Pseudoaneurysm of a Branch of the Maxillary Artery Following Mandibular Sagittal Split Ramus Osteotomy: Case Report and Review of the Literature

Management of pseudoaneurysms of the internal maxillary artery derived from orthognathic surgery based on one case

PURPOSE

The purpose of this article is to highlight the risk of pseudoaneurysms formation after orthognathic surgery, their clinical features and management.

METHODS

A case report of a 24-year-old man who suffered a pseudoaneurysm of the internal maxillary artery after sagittal osteotomy during orthognathic is reported. After three bleeding episodes, a pseudoaneurysm was diagnosed with a computed tomography angiogram (CTA) and treated with an embolization of the internal maxillary artery with polyvinyl alcohol (PVA) successfully.

RESULTS

Pseudoaneurysms derived from the external carotid artery are an uncommon complication of orthognathic surgery, especially related to sagittal osteotomy instead of LeFort I osteotomy.

CONCLUSION

Pseudoaneurysms derived from external carotid artery branches must be suspected when patients show multiple episodes of bleeding (epistaxis or through the surgical approach) within the first two weeks after orthognathic surgery. If so, vascular CT or angiography should be performed to rule out the presence of vascular injuries. In case a pseudoaneurysm is identified, vascular embolization with N-butyl-cyanoacrylate seems to be the best treatment if available. If this treatment is not available or bleeding cannot be controlled, surgical ligature of the injured vessel is a valid treatment.

Management of Mid-Facial Fracture Complicated by Pseudoaneurysm of Posterior Superior Alveolar Artery

Facial fractures, particularly mid-facial fractures, can result in various complications, such as functional and esthetic problems. Prompt reconstruction of the fractured bones is crucial for restoring normal anatomy and function and preventing complications. However, such procedures can be complex and carry the risk of potential complications. The authors report the case of a 27-year-old man who underwent open reduction and internal fixation of the left zygomatic complex fracture and reconstruction of the left inferior orbital wall. During the surgery, heavy bleeding from the posterior superior alveolar artery due to a broken bone near the pterygomaxillary region caused a prolonged surgery time and the development of a pseudoaneurysm. The pseudoaneurysm was eventually treated with superselective transcatheter embolization using 25% N-Butyl cyanoacrylate glue. This case highlights the challenges in the management of mid-facial fractures and the potential complications that can arise during surgery, particularly when dealing with the pterygomaxillary region.

Pseudoaneurysms and Orthognathic Surgery: A Systematic Review and a Proposed Algorithm of Treatment

This study aimed to gather existing evidence regarding the incidence, clinical presentation, and management of pseudoaneurysms (PA) after orthognathic surgery, identify the common blood vessels involved in PA, and propose a treatment algorithm based on current evidence. The protocol for this study was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols and was registered at the International Prospective Register of Systematic Reviews under the registration number CRD42020205479. Although these are rare, oral and maxillofacial surgeons should consider PA as a possible diagnosis, specifically in the maxillary artery of patients with epistaxis, severe facial edema, and swelling following LeFort I osteotomy.

Radiological Analysis of Maxillary Artery Relationships to Key Bony Landmarks in Maxillofacial Surgery

The maxillary artery (MA) is a key structure at risk of injury in numerous oral and maxillofacial surgical (OMS) procedures. Knowledge of safe distances from this vessel to surgically familiar bony landmarks could improve patient safety and prevent catastrophic haemorrhage. Distances between the MA and bony landmarks on the maxilla and mandible were measured using CT angiograms on 100 patients (200 facial halves). The vertical height of the pterygomaxillary junction (PMJ) was mean (SD) measurement of 16 (3) mm. The MA enters the pterygomaxillary fissure (PMF) a mean (SD) distance of 29 (3) mm from the most inferior point of the PMJ. The mean (SD) shortest distance between the MA and medial surface of the mandible was 2 (2) mm (with the vessel directly contacting the mandible in 17% of cases). The branchpoint (bifurcation of the superficial temporal artery (STA) and MA) was directly in contact with the mandible in 5% of cases. The mean (SD) distances between this bifurcation point and the medial pole of the condyle were 20 (5) mm and 22 (5) mm, respectively. A horizontal plane through the sigmoid notch perpendicular to the posterior border of the mandible is a good approximation of the trajectory of the MA. The branchpoint is usually within 5 mm of this line and inferior in 70% of cases. Surgeons should take note that both the branchpoint and the MA contact the surface of the mandible in a significant number of cases.

