1
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Girard A, Lopez CD, Chen J, Perrault D, Desai N, Bruckman KC, Bartlett SP, Yang R. Epistaxis After Orthognathic Surgery: Literature Review and Three Case Studies. Craniomaxillofac Trauma Reconstr 2022; 15:147-163. [PMID: 35633764 DOI: 10.1177/19433875211008086] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Study Design This is a literature review with 3 case studies. Objective Intraoperative and postoperative bleeding are the most common complications of orthognathic surgery and have the potential to become life-threatening. The rarity of severe postoperative epistaxis has resulted in limited characterization of these cases in the literature. The purpose of this study is to 1) differentiate various presentations of epistaxis following orthognathic surgery in the literature, 2) identify management approaches, and 3) to synthesize a treatment algorithm to guide future management of postoperative epistaxis. Methods A literature search of PubMed was conducted and 28 cases from 17 studies were assessed. Results Bleeding within the first week may indicate isolated epistaxis, often resolved with local tamponade. Half of cases were attributed to pseudoaneurysm rupture (n = 14), with epistaxis onset ranging from postoperative day 6 to week 9. Angiography was used in most cases (n = 17), often as the primary imaging modality (n = 11). Nasal endoscopy is a less invasive and effective alternative to angiography with embolization. Proximal vessel ligation was used in 3 cases but is not preferred because collaterals may reconstitute flow through the defect and cause rebleeding. Repeat maxillary down-fracture with surgical exploration was described in 4 cases. Conclusions As outlined in our management algorithm, nasal packing and tamponade should be followed by either local electrocautery or vascular imaging. Angiography with embolization is the preferred approach to diagnosis and management, whereas surgical intervention is reserved for cases of embolization failure or unavailability.
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Affiliation(s)
- Alisa Girard
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Plastic Surgery, Rutgers - Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Christopher D Lopez
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonlin Chen
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Perrault
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Nikhil Desai
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Karl C Bruckman
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Scott P Bartlett
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robin Yang
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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2
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Kumar A, Kaur A, Singh M, Rattan V, Rai S. "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. J Maxillofac Oral Surg 2021; 20:345-355. [PMID: 34408361 PMCID: PMC8313620 DOI: 10.1007/s12663-020-01476-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 10/27/2020] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Arun Kumar
- Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Amanjot Kaur
- Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Manpreet Singh
- Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Vidya Rattan
- Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Sachin Rai
- Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
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3
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Birgi E, Durmaz H, Güreşci K, Ergun O, Çığsar G, Kurtuluş B, Hekimoğlu B. Endovascular management of traumatic arterial emergencies: A single center retrospective study. JOURNAL OF ACUTE DISEASE 2021. [DOI: 10.4103/2221-6189.330741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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4
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Al-Saadi NJ, Bakathir A, Al-Mashaikhi A, Al-Hashmi A, Al-Habsi A, Al-Azri F. Maxillary Artery Pseudoaneurysm as a Complication of Maxillofacial Injuries: Report of three cases and literature review. Sultan Qaboos Univ Med J 2019; 19:e364-e368. [PMID: 31897321 PMCID: PMC6930039 DOI: 10.18295/squmj.2019.19.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/26/2019] [Accepted: 09/19/2019] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Noor J Al-Saadi
- Department of General Surgery, Al Rustaq Hospital, Al Rustaq, Oman
| | - Abdulaziz Bakathir
- Department of Dental & Maxillofacial Surgery, Sultan Qaboos University Hospital, Muscat, Oman
| | - Ali Al-Mashaikhi
- Oral and Maxillofacial Surgery Program, Oman Medical Specialty Board, Muscat, Oman
| | - Ahmed Al-Hashmi
- Department of Dental and Maxillofacial Surgery, Al Nahda Hospital, Muscat, Oman
| | | | - Faisal Al-Azri
- Department of Radiology & Molecular Imaging, Sultan Qaboos University Hospital, Muscat, Oman
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5
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Abstract
Facial trauma varies widely in its severity and is also frequently associated with other injuries which can make prioritisation of injuries difficult. An effective method of triage is important to ensure this. This article describes one such approach and discusses the application of damage control principles to facial injuries. Both these issues commonly impact on the management of multiply injured patients with coexisting facial injuries during the initial stages of resuscitation or soon afterwards. Understanding facial trauma is based in part, on parallels with orthopaedic trauma.
