A pseudoaneurysm (PA) is a collection of blood caused by an incomplete tear in the vessel wall. PA can be arterial or venous in origin. In the maxillofacial region, arterial PA can result from surgical interventions. Venous PAs in the maxillofacial region have never been described. A standardized protocol for management of post-traumatic PAs in the maxillofacial region would help clinicians make treatment decisions. On the basis of the available literature and our institutional experience, we present an algorithm for management of post-traumatic maxillofacial PAs. We also present patients from our institution who illustrate some of the management options in the algorithm.
An aneurysm is an abnormal dilation of a blood vessel wall. This wall is composed of normal histologic layers. In a pseudoaneurysm (PA), the wall is composed of fibrous tissue without distinct histologic layers. The vessel of origin dictates etiology of a PA (ie, arterial or venous). , When an artery sustains an incomplete tear, blood leaks, vessel expands gradually, and an arterial pseudoaneurysm (APA) forms. , APA can rupture and cause sudden life-threatening bleeding. Trauma (eg, blunt , or penetrating ) or manipulation of a vein can cause a venous pseudoaneurysm (VPA). ,
In the maxillofacial region, current literature consists of case series , and case reports , of APAs secondary to trauma , or surgical interventions (eg, orthognathic , or temporomandibular joint surgery, distraction osteogenesis, and/or neck dissection ). VPAs in the maxillofacial region have never been described.
A standardized protocol for management of post-traumatic PAs in the maxillofacial region would help clinicians make treatment decisions. The purpose of this study was to discuss the treatment algorithm for management of post-traumatic maxillofacial PAs. We also will present patients from our institution who illustrate the management options in the algorithm.
We present an algorithm for management of post-traumatic maxillofacial PAs. This algorithm should be modified as necessary during unique patient scenarios and according to the preferences of the patient and treatment team. At our institution, patients are treated by a collaborative multidisciplinary team (as necessary) comprising oral and maxillofacial surgery (OMS), otolaryngology, interventional neuroradiology (INR), and acute and critical care surgery.
The algorithm assumes that patients were stabilized according to the advanced trauma life support (ATLS) protocol before entering the pathway. On the basis of our institution's trauma guidelines, patients with severe midface injuries or those suspected to be actively bleeding undergo computed tomography angiography (CTA) on arrival to the emergency department. Therefore, CTA is often the first available radiographic imaging. CTA is the most sensitive noninvasive imaging modality in diagnosis of PAs. , , CTA shows vessel of origin and exact location of PA. ,
An initial diagnosis of a PA, on the basis of clinical and radiographic evaluations, is the point of entry to this algorithm ( Fig 1 ). The first branching point is the vessel associated with PA: arterial or venous. A ruptured APA presents as pulsatile and bright red blood, and a ruptured VPA presents as profuse, nonpulsatile, and dark red blood.
Next, the bleeding status of PA (ie, ruptured or bleeding, stable or not bleeding) is paramount to decision making. A ruptured PA is assumed to be actively bleeding until proven otherwise. The patient has rapid hemodynamic deterioration. A patient with a stable PA has various clinical presentations ranging from a pulsatile mass to an expanding hematoma with associated clinical deficits (eg, pain, palpable thrill, audible systolic bruit, neurologic deficit of adjacent cranial nerves, difficulty swallowing, and so forth). , ,
A patient with a ruptured APA has potential to develop rapid hemodynamic instability and hypovolemic shock. Therefore, initial urgent management consists of temporary control of bleeding with local pressure to tamponade the vessel and initiation of massive transfusion protocol as per ATLS guidelines. For example, if the artery of origin is believed to be the internal maxillary or descending palatine artery, a ruptured APA presents as pulsatile bright red blood from nose. Bleeding control can be achieved with local digital pressure, anterior and posterior nasal packing, or an inflatable nasal balloon. , CTA determines surgical accessibility. When APA can be accessed, the surgeon ligates proximal and distal ends of vessel and resects APA (case 1). In the maxillofacial region, resection can be complicated by bleeding from collateral and/or bilateral circulation. When the feeder artery is deeply located, APA is not accessible. INR performs selective angiography to locate and embolize APA. , , Embolization occurs via a percutaneous or endovascular approach (case 2). Typically, INR chooses embolic material depending on PA's location, size, anatomy, and collateral circulation. , In the maxillofacial region, INR typically uses coils. , , Cases in which liquid embolic agent is used, a full angiography needs to be performed to evaluate for and rule out dangerous extracranial-intracranial anastomoses.
In the maxillofacial region, CTA determines location and surgical accessibility of a stable APA. At this point of the algorithm, the treatment choices are the same as a ruptured APA (ie, surgically accessible APA undergoes ligation and resection, or nonaccessible APA receives embolization) , , , , , (case 3).
A patient with a ruptured maxillofacial VPA receives immediate control of bleeding via digital pressure, similar to a ruptured APA. Failure to considerably reduce the bleeding might result in hypovolemic shock. When the patient is hemodynamically stable, observation is recommended ; VPA can resolve spontaneously (case 4). When the patient is not hemodynamically stable, venography determines access to VPA. If VPA is surgically accessible, ligation is recommended. When VPA is not surgically accessible, endovascular embolization is recommended. A stable maxillofacial VPA does not require intervention. Computed tomography with contrast is recommended 4 to 6 months after injury to confirm complete resolution of VPA.
Case 1: Post-Traumatic Ruptured APA Managed via Surgical Ligation
A 24-year-old healthy male was involved in an all-terrain vehicle collision ( Fig 2 ). He sustained extensive facial lacerations and fractures (consisting of left naso-orbital-ethmoid type 1, comminuted Le Fort II, and nasal bone and nasal septum fractures). CTA was negative for maxillofacial PA. Initial stabilization of facial injuries consisted of debridement, washout, and closure of lacerations under general anesthesia (GA). The patient was scheduled for definitive open reduction and internal fixation of facial fractures. During his postoperative course, the patient experienced profuse, bright red, and pulsatile bleeding from right nare. A foley catheter was placed in right nare to reach nasopharynx. The balloon was inflated with normal saline. Firm traction was applied to wedge catheter against the posterior wall of nasopharynx. This resulted in cessation of nasal bleeding. A new CTA showed a right descending palatine artery PA, this location was surgically accessible. Under GA, a maxillary vestibular incision was made and Le Fort fracture was exposed. The maxilla was downfractured. The posterior bony wall was removed with a Kerrison punch, and PA of the right descending palatine artery was visualized. Small clips were used to ligate proximal and distal ends and PA was resected. The remaining facial fractures were reduced and plated without complications. The patient was followed for 6 months. He did not experience additional bleeding.
Case 2: Post-Traumatic Ruptured APA Managed Via Embolization
A 12-year-old healthy male sustained a gunshot wound to the right cheek and mandible resulting in comminuted right mandibular angle and nondisplaced right zygomaticomaxillary complex (ZMC) fractures ( Fig 3 ). He had an expanding hematoma in his right cheek. CTA showed a PA of facial artery. This location did not allow for surgical ligation. Therefore, the patient underwent endovascular embolization with coils by INR. OMS treated his mandible fracture via intermaxillary fixation under GA. His ZMC fracture did not require operative intervention.
Approximately 4 years later, the patient presented with coils extruding through mucosa located lingual to right mandibular second molar. The CTA showed interval migration of embolization coil and ballistic fragment and resolution of APA. Under GA, teeth associated with initial injury, coil, and ballistic fragment were removed. INR was available if necessary but was not called. Three months later, the oral cavity was healed.