Abstract
INTRODUCTION/PURPOSE: Rhabdomyosarcomas are rare, highly vascular tumors characterized by an extensive arterial supply. Preoperative embolization is commonly employed in the management of hypervascular lesions to minimize blood loss and enhance surgical safety. The conventional method involves superselective catheterization of the feeding vessels, followed by embolization. However, this intervention can be challenging in lesions with numerous small feeders that are too small to catheterize, or in those with high risk feeders such as branches from the ophthalmic artery. We present a case of alveolar rhabdomyosarcoma with incapacitating nasopharyngeal hemorrhage in which standard endovascular embolization was insufficient, and successful hemorrhage control was ultimately achieved through direct endonasal tumor puncture for embolization using n‐butyl cyanoacrylate (n‐BCA) glue (TruFill, Johnson & Johnson Medtech, New Brunswick, NJ, USA). MATERIALS/METHODS: Single case study RESULTS: A 21‐year‐old male with a known history of alveolar rhabdomyosarcoma was transferred from an outside hospital for evaluation and management of significant nasopharyngeal hemorrhage requiring intubation and multiple transfusions. CTA of the head and neck demonstrated a large, destructive mass centered in the left nasal cavity, consistent with his known malignancy, with invasion into the left orbit and anterior cranial fossa. Initial management by Interventional Neuroradiology included particle embolization (Embosphere 300‐500 µm, Merit Medical, South Jordan, UT, USA) and coil embolization of the left supraorbital artery, distal left internal maxillary artery, and the left zygomatico‐orbital artery. Although the patient did not require further transfusions, the patient continued to experience hemoptysis, particularly with movement. Ongoing management included repeat nasopharyngeal packing by ENT. He was taken back for embolization two days later, which included direct tumor puncture with injection of n‐BCA glue and particle embolization of the left ascending pharyngeal artery, resulting in decreased tumor vascularity. However, bleeding persisted, prompting a follow‐up angiogram and subsequent embolization of the right internal maxillary artery, along with an additional direct tumor puncture embolization, with a more extensive D5W flush leading to better tumor penetration, and complete and durable cessation of hemorrhage and eventual extubation. CONCLUSION: N‐butyl cyanoacrylate glue is a fast‐acting liquid embolic material used in the treatment of a variety of vascular malformations and lesions of the head and neck. Investigations surrounding the use of n‐BCA injections as a new alternative embolic agent began in the 1980's. This case highlights the utility of direct tumor embolization as an effective salvage technique in the management of life‐threatening hemorrhage from hypervascular lesions. In this patient, initial endovascular embolization via the left supraorbital, distal internal maxillary, and zygomatico‐orbital arteries failed to achieve lasting hemostasis, likely due to the presence of numerous small, feeding branches and multiple collateral pathways. Subsequent direct tumor puncture with n‐BCA glue resulted in significant reduction of tumor vascularity. Direct tumor embolization is a valuable adjunctive technique in the management of hypervascular tumors when traditional endovascular approaches are limited or insufficient.