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Affiliation(s)
- Mike Perry
- Consultant oral and maxillofacial surgeon, Northwick Park Hospital, UK
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6
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Bodanapally UK, Sliker CW. Imaging of Blunt and Penetrating Craniocervical Arterial Injuries. Semin Roentgenol 2016; 51:152-64. [DOI: 10.1053/j.ro.2015.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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7
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Morris CS. Role of Vascular and Interventional Radiology in the Diagnosis and Management of Acute Trauma Patients. J Intensive Care Med 2016. [DOI: 10.1177/088506660201700302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Vascular and interventional radiology provides an important service in the diagnosis and management of the acute trauma patient. Historically angiography was used primarily as a diagnostic tool for both vascular and solid organ injuries. However, with technological advances, such as the advent of stents, stent grafts, newer embolization materials and sophisticated delivery devices, micro-catheters, and steerable guide wires, vascular and interventional radiology can now offer definitive treatment in selected cases. Transcatheter embolization can effectively treat acute hemorrhage and is useful in locations that are difficult to access surgically, or when surgical disruption of fascial planes, which may eliminate a tamponade effect, is less desirable. Stents and stent grafts have been used to preserve, rather than sacrifice, an injured blood vessel. In splenic, hepatic, and renal trauma, a trend in nonoperative management has been developed by traumatologists. Transcatheter embolization can increase the success rate of nonoperative management in selected injuries. In general, despite the injury grade, if evidence of ongoing hemorrhage is present, angiography and transcatheter embolization should be considered. Peripheral vascular injuries can be treated with transcatheter embolization or stents and stent grafts. Transcatheter embolization in trauma was first applied to bleeding associated with pelvic fractures and dislocations, and continues to be an important treatment option. Carotid and vertebral artery injuries can now be repaired using stents or stent grafts, although the experience of this treatment strategy is somewhat limited. Likewise, acute traumatic aortic injury has been successfully treated with stent grafts in small series. Conventional catheter thoracic aortography is now used as an adjunctive diagnostic test for indeterminate or questionable findings on noninvasive imaging studies, primarily computed tomography scans of the chest. In summary, vascular and interventional radiology maintains an important role in the diagnosis and management of acute vascular and solid organ injury. The following review illustrates its current status in acute trauma.
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Affiliation(s)
- Christopher S. Morris
- Department of Radiology, University of Vermont College of Medicine, Fletcher Allen Health Care, Burlington, VT,
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8
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Vascular Injuries to the Neck After Penetrating Trauma: Diagnostic Performance of 40- and 64-MDCT Angiography. AJR Am J Roentgenol 2015; 205:866-72. [DOI: 10.2214/ajr.14.14161] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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9
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Gelesko S, Markiewicz MR, Bell RB. Responsible and Prudent Imaging in the Diagnosis and Management of Facial Fractures. Oral Maxillofac Surg Clin North Am 2013; 25:545-60. [DOI: 10.1016/j.coms.2013.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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10
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Rzewnicki I, Kordecki K, Łukasiewicz A, Puławska-Stalmach M, Lewszuk A, Bondyra Z, Rogowski M, Łebkowska U. [Embolization of carotid arteria branch in stanching of nasal bleeding]. Otolaryngol Pol 2013; 67:82-6. [PMID: 23452655 DOI: 10.1016/j.otpol.2012.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 10/09/2012] [Accepted: 10/30/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND Epistaxis is a common clinical problem, especially in otolaryngology. This disorder affects equally both genders. Most cases manifest as spontaneous nasal bleeding. It can also appear as a result of trauma, high blood pressure, Osler-Rendu-Weber disease. When the bleeding is massive it can be potentially life-threatening. A great majority of epistaxis can be treated conservatively, if not it sometimes requires endovascular treatment. It is specially reserved for extensive, dangerous epistaxis. Angiography with selective embolization has become an accepted method of treating epistaxis that is not controlled with conservative methods. MATERIAL AND METHODS Authors analyzed the efficacy of selective embolization treatment of epistaxis. 61 patients treated in the Department of Otolaryngology in Bialystok in years 1999-2011 were examined. There were 39 men and 22 women aged 24-48 years. Patients were referred for endovascular treatment when primary management was ineffective. Arteries suspected of bleeding were embolized superselectively. RESULTS Immediate, complete control of bleeding was achieved in 100% patients. After few hours recurrent nasal bleeding occurred in 4 (7%) patients who underwent successful reembolization. There were no severe complications after procedure. Nine patients experienced few days lasting mild headache which disappeared after medicament treatment. Five patients suffered from unaided removing facial oedema. Out of 61 patients, 56 were available for 12-month follow-up evaluation. No neurological or otolaryngological complications were certified. There was also no relapse of epistaxis. CONCLUSIONS Selective angiographic embolization is an effective method that should be considered in the treatment of refractory epistaxis. It is safe and not traumatic for patients.