"Signs and Symptoms Tell All"-Pseudoaneurysm as a Cause of Postoperative Bleeding after Orthognathic Surgery-Report of a Case and a Systematic Review of Literature

PURPOSE

Pseudoaneurysms are one of the rare complications that can be encountered after the orthognathic surgery. We are presenting a new case of pseudoaneurysm of bilateral sphenopalatine artery after Bijaw Surgery in a young male and a systematic review of all the cases in the literature emphasizing on signs and symptoms, epistaxis or bleeding episodes and treatment outcomes.

METHODS

A systematic research strategy was planned according to the PRISMA guidelines, and articles were taken from 1986 to September, 2019. A total of 899 articles were selected for screening, out of which only 26 articles met our inclusion and exclusion criteria. These were included in the study for qualitative analysis.

RESULTS

Most PAs were associated with Lefort I osteotomy (69.7%), followed by sagittal split osteotomy (24.24%). Average intraoperative blood was 635 ml. Maximum number of episodes of epistaxis/swelling or bleeding occurred in second week. Mean bleeding episodes were 2.58 ± 0.996. The arteries commonly affected were internal maxillary artery (42%), sphenopalatine artery (27.27%), facial artery (15.15%), descending palatine artery (12.12%), internal carotid artery (9.09%) and infraorbital artery (3.03%). Embolization was treatment of choice in 81.81% cases.

CONCLUSION

If a patient has recurrent epistaxis or swelling after orthognathic surgery, it is advisable to go for diagnostic imaging like angiography without any delay. In recent times, advanced techniques and expertise are readily available for early diagnosis and management of pseudoaneurysm.

A rare case of large left internal maxillary artery pseudoaneurysm secondary to mandibular fracture: A case report and review of the literature

INTRODUCTION AND IMPORTANCE

Pseudoaneurysms secondary to traumatic vessel wall disruption are a rare but potentially fatal complication after traumatic injury. The majority of the cases are found incidentally.

CASE PRESENTATION

An 80-year-old woman was brought into our Level 1 Trauma Center after sustaining a ground-level fall with significant facial swelling. Her imaging revealed an acute traumatic comminuted fracture of the right mandibular condyle and left mandibular ramus. The patient underwent closed maxillomandibular fixation (MMF) to stabilize fractures, and allow the swelling to decrease for definitive fixation. During the definitive procedure, profuse bleeding was encountered. CT angiography evaluation was immediately performed and determined the presence of a left internal maxillary artery pseudoaneurysm which was successfully treated by coil and glue embolization.

CLINICAL DISCUSSION

This case highlights an unusual presentation of a vascular injury following major traumatic mandibular fracture and its management. Mandibular fractures have been reported in a series of cases to be a risk factor for vascular injuries. When a vascular injury is suspected, or the evaluation is unclear, surgeons should carefully determine the necessity to perform additional studies like CT angiogram. Vascular injuries secondary to mandibular fractures can be fatal if left unrecognized and untreated. Hence adequate recognition and treatment are warranted to avoid prolonged length of stay with bad outcomes.

CONCLUSION

Optimal management of pseudoaneurysms is achieved by endovascular approach with prior resuscitation and adequate hemodynamic stabilization. Open surgical management is deferred only for those cases where endovascular treatment is not available, or disruption is found intraoperatively.

Pseudoaneurysm of the Maxillary Artery With Prebleeding Warning Signs After Le Fort I Osteotomy

ABSTRACT

Epistaxis after Le Fort I osteotomy is one of the relatively common postoperative complications. It can be controlled with conservative treatment, such as nasal packing, and will usually improve in a few days. However, if the epistaxis is repeated, the outcome can be life-threatening. A 22-year-old woman underwent Le Fort I osteotomy in order to correct her malocclusion. Postoperatively, pseudoaneurysm was formed in the descending palate artery, causing repeated epistaxis. Then, angiography and embolization were performed. Before the onset of epistaxis, there was discomfort around the nasal area. The patient remained asymptomatic during the 6-month follow-up. Some epistaxis after Le Fort I osteotomy is due to pseudoaneurysm formation in the maxillary artery. It is very rare. The epistaxis is delayed and recurrent. It can cause massive bleeding, and so, requires proper diagnosis and treatment. There may be signs of bleeding as in this case.

