Uncommon complication of facial fractures

Abstract

Vascular complications after head and neck surgical procedures are rare but can life-threatening. A pseudoaneurysm may appear weeks or months after the initial injury and may be difficult to diagnose. The authors report the case of a 43-year-old man involved in a motor vehicle accident presenting with multiple facial fractures, which after surgical treatment presented episodes of bleeding. After an angiography was performed, a pseudoaneurysm of the facial artery was detected. The patient later underwent endovascular embolization and had a satisfactory resolution.

A pseudoaneurysm is a rare delayed vascular complication subsequent to head and neck injuries because facial vessels are protected by soft tissues. A pseudoaneurysm is a vascular injury that involves the rupture of either the inner 2 or all 3 layers of the artery. A haematoma is produced in the surrounding soft tissue and its liquefaction causes a pseudoaneurysm that, with increased pressure, may rupture and cause haemorrhage. The clinical signs and symptoms are pain, erythema , asymmetry , bleeding , swelling , pulsatile mass, neurological deficits and it may produce a rapid life-threatening haemorrhage .

Complete transection is more likely than partial laceration . The etiology can be traumatic or iatrogenic. Gunshot wounds, blunt and penetrating trauma and motor vehicle accidents account for most cases in which pseudoaneurysm is the result of direct trauma.

Surgical trauma is the most frequent cause of iatrogenic pseudoaneurysms. Branches of the external carotid artery such as the maxillary , superficial temporal and facial are the vessels most commonly involved with pseudoaneurysms in the maxillofacial region. The authors report a case of a pseudoaneurysm involving the facial artery after surgical treatment of facial fractures.

Case report

A 43-year-old healthy, Caucasian male patient was brought to hospital after a motor vehicle accident; he presented with multiple facial and orthopaedic injuries. On arrival his Glasgow Coma Scale (GCS) score was 14. Neurological injuries were promptly discharged. Clinical evaluation, Waters’ radiograph and a lateral oblique radiograph of the mandible revealed multiple facial fractures, such as Le Fort II, zygomaticomaxillary complex, nasal and mandibular fractures. Nine days later, he underwent open reduction and internal fixation of the fractures through Risdon, subciliary, extended preauricular and maxillary gingival buccal sulcus approaches. No immediate surgical complication was detected. On the fourth postoperative day, he developed a painful, pulsatile haematoma and haemorrhage through the submandibular approach. Strong manual compression was applied and the bleeding stopped. A haemogram was obtained showing that the haemoglobin concentration was 9.3 mg/dl. On the seventh postoperative day, the patient was discharged without any complaint. A week later the patient was carried to the hospital emergency department with severe bleeding. He had a pasty appearance, was dyspneic, had hypotension (100 × 60 mmHg) and tachycardia. Haemophilia and other blood diseases had been investigated in the preoperative examinations. Manual compression was reapplied to control bleeding. About 2000 ml of intravenous 0.9% saline solution was necessary to reestablish haemodynamic stability.

A new haemogram revealed his haemoglobin had dropped to 7.4 mg/dl. A blood transfusion was required, and 2 units of red blood cells were necessary. A few days later, the patient was referred to a vascular surgery institute. Arteriography was performed by a vascular surgeon and a pseudoaneurysm (1.23 cm × 0.96 cm) of the left facial artery was confirmed ( Fig. 1 ). Planned initial treatment was embolization of the facial artery with 2 coils placed distally and proximally to the aneurysm, but because of its intensive flow and large dimension, this was not possible. Two Vortx-18 fibred platinum coils (Boston Scientific Corp., Watertown, MA, USA), 2 mm × 5 mm × 60 mm and 2 mm × 6 mm × 85 mm were placed through a rapid transit microcatheter and after liberation bleeding was still present ( Fig. 2 ). Then n-butyl-2-cyanocrylate-histoacryl glue (Histoacryl ^®, B. Braun Melsungen AG, Germany) was injected through the microcatheter to repair the arterial wall ( Fig. 3 ) and the bleeding stopped. There was no subsequent haemorrhage.