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11
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Rzewnicki I, Kordecki K, Lukasiewicz A, Janica J, Puławska-Stalmach M, Kordecki JK, Lebkowska U. Palliative embolization of hemorrhages in extensive head and neck tumors. Pol J Radiol 2012; 77:17-21. [PMID: 23269932 PMCID: PMC3529707 DOI: 10.12659/pjr.883624] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 10/30/2012] [Indexed: 11/18/2022] Open
Abstract
Background: A lot has changed in terms of intervention technique, indications and embolic agents since Duggan introduced embolization to management of postraumatic epistaxis in 1970. Embolization is used in treatment of spontaneous and traumatic epistaxis, palliative tumors and vascular defects, as well as vascularized tumors and juvenile nasopharyngeal angiofibromas. The possibility of simultaneous visualization of pathology and implementation of therapy is one of its greatest advantages. Material/Methods: Authors analyzed the efficacy of selective embolization treatment of haemorrhage in advanced head and neck tumors. Seventy-six patients with such tumors treated at the Department of Otolaryngology in Bialystok between1999 and 2011 were examined. Results: Embolization of bleeding vessel within the tumor was effective (hemorrhage was stopped) in 65 patients (86%). Although the method is highly efficient, it is still associated with complications. Fourteen patients suffered from headaches that lasted for several days and six from face edema. Rebleeding was rare. Unfortunately, there was one case of hemiparesis. Conclusions: We conclude that superselective endovascular treatment deserves to be considered alongside standard options for the palliative or preoperative management of acute hemorrhage from advanced head and neck cancers.
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Affiliation(s)
- Ireneusz Rzewnicki
- Department of Otolaryngology Medical University of Białystok, Białystok, Poland
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12
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Mathews SS, Kumar RM, Rupa V. Iatrogenic pseudoaneurysm: a rare complication of sinonasal surgery. Am J Otolaryngol 2011; 32:607-10. [PMID: 21035916 DOI: 10.1016/j.amjoto.2010.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 08/11/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We report 2 patients with iatrogenic pseudoaneurysms, which developed following sinus surgery. METHOD Case reports and a review of literature of the management of iatrogenic pseudoaneurysm. RESULTS For one patient who presented with massive epistaxis, the only lifesaving option available was to perform an urgent angiogram followed by selective embolization of the feeding vessel. In the second patient who presented with persistent nasal obstruction and discharge and no epistaxis, a traumatic aneurysm of the internal carotid artery was demonstrated on magnetic resonance imaging scan that was later confirmed by angiography; he, however, declined further treatment. CONCLUSION Iatrogenic pseudoaneurysms that develop following a vascular injury, though rare, can cause life-threatening epistaxis or a thromboembolism. In this report, we describe 2 different manifestations of iatrogenic vascular malformations following sinus surgery. The role of angiography and subsequent endovascular therapy in the management of these lesions is emphasized.
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13
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Abstract
Carotid vascular trauma has high mortality. The two primary causes of death are associated head injury and vascular injuries that cause exsanguination or stroke. In the past two decades interventional radiology, i.e. techniques of transcatheter embolisation, has become a vital component of the care of these cases. External carotid artery injuries are complex and are often inaccessible causes of exsanguinating haemorrhage. Transcatheter techniques have been shown to be highly effective in controlling this haemorrhage. An overview of injuries of the external carotid artery and its branches is presented.
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Affiliation(s)
- Sundeep Mangla
- SUNY Downstate Health Science Center, Brooklyn, NY 11203-2098, USA.