A rare complication of an Arteriovenous shunt after bimaxillary surgery

The most common complications following bimaxillary surgery are inferior alveolar nerve damage, hemorrhage, and relapse. Severe complications are rare, but few cases of vascular arteriovenous malformation, cavernous sinus thrombosis, formation of an aneurysm or arteriovenous shunting are reported in literature. We present a case of a 20-year-old male patient who developed a right sided tinnitus and visible pulsations close to the mandibular angle on the right side after bimaxillary surgery. CT-angiography and subsequent digital subtraction angiography (DSA) six months after surgery showed an arteriovenous fistula (AVF) from the external carotid artery to the external jugular vein. The AVF was treated by endovascular coil embolization. At six months after intervention there were no residual complaints. We discuss the possible etiology and trauma mechanisms that might have caused this pathology and present recommendations to avoid this type of complications.

External auditory canal haemorrhage as the first sign of internal carotid artery pseudoaneurysm, a rare case: a case report

Assessing the cause, severity of bleeding and strategies to control bleeding is crucial. We describe a rare case of a patient who was presented with epistaxis and left ear haemorrhage, as a probable complication of a ruptured internal carotid artery pseudoaneurysm. The massive haemorrhage compelled blood transfusion and clinical intervention. The diagnosis of internal carotid artery (ICA) pseudoaneurysm measuring 2.9 cm x 3.7 cm was concluded by computed tomography. Several coils were used to embolize the internal carotid artery pseudoaneurysm and arrest the bleeding with the guidance of an angiography. Coiling the pseudoaneurysm is highly recommended. Yet, the best methods to completely treat aneurysm are still in question. After the clinical intervention, the patient remained symptom-free and no episodes of bleeding were noted.

An idiopathic delayed maxillary hemorrhage after orthognathic surgery with Le Fort I osteotomy: a case report

A Le Fort I osteotomy is a common procedure for correcting dental and facial deformities in orthognathic surgery. In rare cases, a delayed hemorrhage can occur as early as several hours or up to 12 weeks, postoperatively. The most frequently involved blood vessels in a delayed hemorrhage are the descending palatine artery, the internal maxillary artery, and the pterygoid venous plexus of veins. Intraoral bleeding accompanied by severe epistaxis in these cases makes it difficult to locate the precise bleeding focus. Eventual uncontrolled bleeding would require Merocel packing or surgical intervention. In general, a severe late postoperative hemorrhage is most effectively managed by angiography and embolization. Herein we describe a delayed hemorrhage case in which the cause was not evident on angiography. We were able to detect the bleeding point through an endoscopic nasal approach and treat it using direct cauterization.

Maxillary Artery Pseudoaneurysm as a Complication of Maxillofacial Injuries: Report of three cases and literature review

Traumatic maxillary artery pseudoaneurysm is an uncommonly reported complication in the field of oral and maxillofacial surgery. It is usually discovered incidentally, either early after trauma or weeks-to-months later. Quick recognition and prompt management are essential to avoid devastating consequences. In this paper, we report three uncommon cases of maxillary artery pseudoaneurysm recognised during the surgical management of maxillofacial injuries in Muscat, Oman. All cases presented as sudden brisk bleeding during the intraoperative surgical repair and were subsequently diagnosed and successfully managed by endovascular embolisation with platinum coils. This case report highlights the clinical presentation, diagnosis and management of maxillary artery pseudoaneurysm, in addition to a brief review of the literature.

Transverse Cervical Artery Pseudoaneurysm: An Unusual Delayed Complication of Radical Neck Dissection

Pseudoaneurysm formation in the transverse cervical artery, post radical neck dissection, leading to massive hemorrhage, is a rare but life threatening occurrence. We report a patient with pseudoaneurysm of transverse cervical artery, post salvage radical neck dissection, presenting with recurrent and significant hemorrhage after 3 weeks of surgery. A pseudoaneurysm involving transverse cervical artery was revealed by digital subtraction angiography and treated by endovascular coil embolization.

