Surviving the Nightmare: Massive Bleeding From Large Intraoral Arteriovenous Malformation During Airway Management for Angioembolization Procedure

Arteriovenous malformations (AVMs) in the head and neck present significant challenges due to airway management complexities and hemorrhage risks. This case report describes a 15-year-old female with a congenital facial AVM causing dyspnea and obstructive symptoms. The patient required angioembolization of the AVM, but many hospitals deferred the procedure due to the anticipated difficult airway and severe bleeding risks. We did two attempts of awake fiberoptic intubation but could not succeed due to patient intolerance. Subsequently, inhalational induction started and video laryngoscopy performed but also failed due to anatomical distortion. With attempts to bag mask ventilate, severe venous engorgement started and patient experienced massive hemorrhage and circulatory collapse, necessitating prolonged resuscitation and intubation efforts. Eventually, intubation was successful after 40 min using suction assisted laryngoscopy and decontamination (SALAD) technique by video laryngoscope. She underwent angioembolization and shifted to the ICU where she remained on mechanical ventilation for 9 days. After tracheostomy was performed, she was gradually weaned off from ventilator and was later discharged. This case highlights the need for meticulous planning, comprehensive airway evaluation, backup strategies, and multidisciplinary support, suggesting video laryngoscopy as a valuable alternative in high-bleeding-risk cases.