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14
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Perry M, O'Hare J, Porter G. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 3: Hypovolaemia and facial injuries in the multiply injured patient. Int J Oral Maxillofac Surg 2008; 37:405-14. [PMID: 18262768 DOI: 10.1016/j.ijom.2007.11.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Revised: 07/29/2007] [Accepted: 11/06/2007] [Indexed: 11/30/2022]
Abstract
Hypovolaemic shock is a common cause of morbidity and mortality following trauma, accounting for approximately 30% to 40% of trauma deaths. Life-threatening blood loss from the maxillofacial region is uncommon, but represents one of a number of possible sites which must be rapidly identified and controlled. Bleeding from the face may not be obvious especially in awake, supine patients and it poses an obvious threat to the unprotected airway. Identification requires careful assessment. Control of bleeding in the maxillofacial region requires a number of correctly sequenced techniques. Computerized tomographic imaging is now playing an increasingly important role in identifying blood loss, especially in the chest, abdomen and pelvis. This need may potentially result in the transfer of patients, with unrecognised facial injuries, outside the relative safety of the emergency department. The concepts of the 'lethal triad' and 'biologic first hit' have resulted in new strategies in managing the profoundly shocked patient, although some of these remain controversial. Debate continues over the optimal blood pressure, fluid administration and role of surgical intervention in the actively bleeding patient. These may have an impact on the timing and extent of any proposed maxillofacial repairs, and are discussed.
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Affiliation(s)
- M Perry
- Regional and Maxillofacial Trauma Units, Belfast, UK.
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15
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MR angiography at 3 T for assessment of the external carotid artery system. AJR Am J Roentgenol 2007; 189:1088-94. [PMID: 17954645 DOI: 10.2214/ajr.07.2235] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE A number of clinical situations exist in which high-resolution depiction of the external carotid artery system is required, a task not previously addressed by MR angiography. The purpose of this study was to evaluate the extent to which high-spatial-resolution MR angiography at 3 T can be used to map the normal external carotid artery system. SUBJECTS AND METHODS Twenty-three consenting adult patients were prospectively evaluated. Images acquired were evaluated by two independent observers, and each branch vessel was scored with regard to image quality, presence and grade of stenoses, and artifacts. Interobserver agreement regarding image quality and the presence and degree of stenosis was tested using the kappa coefficient. Differences in quality ratings between the two observers were assessed using the paired Student's t test. RESULTS Of 828 vessels analyzed, 92.63% were designated of diagnostic quality with no significant difference between the observers' image quality scores (p = 0.63). Good agreement was determined regarding image quality achieved (kappa = 0.716). All examinations were free of artifact sufficient to interfere with confident interpretation. Excellent correlation was seen with regard to stenosis detection and grading (kappa = 0.857). Of the external carotid artery systems assessed, 82.6% showed conventional anatomic vascular branching. CONCLUSION High-spatial-resolution, 3D contrast-enhanced MR angiography at 3 T using sagittal source data acquisition and an advanced acceleration factor of 6 allows high-quality (92.63% of arterial segments) visualization of the external carotid artery system, with complete head and neck vascular coverage.
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16
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Abstract
The technical skill set of peripheral interventional radiologists is well-suited to the performance of most transcatheter embolization procedures in the external carotid artery (ECA). These procedures center in large part on hypervascular tumors, epistaxis, and trauma. ECA embolization in the trauma patient is well-defined, albeit in small patient series. The transcatheter treatment of epistaxis is still mostly reserved for cases that are intractable to conservative therapy. Preoperative embolotherapy for vascular tumors remains popular, although it is somewhat controversial in terms of its risk-benefit ratio. The purpose of this review is to highlight pertinent anatomy, selected technical procedural aspects, and the available literature to better characterize the role of ECA embolization in the hands of the practicing peripheral interventionist.
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Affiliation(s)
- Tony P Smith
- Department of Radiology, Duke University Medical Center, Room 1502, Box 3808, Durham, North Carolina 27710, USA.