Proximity of the maxillary artery to the neck of the mandibular condyle: anatomical study

PURPOSE

The objective of this study was to evaluate the anatomical distance of the maxillary artery, the most superior portion of the condyle and subcondyle in standardized coronal sections, acquired from 16 hemifaces in 8 cadavers.

METHODS

Measurements were taken to evaluate the distance between the uppermost portion of the mandibular condyle and the height of the maxillary artery (AB) and between the lateral (CD) and medial (EF) sides of the condylar neck to the artery.

RESULTS

The mean for AB was 21.1 mm hemiface right and 22.9 mm left on the anterior face, 22.5 mm and 20.7 mm, respectively, on the rear face. The CD measurement presented 6.7 mm right side in the anterior face and 6.3 mm left, and the posterior face was 6.3 mm right side and 5.4 mm left; EF presented a mean of 2.2 mm right and 1.5 mm left on the anterior face and 1.6 mm for both sides on the posterior face.

CONCLUSIONS

There was no statistically significant difference between hemifaces. The proximity of the maxillary artery to the medial face of the neck of the mandibular condyle is millimetric and presents risks of severe hemorrhage for interventions in the infratemporal fossa.

Pseudoaneurysm in internal maxillary artery after gunshot wound: Critical review and case report

INTRODUCTION

Pseudoaneurysm is a vascular injury typically caused by rupture of arteries with extravasation of blood. The involvement of this entity in facial arteries after firearm aggression is extremely rare, and they need treatment as early as possible, thus avoiding irreversible damage to patients.

STUDY DESIGN

A 40-year-old male victim of gunshot attack with an entrance orifice in the right posterior cervical region with ascending trajectory, lodging in the ipsilateral zygomatic-orbitary complex, which was submitted to removal of the bone fragments and the bullet. In the intraoperative period, the patient developed profuse hemorrhage and, after complementary examinations, he was diagnosed with pseudoaneurysm of the internal maxillary artery, which was treated by selective endovascular embolization.

RESULTS

The patient was hemodynamically stable, with no complaints and was discharged after 48 hours, without postoperative bleeding recurrences. He had no more complications after 8 months of follow-up.

CONCLUSIONS

The main forms of treatment and diagnosis of vascular lesions are reviewed, and embolization is demonstrated as a technically safe procedure with few complications. Key words:Gunshot wound, pseudoaneurysm, maxillary artery, therapeutic embolization.

Traumatic Pseudoaneurysm of the Internal Maxillary Artery: A Rare Life-Threatening Hemorrhage as a Complication of Maxillofacial Fractures

Pseudoaneurysm of the internal maxillary artery due to a traumatic event is a rare condition. Pseudoaneurysms are usually directly produced by arteries break with extravasation of blood. The compressed perivascular tissue forms the wall of aneurysmal sac. Then, this sac gradually expands and can be damaged. It is rare to see pseudoaneurysms of IMA. They are usually associated with fracture of the neck of the mandible. To the best of our knowledge the pseudoaneurysm of the internal maxillary artery related to maxillofacial trauma is an event extremely rare in the literature and if not quickly managed can lead to the patient's death. This case underlines how the close cooperation between surgeons and radiologists results in a quick diagnosis and management of such pathological events.

Endovascular Management of a Traumatic Infraorbital Pseudoaneurysm Causing Orbital Compartment Syndrome

An 89-year-old woman presented after blunt injury to the left orbit from a fall. Examination findings were suggestive of left-sided orbital compartment syndrome, unresponsive to emergent lateral canthotomy and cantholysis. CT revealed a left-sided orbital floor blowout fracture involving the infraorbital canal, with a large maxillary and infraorbital hematoma. Angiography revealed a pseudoaneurysm supplied by the infraorbital artery. Interventional neuroradiology successfully achieved hemorrhage control by endovascular obliteration of the parent artery close to the pseudoaneurysm. To our knowledge, this is the first reported case of successfully managing active intraorbital hemorrhage causing orbital compartment syndrome by endovascular vessel sacrifice of an infraorbital artery pseudoaneurysm.

