Armamentarium

History of the Procedure

The earliest operations on the carotid arteries were ligations to control bleeding after trauma or surgical injury. The first recorded ligation of a common carotid artery was performed by Ambroise Paré in 1551. In 1807, Amos Twitchell was the first American surgeon to successfully ligate the common carotid artery of a soldier to stop hemorrhage from a bullet wound. In the next few decades, common carotid artery ligations were also used to treat aneurysms, arteriovenous fistulas, and bleeding neoplasms. Unfortunately, ligation of the common carotid artery carried a high complication rate. In 1878, John Wyeth, an American surgeon, reported 898 cases of common carotid artery ligation with a mortality rate of 41%. On the other hand, he found a mortality rate of only 4.5% after external carotid artery ligation. In 1908, Barrett and Orr were among the earliest authors to report external carotid artery ligation to treat postoperative nasal bleeding. In 1963, Malcomson also advocated early surgical ligation to arrest nasal bleeding. In addition to their use to arrest nasal hemorrhage, external carotid artery ligation was performed as a presurgical procedure to reduce bleeding before composite resection of oral carcinomas.

In the 1970s and 1980s, some authors advocated ligation of more specific vessels to control epistaxis, such as the internal maxillary artery and the anterior ethmoidal artery. Although this is consistent with the surgical principle of tying off the vessels nearest the bleeding site, it is technically more difficult and may produce more complications. Transantral ligation of the internal maxillary artery requires access through a Caldwell-Luc approach. Once the posterior maxillary wall has been removed, the internal maxillary artery is difficult to identify due to the many branches present in the pterygoid fossa. As interventional radiology techniques advanced in the 1980s, transcatheter arterial embolization became a popular alternative to arterial ligation in controlling facial hemorrhages. However, ligation of the external carotid artery and/or its branches remains an important tool when other methods have failed. Therefore, arterial ligation is an important emergency technique that all maxillofacial surgeons should know.

History of the Procedure

The earliest operations on the carotid arteries were ligations to control bleeding after trauma or surgical injury. The first recorded ligation of a common carotid artery was performed by Ambroise Paré in 1551. In 1807, Amos Twitchell was the first American surgeon to successfully ligate the common carotid artery of a soldier to stop hemorrhage from a bullet wound. In the next few decades, common carotid artery ligations were also used to treat aneurysms, arteriovenous fistulas, and bleeding neoplasms. Unfortunately, ligation of the common carotid artery carried a high complication rate. In 1878, John Wyeth, an American surgeon, reported 898 cases of common carotid artery ligation with a mortality rate of 41%. On the other hand, he found a mortality rate of only 4.5% after external carotid artery ligation. In 1908, Barrett and Orr were among the earliest authors to report external carotid artery ligation to treat postoperative nasal bleeding. In 1963, Malcomson also advocated early surgical ligation to arrest nasal bleeding. In addition to their use to arrest nasal hemorrhage, external carotid artery ligation was performed as a presurgical procedure to reduce bleeding before composite resection of oral carcinomas.

In the 1970s and 1980s, some authors advocated ligation of more specific vessels to control epistaxis, such as the internal maxillary artery and the anterior ethmoidal artery. Although this is consistent with the surgical principle of tying off the vessels nearest the bleeding site, it is technically more difficult and may produce more complications. Transantral ligation of the internal maxillary artery requires access through a Caldwell-Luc approach. Once the posterior maxillary wall has been removed, the internal maxillary artery is difficult to identify due to the many branches present in the pterygoid fossa. As interventional radiology techniques advanced in the 1980s, transcatheter arterial embolization became a popular alternative to arterial ligation in controlling facial hemorrhages. However, ligation of the external carotid artery and/or its branches remains an important tool when other methods have failed. Therefore, arterial ligation is an important emergency technique that all maxillofacial surgeons should know.

Indications for the Use of the Procedure

Massive facial hemorrhage is a rare but potentially life-threatening event. It is frequently associated with maxillofacial trauma or surgical injury, and the incidence ranges from 1.25% to 9.4%. Some authors have attempted to classify the amount of blood loss to guide management ; however, the critical factor in effective control of massive facial hemorrhage is early recognition.