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17
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Fox CJ, Gillespie DL, Weber MA, Cox MW, Hawksworth JS, Cryer CM, Rich NM, O'Donnell SD. Delayed evaluation of combat-related penetrating neck trauma. J Vasc Surg 2006; 44:86-93. [PMID: 16828429 DOI: 10.1016/j.jvs.2006.02.058] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2005] [Accepted: 02/19/2006] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The approach to penetrating trauma of the head and neck has undergone significant evolution and offers unique challenges during wartime. Military munitions produce complex injury patterns that challenge conventional diagnosis and management. Mass casualties may not allow for routine exploration of all stable cervical blast injuries. The objective of this study was to review the delayed evaluation of combat-related penetrating neck trauma in patients after evacuation to the United States. METHOD From February 2003 through April 2005, a series of patients with military-associated penetrating cervical trauma were evacuated to a single institution, prospectively entered into a database, and retrospectively reviewed. RESULTS Suspected vascular injury from penetrating neck trauma occurred in 63 patients. Injuries were to zone II in 33%, zone III in 33%, and zone I in 11%. The remaining injuries involved multiple zones, including the lower face or posterior neck. Explosive devices wounded 50 patients (79%), 13 (21%) had high-velocity gunshot wounds, and 19 (30%) had associated intracranial or cervical spine injury. Of the 39 patients (62%) who underwent emergent neck exploration in Iraq or Afghanistan, 21 had 24 injuries requiring ligation (18), vein interposition or primary repair (4), polytetrafluoroethylene (PTFE) graft interposition (1), or patch angioplasty (1). Injuries occurred to the carotid, vertebral, or innominate arteries, or the jugular vein. After evacuation to the United States, all patients underwent radiologic evaluation of the head and neck vasculature. Computed tomography angiography was performed in 45 patients (71%), including six zone II injuries without prior exploration. Forty (63%) underwent diagnostic arteriography that detected pseudoaneurysms (5) or occlusions (8) of the carotid and vertebral arteries. No occult venous injuries were noted. Delayed evaluation resulted in the detection of 12 additional occult injuries and one graft thrombosis in 11 patients. Management included observation (5), vein or PTFE graft repair (3), coil embolization (2), or ligation (1). CONCLUSIONS Penetrating multiple fragment injury to the head and neck is common during wartime. Computed tomography angiography is useful in the delayed evaluation of stable patients, but retained fragments produce suboptimal imaging in the zone of injury. Arteriography remains the imaging study of choice to evaluate for cervical vascular trauma, and its use should be liberalized for combat injuries. Stable injuries may not require immediate neck exploration; however, the high prevalence of occult injuries discovered in this review underscores the need for a complete re-evaluation upon return to the United States.
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Affiliation(s)
- Charles J Fox
- Department of Surgery, Vascular Surgery Service, Walter Reed Army Medical Center, Washington, DC 20307, USA.
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18
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Kurt A, Tanrivermiş A, Ipek A, Tosun O, Gümüş M, Yazicioğlu KR, Taş I. A challenging problem. Vertebral pseudoaneurysm and arteriovenous fistula involving vertebral artery and ipsilateral internal jugular vein due to craniocervical penetrating trauma. Interv Neuroradiol 2006; 12:171-5. [PMID: 20569571 DOI: 10.1177/159101990601200213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2006] [Accepted: 05/15/2006] [Indexed: 11/16/2022] Open
Abstract
SUMMARY Vertebral pseudoaneurysm and arteriovenous fistulas are very rare and are commonly due to penetrating trauma to craniocervical region. A 20-year-old man was presented with progressive swelling and pulsatile mass on the left side of his face. He had been stabbed two weeks ago on the left side of his face. Doppler Ultrasound revealed large left vertebral pseudoaneursym and arteriovenous fistulisation with the ipsilateral internal jugulat vein. MR Angiography and conventional angiography confirmed arteriovenous fistula between left vertebral artery and ipsilateral internal jugular vein and large pseudoaneurysm formation on vertebral artery. Arteriovenous fistula was closed surgically and embolized with surgicell. But the pseudoaneurysm was treated with endovascular covered stent placement.
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Affiliation(s)
- A Kurt
- Ankara Atatürk Education and Research Hospital Department of Radiology, Ankara-Turkey Assistant, Radiology Department, Instructor, Radiology Department -
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19
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Abstract
Traumatic injury to the major vessels of the head and neck can result in potentially devastating neurologic sequelae. Until recently, conventional angiography was the primary imaging modality used to evaluate these often challenging patients. Advances in cross-sectional imaging have improved the ability to screen for these lesions, which have been found to be more common than previously thought; however, accepted protocols of imaging evaluation have not yet been fully established. This article presents a general approach to the patient with suspected neurovascular injury. This includes a discussion of the histopathologic spectrum, clinical presentation, mechanisms, radiologic work-up, pertinent issues of the most common lesions, and some of the endovascular techniques used in their management.