Pseudoaneurysm of the carotid arterial system

Pseudoaneurysms of internal, external, and common carotid arteries are seen rarely. Blunt traumas caused by automobile accidents are the prior reasons to this. Central venous catheterization, ballistic trauma, cystic medial necrosis, fibromuscular dysplasia, atherosclerosis, and other inflammatory processes are some other potential reasons for pseudoaneurysm. In contrast to true aneurysms, it does not contain 3-layer structure with adventitia, media, and intima sublayers in its wall. The wall contains coagulum and fibrous capsules. Clinically, after trauma, it presents itself as swelling after days to weeks of damage to vascular walls. Because it causes morbidity and mortality when it is ruptured, It should be treated via surgical or vascular intervention.

Non-pulsatile traumatic pseudoaneurysm of the internal maxillary artery following trauma to mandible

Traumatic pseudoaneurysm involving the maxillary artery is rare. Owing to its anatomic location, internal maxillary artery is usually protected by its surrounding structures. Formation of pseudoaneurysm usually takes place after several weeks to months of the initial injury. In this case, we reported a pseudoaneurysm arising from left internal maxillary artery following blunt injuries within 3 hours after a road accident and the treatment with endovascular embolization with titanium coils prior to open reduction and internal fixation of the fractured mandibles.

Embolization treatment of pseudoaneurysms originating from the external carotid artery

OBJECTIVE

The purpose of this study was to review a single-institution contemporary experience with embolization treatment of pseudoaneurysms (PAs) from the external carotid artery (ECA).

METHODS

From December 2000 to June 2014, PAs in the head and neck of 17 patients underwent embolization treatment and were retrospectively evaluated. All were treated with obliteration of the feeding artery or the PA by detachable coils or fibered coils, or both. Clinical follow-up was a mean of 91.9 months (range, 4-173 months) and was performed for all patients. Therapeutic outcomes were determined by evaluating the postprocedural image and clinical outcome of symptoms and signs.

RESULTS

The 17 consecutive patients with head and neck PAs who underwent coils embolization treatment consisted of 14 male patients (82.3%) and three female patients (17.7%). The average age was 37.5 years (range, 16-57 years). The most common symptom and sign was a pulsatile mass, seen in 15 of 17 patients, and other symptoms included pain (three patients) or bleeding (four patients). Digital substraction angiography revealed that the PAs originated from the ECA in 3 patients and others originated from the branches of the ECA, including the superficial temporal artery in 6 patients, internal maxillary artery in 4, superior thyroid artery in 2, and the facial artery and posterior auricular artery in 1. Seventeen coils embolizations for occlusion of the parent artery were performed in 14 patients with a transarterial approach and in three by direct percutaneous puncture. All patients remained symptom free, and no procedure-related complications occurred.

CONCLUSIONS

Embolization treatment of PAs from the ECA is a useful alternative to standard surgical repair. This modality avoids the necessity for surgical exposure of the face and of the neck with its inherent morbidity.

Management of Late Post-traumatic Facial Artery Pseudoaneurysmal Cyst: Review of Literature

Pseudoaneurysms of the branches of the external carotid artery as a result of trauma are rare in oral and maxillofacial surgery practice. The most affected branches are the superficial temporal artery, internal maxillary artery and distal part of facial artery, usually where they pass over the bone. Very few cases of facial artery pseudoaneurysms of proximal parts (from external carotid artery up to the lower border of the mandible) are reported in the literature. We present a review of literature for management of late post-traumatic pseudoaneurysmal cyst and a case report involving proximal part of facial artery in the submandibular region following open reduction and rigid fixation of the condylar fracture in a 25-year-old male. To our knowledge this is the fourth reported case of proximal facial artery pseudoaneurysm.

Left maxillary artery pseudoaneurysm: a rare and late postoperative complication after head and neck cancer treatment

We report a case of a 50-year-old man presented with pulsatile swelling in the left side of the face since 2 months and a continuous sinus discharge since 3 days. Three years earlier, he was operated for squamous cell carcinoma (SCC) of the left lower alveolus and underwent surgical excision with myocutaneous flap reconstruction, followed by chemoradiotherapy. CT angiogram of the expansile swelling revealed pseudoaneurysm of third part of the left maxillary artery and treated by surgical intervention.

Pseudoaneurysm of the internal maxillary artery: a rare complication of condylar fracture

Pseudoaneurysms are among very rare complications of maxillofacial trauma. When encountered, they have the potential to cause life-threatening hemorrhage. A wise surgeon should consider the possibility of underlying aneurysm even if the classic sign of pulsatile mass is not present. The role of interventional radiology is immaculate in the management of these aneurysms.

