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Facial artery pseudoaneurysm after repair of mandibular fracture.

The development of a facial artery pseudoaneurysm (PA) after facial fracture surgery is an extremely uncommon occurrence, but may result in serious bleeding in the post-operative period. (1) A PA is a contained collection of blood flow in direct communication with an artery that results from a partial injury to the arterial wall. The PA may rupture under the strain of arterial pressure, resulting in delayed hemorrhage. (2) This bleeding may occur weeks after the initial surgical procedure and may be life threatening. (1) The facial artery is vulnerable to surgical trauma because it may be encountered during the transfacial exposure of the mandible. We present a case of facial artery PA that led to recurrent episodes of oral bleeding after the transfacial repair of multiple mandibular fractures. Once the bleeding source was identified, the patient underwent successful endovascular embolization without complication.

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CASE REPORT

A 59-year-old, African-American male was brought to the emergency department after an assault to his face and head. Clinical evaluation and computed tomography of his head and face revealed a small intraparenchymal hemorrhage of the right posterior temporal lobe, as well as a comminuted left parasymphyseal fracture and a displaced left mandibular angle fracture extending up thru the coronoid process (Figure 1).

He was observed in the intensive care unit and subsequently developed respiratory failure requiring orotracheal intubation. He was given neurosurgical clearance for surgery and was taken for open reduction and internal fixation of his fractures seven days after presentation. His parasymphseal fractures were repaired thru an intraoral incision while his angle was addressed thru a retromandibular, retroparotid approach. He was edentulous and was therefore not placed in maxillomandibular fixation (MMF) with arch bars.

On the second post-operative day, the patient failed extubation and was unable to be reintubated. An airway was reestablished by urgent tracheostomy but not before he suffered an anoxic brain injury. On the ninth post-operative day the patient acutely bled approximately 300ccs into his mouth. Pressure was applied to the left side of his face, and the surgical staff was notified. On examination, there was no identifiable bleeding source. The following day, the patient developed fever and leukocytosis. He began draining purulent material from his retromandibular incision, and this was opened and the abscess drained. On the 11th post-operative day the patient had another episode of bleeding, which prompted angiography of the left carotid arterial system. The angiogram was unremarkable.

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One week later, the patient had another large volume bleed from his oral cavity. Again, a source could not be identified on direct examination, and computed tomography angiogram (CTA) was obtained that showed an 8mm facial artery PA (Figure 2). He was subsequently taken to the interventional radiology suite, where endovascular glue embolization was performed nearly three weeks after fracture repair (Figure 3). There was no subsequent hemorrhage.

DISCUSSION

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Pseudoaneurysms of the extracranial arterial system (ECAS) are rare. The few reported cases more often involve the facial artery, likely, because it's course adjacent to the mandible makes it vulnerable to trauma. (2) PA may result from blunt or direct trauma, including surgical trauma. (3) Iatrogenic PAs have been reported after dental extractions, (4) orthognathic surgery, (5) and facial fractures. (1) PA may be diagnosed by clinical signs and symptoms, including pain, erythema, asymmetry, bleeding, swelling, pulsatile mass, and/ or neurologic changes. (1) In this case, the patient's anoxic brain injury made it impossible to evaluate him for neurologic changes or facial pain. Additionally, his post-surgical changes (edema, swelling) and infection (erythema) complicated his clinical exam. His potential for life threating hemorrhage was great because he was unable to notify the nursing staff when he developed intraoral bleeding. He was maintained on ICU status so that the nursing staff could closely monitor him for bleeding episodes.

Interestingly, his PA was not identified on his first arteriogram, despite the fact that this was performed after a serious bleeding episode. CTA was performed after a subsequent bleeding episode, and the PA was identified at that time. Given the sequence of events, one must consider the possibility that the soft tissue infection contributed to the development of the PA. The patient was then promptly taken to the angiography suite for embolization.

Endovascular embolization techniques make it possible to gain control of the damaged vessel in places difficult to access surgically and to reduce the risks of PA revascularization by collateral circulation. (3) In this case, the PA was emoblized with glue in an effort to minimize retrograde filling of the PA via collateral flow.

This complication reinforces the importance of careful dissection around the facial vessels when using a transfacial approach to the mandible. If an injury of the facial artery is suspected, the vessel should be ligated in order to prevent the development of serious vascular complications, particularly if the patient has unfavorable circumstances that limit his examination and before the clinical picture. Finally, it is important to consider that patients with multiple facial fractures and significant post-traumatic/post-operative edema will likely have some degree of airway compromise. It is imperative to have a plan for quickly reestablishing the airway in the event that the patient fails extubation.

REFERENCES

(1.) Nardis AC, Boraks G, Torres AM, et al. Uncommon complication of facial fractures. Int J Oral Maxillofac Surg 2011;40(4):440-2.

(2.) Germiller JA, Myers LL, Harris MO, et al. Pseudoaneurysm of the proximal facial artery presenting as oropharyngeal hemorrhage. Head Neck 2001;23(3):259-63.

(3.) Cox MW, Whittaker DR, Martinez, et al. Traumatic pseudoaneurysms of the head and neck: early endovascular intervention. J Vasc Surg 2007;46(6):1227-33.

(4.) Marco de Lucas E, Gutierrez A, Gonzalez Mandly A, et al. Life-threatening pseudoaneurysm of the facial artery after dental extraction: successful treatment with emergent endovascular embolization. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106(1):129-32.

(5.) Madani M, Veznedaroglu E, Pazoki A, et al. Pseudoaneurysm of the facial artery as a late complication of bilateral sagittal split osteotomy and facial trauma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110(5):579-84.

Craig Blum, MD; Taylor Theunissen, MD; Jonathan Kaplan, MD, MPH

Dr. Blum is a Plastic Surgery Resident in the Tulane Division of Plastic Surgery. Drs. Theunissen and Kaplan are Plastic Surgeons at Our Lady of the Lake Medical Center in Baton Rouge.
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Author:Blum, Craig; Theunissen, Taylor; Kaplan, Jonathan
Publication:The Journal of the Louisiana State Medical Society
Article Type:Case study
Geographic Code:1USA
Date:Jul 1, 2012
Words:1058
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