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MESH Headings
- Aneurysm, False/diagnosis
- Aneurysm, False/diagnostic imaging
- Angiography/methods
- Angiography, Digital Subtraction/methods
- Blood Vessels/injuries
- Carotid Artery, Internal, Dissection/diagnosis
- Carotid Artery, Internal, Dissection/diagnostic imaging
- Craniocerebral Trauma/diagnosis
- Craniocerebral Trauma/diagnostic imaging
- Diagnosis, Differential
- Humans
- Intracranial Arteriovenous Malformations/diagnosis
- Intracranial Arteriovenous Malformations/diagnostic imaging
- Magnetic Resonance Angiography/methods
- Magnetic Resonance Imaging/methods
- Neck/blood supply
- Neck Injuries/diagnosis
- Neck Injuries/diagnostic imaging
- Tomography, X-Ray Computed/methods
- Vertebral Artery Dissection/diagnosis
- Vertebral Artery Dissection/diagnostic imaging
- Wounds, Penetrating/diagnosis
- Wounds, Penetrating/diagnostic imaging
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Affiliation(s)
- M J B Stallmeyer
- Division of Diagnostic and Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland School of Medicine, Baltimore, MD 21208, USA.
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20
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O'Shaughnessy BA, Bendok BR, Parkinson RJ, Shaibani A, Batjer HH. Transarterial coil embolization of a high-flow vertebrojugular fistula due to penetrating craniocervical trauma: case report. ACTA ACUST UNITED AC 2005; 64:335-40; discussion 340. [PMID: 16182005 DOI: 10.1016/j.surneu.2004.11.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2004] [Revised: 10/25/2004] [Accepted: 11/08/2004] [Indexed: 11/23/2022]
Abstract
BACKGROUND Vertebrojugular fistulas after penetrating cervical trauma (gunshot or stab wounds) are rarely reported. Successful endovascular coil embolization of an acute fistulizing vertebral artery pseudoaneurysm involving an obstructed internal jugular vein is presented and the various treatment strategies for such a lesion are described. CASE DESCRIPTION A 23-year-old man presented from an outside institution after sustaining 2 gunshot wounds in a civilian conflict. Neuroimaging revealed a right vertebral artery pseudoaneurysm, which formed a fistulous connection with the internal jugular vein. Because venous outflow obstruction was present just below the fistula, a high-flow shunt was directed intracranially. Both the pseudoaneurysm and arteriovenous fistula were accessed percutaneously via a transfemoral route and coil embolization was performed. Perfusion of the basilar artery circulation was assumed by the contralateral vertebral artery. The ipsilateral posteroinferior cerebellar artery filled through retrograde flow down the vertebral confluence. CONCLUSIONS Coil embolization is a safe and reliable strategy by which to obliterate an acute traumatic vertebrojugular fistula as well as pseudoaneurysm. Serial angiographic follow-up is mandatory to document a persistent cure.
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Affiliation(s)
- Brian A O'Shaughnessy
- Department of Neurological Surgery, The Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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21
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Perry M, Dancey A, Mireskandari K, Oakley P, Davies S, Cameron M. Emergency care in facial trauma--a maxillofacial and ophthalmic perspective. Injury 2005; 36:875-96. [PMID: 16023907 DOI: 10.1016/j.injury.2004.09.018] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2004] [Revised: 09/10/2004] [Accepted: 09/10/2004] [Indexed: 02/02/2023]
Abstract
Facial trauma, with or without life- and sight-threatening complications, may arise following isolated injury, or it may be associated with significant injuries elsewhere. Assessment needs to be both systematic and repeated, with the establishment of clearly stated priorities in overall care. Although the American College of Surgeons Advanced Trauma Life Support (ATLS) system of care is generally accepted as the gold standard in trauma care, it has potential pitfalls when managing maxillofacial injuries, which are discussed. Management of facial trauma can arguably be regarded as "facial orthopaedics", as both specialities share common management principles. This review outlines a working approach to the identification and management of life- and sight-threatening conditions following significant facial trauma.
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Affiliation(s)
- Michael Perry
- Maxillofacial Unit, The Royal Group of Hospitals, Grosvenor Road, Belfast BT12 6BA, Northern Ireland, UK.
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22
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Aksoy M, Taviloglu K, Yanar H, Poyanli A, Ertekin C, Rozanes I, Guloglu R, Kurtoglu M. Percutaneous transcatheter embolization in arterial injuries of the lower limbs. Acta Radiol 2005; 46:471-5. [PMID: 16224920 DOI: 10.1080/02841850510021670] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of percutaneous transcatheter arterial embolization (PTE) in lower extremity arterial injuries. MATERIAL AND METHODS From January 2000 to June 2004, patients who presented with a penetrating trauma of the lower limbs, along with bleeding and with no sign of ischemia or hemodynamic instability, were included in the study. The injuries were embolized by coils and Gelfoam. The efficacy of PTE was defined as its ability to stop bleeding both radiographically and clinically, and its safety was determined by the complication rate. RESULTS There were 10 embolizations, which consisted of 5 profundal femoral, 3 superior gluteal, and 2 inferior gluteal artery embolizations. PTE was effective in all patients. There were two inguinal hematomas, which did not require any intervention, and there was a temporary renal function alteration. The mean hospital stay of these patients was 2.67 +/- 0.91 days. CONCLUSION PTE may be an effective and safe method of treatment in certain cases with lower limb arterial injuries. However, patients should be selected meticulously by both the vascular surgeon and the interventional radiologist, and PTE should be undertaken only in experienced hands.