The main arterial supply of the maxillofacial region is the carotid artery, which branches in the neck and becomes the internal and external carotid artery. Bleeding in the midface region is mainly from the external carotid artery, especially the internal maxillary artery and its intraosseous branches. In the upper face and the roof of the nasal cavity, bleeding also comes from branches of the internal carotid artery, such as the lacrimal arteries and the ethmoidal arteries.

Management of facial hemorrhage is largely dependent on the surgeon’s ability to access the source of bleeding. Bleeding from superficial wounds is the result of injuries to end arterioles and the capillaries. This may be controlled by applying pressure or cauterizing the offending vessels. Sometimes hemostatic agents, such as prothrombin (Floseal; Baxter, Deerfield, Illinois), can be applied to aid hemostasis. However, bleeding from deep vessels, such as the internal maxillary artery and its branches, is difficult to localize and treat. Bleeding from these deep vessels frequently funnels into the oral and nasal cavity. Therefore, a significant amount of blood can be swallowed by the patient, and severe hemorrhage can be easily missed.

Various methods are used to treat massive facial hemorrhages from deep facial vessels. These include oronasal packing, early fracture reduction, transcatheter arterial embolization (TAE), and external carotid artery ligation. It is a well-known surgical principle that the first step of hemorrhage control is direct pressure on the offending vessel; subsequent, definitive control can be achieved by tying off or cauterizing the vessel. However, when the source of bleeding is not immediately identifiable or accessible, indirect pressure with packing to tamponade the bleeding should be attempted. For epistaxis, the posterior nasal cavity can be packed with a 14 French Foley catheter, and the anterior nasal cavity can be packed with stacked gauze strips. Commercially available nasal tampons (e.g., Merocele [Medtronic Xomed, Jacksonville, Florida] and Rhino Rocket [Denver Splint Corp., Englewood, Colorado]) are also helpful in providing quick and effective tamponade. Early fracture reduction, especially in the midface, can be effective if the bleeding comes mainly from the intraosseous vessels. If the bleeding continues despite oronasal packing and/or early fracture reduction, either transcatheter arterial embolization or external carotid artery ligation should be considered.

The decision whether to use transcatheter arterial embolization or external carotid artery (ECA) ligation has long been discussed in the literature. In the past, this choice often was determined more by the availability of a skilled interventional radiologist proficient in angiography and embolization and the ability of the surgeon to perform ligation of the ECA. However, due to increased availability of these practitioners and to technical advances, many authors now prefer TAE over arterial ligation when other noninvasive measures fail. This is due largely to the specificity and repeatability of TAE. Therefore, if a patient is stable and the bleeding is temporarily slowed by packing, TAE should be attempted first. If the bleeding cannot be controlled and the patient becomes unstable, immediate surgical arterial ligation should be considered. Ligation of the external carotid artery is a relatively simple, low-risk procedure that can be performed quickly under general or local anesthesia. The surgical access to the external carotid artery is straightforward compared to the internal maxillary artery. When dire conditions call for emergency control of facial hemorrhage, ligation of the external carotid artery is a valuable tool in any maxillofacial surgeon’s surgical armamentarium.

Limitations and Contraindications

It is a well-known surgical axiom that a vessel should be tied as close as possible to the point of hemorrhage to defeat anastomotic contributions to the vascular leak. However, this is not always possible in the maxillofacial region due to the highly dense and valuable structures in this area. The rich vascular network in this region ensures the vitality of tissue in the event of trauma or surgical injury. However, this extensive collateral blood supply diminishes the effectiveness and predictability of arterial ligation. The more distal the bleeding source, the more likely it has a collateral blood supply, from the ipsilateral side or even from the contralateral side. Therefore, ligation of the external carotid artery is not always successful. If the bleeding involves the upper face and nasal cavity, contribution from the internal carotid artery via the ethmoidal arteries may necessitate a combined ligation of the external carotid artery and the anterior ethmoidal artery. For the same reason, transcatheter embolization can be more effective due to its ability to reach distant arteries, and it can be more selective. If transcatheter embolization fails, ligation of the external carotid artery is still an option. On the other hand, if the external carotid artery is ligated first, the option to embolize through the same vessel no longer exists. Therefore, it is important to exhaust all other options before arterial ligation.

Technique: External Carotid Artery Ligation