Massive epistaxis due to pseudoaneurysm of the sphenopalatine artery: a rare post-operative complication of orthognathic surgery

OBJECTIVE

To introduce pseudoaneurysm of the sphenopalatine artery as the possible aetiology of acute massive epistaxis in patients with a history of orthognathic surgery accompanied by Le Fort I osteotomy.

METHODS

Case report and literature review.

RESULTS

This paper reports a case of acute life-threatening epistaxis following Le Fort I osteotomy. Computed tomography and angiography showed a pseudoaneurysm of the sphenopalatine artery, which was successfully treated by endovascular embolisation.

CONCLUSION

Although a pseudoaneurysm of the sphenopalatine artery following Le Fort I osteotomy is extremely rare, it should be considered as the possible aetiology of acute massive epistaxis in patients with a history of orthognathic surgery accompanied by Le Fort I osteotomy.

A critical review of the literature and an evidence-based approach for life-threatening hemorrhage in maxillofacial surgery

BACKGROUND

Life-threatening facial hemorrhage in Maxillofacial Surgery (MFS) has an approximate incidence of 1% in the trauma patient and in elective surgery. The treatment of acute life-threatening hemorrhage in MFS to prevent hypovolemic shock or airway obstruction forms the basis of emergency care and necessitates the need for further analysis given the multitude of options proposed for treatment. A systematic review of the literature was undertaken to formulate an evidence-based approach to the treatment of life-threatening hemorrhage in MFS.

MATERIALS AND METHODS

A comprehensive search of journal articles was performed using PubMed and Ovid databases. Keywords and phrases used were "life threatening facial hemorrhage," "life threatening facial bleeding," "external carotid artery ligation," and "external carotid artery embolization." Our search yielded 1441 articles. In an attempt to focus on hemorrhage exclusively from traumatic and operative events, articles that cited hematological disorders as the underlying cause of bleeding were excluded from the study. There were 40 articles which met the full inclusion criteria and form the basis of this systematic review. The articles were rated based on the level of evidence. There was 1 Level II, 21 Level III, 12 Level IV, and 6 Level V papers.

RESULT

Seven Level III evidence-based studies noted a high association between midface injuries, particularly Lefort III fractures and massive oronasal hemorrhage. One Level II study, 8 Level III studies, and 3 Level IV studies concluded that the internal maxillary artery was most frequently associated with intractable posttraumatic hemorrhage. One Level II, 16 Level III, 3 Level IV, and 3 Level V articles cited anterior and posterior nasal packing and conservative measures as the first attempt to manage traumatic hemorrhage. Subsequently, 8 Level III studies re-enforced the importance of temporary reduction of facial fractures as an effective means to control massive hemorrhage early in the algorithm. Seven Level III studies, 4 Level IV, and 2 Level V studies documented the importance of ligation of arteries as one of the absolute measures to manage facial hemorrhage, whereas 1 Level II, 14 Level III, 2 Level IV, and 3 Level V studies alluded to embolization as the most reliable technique for control of the hemorrhage. In orthognathic surgery, the internal maxillary artery was most frequently the source of massive hemorrhage according to 2 Level III, 4 Level IV, and 1 Level V studies. Two Level III, 5 Level IV, and 1 Level V study proposed packing as the first attempt to tamponade the hemorrhage. Two Level IV and 1 Level V study cited pseudoaneurysm as a potentially life-threatening vascular complication after elective surgery.

CONCLUSIONS

Management of facial hemorrhage should be performed in a sequential and consistent manner to optimize outcome. An evidence-based algorithm for posttraumatic and elective life-threatening hemorrhage in MFS based on this critical review of the literature is presented and discussed.

Pseudoaneurysm of the facial artery occurred after mandibular sagittal split ramus osteotomy

Introduction

Pseudoaneurysms are caused by rupture of arteries with extravasation of blood. The compressed perivascular tissue forms the wall of aneurysmal sac. Pseudoaneurysm directly related with surgical procedure of sagittal split ramus osteotomy (SSRO) was reported quite rarely especially related with facial artery during the vertical osteotomy.