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Affiliation(s)
- M Aksoy
- Department of Surgery, Medical Faculty of Istanbul, Istanbul University, Turkey.
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23
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Fernández-Prieto A, García-Raya P, Burgueño M, Muñoz-Caro J, Frutos R. Endovascular treatment of a pseudoaneurysm of the descending palatine artery after orthognathic surgery: technical note. Int J Oral Maxillofac Surg 2005; 34:321-3. [PMID: 15741042 DOI: 10.1016/j.ijom.2004.06.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2004] [Indexed: 11/28/2022]
Abstract
We report the clinical presentation (relapsing epistaxis after Le Fort I osteotomy), craniofacial digital subtraction angiography findings, and endovascular embolization through a microcatheter, in a 26-year-old patient with a pseudoaneurysm of the descending palatine artery.
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Affiliation(s)
- A Fernández-Prieto
- Department of Radiology, Neuroradiology Section, University Hospital La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain.
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24
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Buchalter GM, Johnson LP, Reichman MV, Jacobs J. Penetrating Trauma to the Head and Neck from a Nail Gun: A Unique Mechanism of Injury. EAR, NOSE & THROAT JOURNAL 2002. [DOI: 10.1177/014556130208101112] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Published reports of nail gun injuries to the head and neck are rare. We describe the cases of three patients who sustained nail gun injuries to the head and who were managed at our institution. All patients were treated successfully and all recovered with minimal morbidity. Any physician who is called on to manage a nail gun injury to the head or neck should understand that most likely the patient will have sustained a surprisingly limited amount of tissue injury, owing to the relatively low velocity of the projectile compared with that delivered by firearms. Computed tomography and selective angiography can play a vital role in assessing the integrity of relevant vascular structures. Moreover, catheter angiography with embolization can be a most useful nonsurgical adjunct to control the extent of vascular injury.
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Affiliation(s)
- Gregory M. Buchalter
- Ear, Nose, and Throat Department, Phoenix (Ariz.) Indian Medical Center, Salt Lake City
| | - Leland P. Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Utah Medical Center, Salt Lake City
| | | | - John Jacobs
- Department of Radiology, LDS Hospital, Salt Lake City
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25
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Albuquerque FC, Javedan SP, McDougall CG. Endovascular management of penetrating vertebral artery injuries. THE JOURNAL OF TRAUMA 2002; 53:574-80. [PMID: 12352501 DOI: 10.1097/00005373-200209000-00032] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Felipe C Albuquerque
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona 85013, USA
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26
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Abstract
Traumatic vascular lesions can occur after severe or even the most mild of head and cervical trauma. The initial evaluation of the injured patient must be thorough and the clinical suspicion of vascular injury must be highly suspected based on the mechanism of injury. Traumatic vascular injuries can be broadly classified into traumatic aneurysms, dissections and occlusions and fistulae of the carotid or vertebral arteries. The current management and treatment options of each condition are discussed.
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Affiliation(s)
- L L Guyot
- Department of Neurological Surgery, Wayne State University, Detroit Medical Center, Detroit, MI,
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27
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Abstract
Interventional radiology has assumed an expanded role in the management of the pediatric trauma patient. Transcatheter endovascular embolization for the polytraumatized and bleeding patient has proven to be effective and potentially life saving. Nonvascular interventional techniques can be applied to the pediatric trauma patient with curative or temporizing effects. The minimally invasive nature and rapidity of these procedures allows their emergent use in both the unstable and stable pediatric trauma patient.
