches is reported to be 93%e100%
series involved bilateral embolization of the internal maxillary for initial success, and 77%e94% when early rebleeding is
artery, distally by Vortex pushable coils and proximally with taken into consideration with an acceptable safety profile.15,16
nBCA. The target of embolization was the segment of the It is important to note that embolization for TMJ surgery dif-
IMAX medial and deep to the ramus of the mandible. This fers from epistaxis treatment in that it involves a more proximal
segment was chosen because it is the most difficult site for segment of the IMAX with preservation of nasal mucosa flow
the surgeon to achieve proximal control. The pushable coils via collateral circulation.
were used to define the distal end of the segment to be
embolized, as distal embolization is not necessary in TMJ Limitations
surgery, and to protect from inadvertent embolization of the In our series, there were several unavoidable inherent limitations
ethmoidal arteries and collaterals. nBCA was used to create a because of the retrospective design of the case series. The
cast occluding the IMAX deep to the maxillary ramus until the treatment allocation was based on clinical judgment of treating
proximal safety zone. The purpose was to achieve controlled physicians and was therefore nonrandom, which represents se-
occlusion of a defined segment, with no residual blood flow in lection bias. Another major limitation is the absence of an un-
the embolized segments. The use of bilateral IMAX treated control group with which to compare the safety and
embolization in our series is supported by the previous report efficacy of preoperative IMAX embolization in this condition. This
of failure of unilateral embolization to prevent bleeding in this series does not allow comparison with other potential emboli-
condition.7 Bilateral embolization of the distal IMAX is an zation techniques. While bilateral distal IMAX embolization is safe
established and safe technique in the treatment of epistaxis as in epistaxis treatment, there are fewer data regarding bilateral

WORLD NEUROSURGERY 101: 254-258, MAY 2017 257


proximal IMAX embolization, as it is rarely performed for other which patient populations would benefit the most from this
conditions. Finally, the small number of patients undergoing this intervention.
therapy limited our ability to conduct quantitative analysis and to
determine rare complications. Potential complications include ACKNOWLEDGMENTS
ischemia in the surgical field and inadvertent embolization of
Yazan J. Alderazi, Darshan Shastri, and Chirag D. Gandhi
other potentially eloquent territories through anastomosis or
conceived and designed the study. Yazan J. Alderazi, Darshan
Shastri, John Wessel, a Melvin Mathew acquired the data. Yazan
J. Alderazi, Darshan Shastri, and Tareq Kass-Hout analyzed and
CONCLUSION interpreted the data. Yazan J. Alderazi and Darshan Shastri wrote
The present series demonstrates technical feasibility and pre- the manuscript. Charles J. Prestigiacomo, John Wessel, and
liminary safety of this technique. However, further research with Chirag D. Gandhi provided critical revision and important intel-
a comparison group and quantitative analysis is necessary to lectual content. Charles J. Prestigiacomo, Shahid R. Aziz, and
elucidate the risks and benefits of preoperative embolization and Chirag D. Gandhi supervised the study.

ankylosis. J Oral Maxillofac Surg. 2014;72: hypervascular head, neck, and spinal tumors:
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