Case report

SSRO was carried out for a 19-year-old male; the patient visited the emergency room with notable swelling 3 weeks after the surgery. We experienced severe intra-oral bleeding with surgical exploration. Angiography revealed a pseudoaneurysm of the right facial artery that might be related with vertical osteotomy over lateral cortex of the mandibular body during orthognathic surgery. This implies that the minor vascular trauma from vertical osteotomy of the mandibular body during the conventional orthognathic surgery might cause later development of pseudoaneurysm.

Sphenopalatine artery pseudoaneurysm after endoscopic sinus surgery: a case report and literature review

Previously reported cases of iatrogenic sphenopalatine artery (SPA) pseudoaneurysm have occurred only after trans-sphenoidal surgery for pituitary tumors or maxillofacial surgery. In this article, the author presents what to the best of her knowledge is the first reported case of an SPA pseudoaneurysm that developed following endoscopic sinus surgery (ESS). The patient was a 76-year-old woman with myelodysplastic syndrome who presented with a 6-month history of unilateral sinus symptoms. She underwent septoplasty and unilateral ESS, which included frontal recess clearance and sphenoidotomy. However, during surgery, severe generalized bleeding was encountered. The bleeding was arrested only after anterior and posterior nasal packing. After two attempts to remove the packing failed, angiography was obtained. It revealed an SPA pseudoaneurysm, which was immediately and successfully embolized. SPA pseudoaneurysm is a rare but significant complication of ESS, and it should be considered in patients with posterior epistaxis after ESS or prolonged posterior nasal packing. The pathogenesis may include intraoperative trauma, infection, pressure necrosis from packing, or a combination of these factors. Optimal management includes either ligation or embolization, depending on anatomic, patient, staff, and resource factors. The author reviews the pertinent anatomy and the pathophysiology, diagnosis, management, and prevention of this rare complication.

Topography of the arteries supplying the masseter muscle: Using dissection and Sihler's method

Various surgical procedures require surgeons to have detailed knowledge of the course of blood vessels in the masseter muscle, such as masseter muscle flap formation, mandibular angle resection, parotidectomy, and mandibular ramus osteotomy. Without this knowledge serious complications can occur, endangering the lives of patients. Occasionally, during routine dissections we sometimes encounter an additional branch. The purpose of this study was to provide a comprehensive detailed anatomic description of the blood supply of the masseter muscle. This will provide critical information for various surgical procedures. Twenty-five Korean cadavers were dissected and subjected to modified Sihler's method to reveal the branching patterns of the arteries surrounding the masseter muscle, and its intramuscular blood supply. The masseter can be supplied by seven branches from the external carotid artery. Among these, the masseteric branch from the deep temporal artery has not been described previously. This previously undescribed branch enters the medial surface of the masseter, turning medially around the anterior border of the ramus immediately after the branching point of the deep temporal artery. The branch originating from the transverse facial artery was the largest, and the branches originating from the external carotid artery and deep temporal artery were the smallest. Examination of intramuscular patterns revealed that the branches of the transverse facial artery were the most widely distributed. When considering arterial diameters and distribution areas, the branches of the transverse facial artery can be considered the main components of the seven branches supplying the masseter muscle.

Maxillary artery pseudoaneurysm after Le Fort I osteotomy: treatment using transcatheter arterial embolization

Life-threatening hemorrhage is a rare complication after Le Fort I osteotomy. However, owing to the gravity of this complication, all surgeons who perform Le Fort I osteotomy should be aware of the potential for this complication and options for its resolution. The following case report describes an episode of subacute, life-threatening bleeding, after a Le Fort I osteotomy for the treatment of midface hypoplasia. Emergent angiographic evaluation demonstrated an internal maxillary artery pseudoaneurysm with fistulous drainage via the cavernous sinus. This was treated by arterial embolization in which the pseudoaneurysm was packed with microcoils. This report reaffirms the importance of maintaining a high clinical suspicion for pseudoaneurysm as a possible etiology of delayed postoperative bleeding in patients after craniomaxillofacial surgery.

Endovascular treatment of a giant aneurysm of the maxillary artery

Aneurysms of the maxillary artery are rare and the majority of the literature refers to false aneurysms. We report the first case of what we believe to be a spontaneous true maxillary artery aneurysm and its endovascular management.