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Affiliation(s)
- R Christensen
- Department of Radiology, Memorial Hospital, 1400 E Boulder, Colorado Springs, CO 80909, USA
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28
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Naidoo NM, Corr PD, Robbs JV, Maharaj J, Nair R. Angiographic embolisation in arterial trauma. Eur J Vasc Endovasc Surg 2000; 19:77-81. [PMID: 10706840 DOI: 10.1053/ejvs.1999.0978] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to evaluate the use of endovascular occlusion in the treatment of arterial trauma. METHODS records of patients with penetrating arterial injuries treated by endovascular occlusive techniques were culled from the computerised database of the vascular service. RESULTS the study period spanned 7 years. Forty-two patients were studied with injuries to the cervicofacial vessels (24), lower limb (16) and upper limb (1). 13 had an arteriovenous fistula. There were 4 failures. In 2 cannulation was not achieved and in 2 with A-VF distal vessel occlusion was impossible. Two patients developed complications. In the remainder, treatment was effective and durable. CONCLUSION this treatment modality is effective and safe in the treatment of penetrating trauma in selected patients.
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Affiliation(s)
- N M Naidoo
- Department of Surgery, University of Natal, South Africa
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29
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30
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Velmahos GC, Demetriades D, Chahwan S, Gomez H, Hanks SE, Murray JA, Asensio JA, Berne TV. Angiographic embolization for arrest of bleeding after penetrating trauma to the abdomen. Am J Surg 1999; 178:367-73. [PMID: 10612529 DOI: 10.1016/s0002-9610(99)00212-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Angiographic embolization is an effective technique to control bleeding after blunt trauma to the liver or pelvis. Its role in penetrating trauma to the abdomen has not been studied. METHODS From January 1992 to May 1998, 40 patients underwent angiography for bleeding resulting from intra-abdominal penetrating injuries (33 gunshot wounds, 7 stab wounds). Angiographic embolization of intraperitoneal or retroperitoneal vessels was performed by standard angiographic techniques with gelatin sponge and/or coils. Data were extracted from medical records, radiology data bank, trauma registry, and morbidity/mortality records, and compared by Student's t test and chi-square test. The main outcome measures were failure of angiographic embolization to control bleeding and complications of angiographic embolization. RESULTS Angiography was performed during a course of nonoperative management in 6 patients (group A), because of failure to control bleeding surgically in 23 (group B), and because of late vascular complications after an initially successful operation in 11 more (group C). In 32 patients, angiography revealed active bleeding; 29 (91 %) underwent successful angiographic embolization. Of the remaining 3 patients, 2 were successfully managed surgically (1 each from groups A and B) and 1 died despite multiple surgical maneuvers (group B). One patient who developed postoperatively a large, bleeding superior mesenteric artery pseudoaneurysm, suffered extensive bowel necrosis after angiographic embolization. No other significant complication was related to angiographic embolization. CONCLUSIONS Angiographic embolization after penetrating injuries to the abdomen is safe and effective for a small number of selected patients. It is a valuable tool for bleeding control when surgery has failed. It may be ideal for control of late vascular complications when reoperation is not desirable. It may prove to be a useful adjunct in the nonoperative treatment of selected injuries.
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Affiliation(s)
- G C Velmahos
- Department of Surgery, University of Southern California School of Medicine and the Los Angeles County + University of Southern California Medical Center, 90033-4525, USA
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Abstract
OBJECTIVE To review the presentation, symptoms and management associated with low velocity gunshot injuries to the temporal bone. METHODS A retrospective analysis of 26 patients treated for low velocity gunshot injuries to the temporal bone. RESULTS Initial presentation included otorrhoea (69 per cent), facial nerve injury (27 per cent), hearing loss (65 per cent), intracranial injuries (50 per cent), and cranial neuropathies (58 per cent). Nine patients (35 per cent) underwent angiography, which showed vascular injury in five of them. Four patients died. CONCLUSIONS Low velocity gunshot injuries can be devastating and may result in functional sequelae. Low velocity missiles crush and lacerate surrounding structures, while high velocity missiles cause extensive wound cavity formation. Early aggressive management for intracranial, vascular and facial nerve injury can improve outcome.
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Affiliation(s)
- S L Sabin
- State University of New York-Health Science Center at Brooklyn, USA
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32
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Gerbino G, Roccia F, Grosso M, Regge D. Pseudoaneurysm of the internal maxillary artery and Frey's syndrome after blunt facial trauma. J Oral Maxillofac Surg 1997; 55:1485-90. [PMID: 9393413 DOI: 10.1016/s0278-2391(97)90657-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- G Gerbino
- Divisione di chirurgia maxillo-facciale, Università di Torino, Italia
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