Arterial Embolism After Facial Fat Grafting: A Systematic Literature Review

BACKGROUND

While autologous fat grafting of the face is considered a generally safe procedure, severe complications such as arterial embolism (AE) have been reported.

OBJECTIVE

To summarize data on injection-related visual compromise, stroke, and death caused by arterial embolism after facial fat transplantation.

MATERIALS AND METHODS

Plastic surgery societies were contacted for reports on AE after autologous facial fat injection. In addition, a systematic literature review was performed. Data extracted included study design, injection site/technique, symptoms, management, outcome, and etiology.

RESULTS

61 patients with a mean age of 33.56 ± 11.45 years were reported. Injections targeted the glabella or multiple facial regions (both n = 16/61, 26.2%) most commonly, followed by injections in the temples (n = 10/61, 16.4%) and the forehead (n = 9/61, 14.8%). The mean volume injected was 21.5 ± 21.5 ml. Visual symptoms were described most frequently (n = 24/58, 41.4%) followed by neurological symptoms (n = 20/58, 34.5%), or both (n = 13/58, 22.4%). Ophthalmic artery (OA, n = 26/60, 43.3%), anterior or middle cerebral artery (CA, n = 11/60, 18.3%) or both (n = 14/60, 23.3%) were most frequently occluded. Outcome analysis revealed permanent vision loss in all patients with OA occlusion (n = 26/26, 100%), neurological impairment in most patients with CA occlusion (n = 8/10, 80%), and vision loss in most patients suffering from both OA and CA occlusion (n = 7/11, 63.6%). Six patients died following embolisms.

CONCLUSIONS

AE causes severe complications such as blindness, stroke, and death. Due to a lack of high-quality data, no evidence-based treatment algorithms exist. To increase patient safety, a database collecting cases and complications should be established.

LEVEL OF EVIDENCE III

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Atrial standstill associated with lamin A/C mutation: A case report

The case report shares evidence for a better understanding of atrial standstill. This being a rare arrhythmogenic condition. This is a 46-year-old woman presented with multiple sites of arterial embolism, including lower extremity arteries, coronary artery, and cerebral artery. Unexpectedly, multiple arterial embolization in the patient was due to atrial standstill by transthoracic echocardiography and cardiac electrophysiological study. An additional family investigation revealed that the patient's brother and sister also suffered from this disease. In search of further understanding the case, we carried out the genetic testing of the family and a frame shift double-G insertion mutation at c.1567 in the LMNA gene was found in all the three individuals. The patient recovered well after anticoagulation therapy and left bundle branch area pacing. This report remarks on the importance of multiple sites of arterial embolism which should be wary of family atrial standstill.

Lung tumor presenting with acute myocardial infarction and lower extremity arterial embolism

BACKGROUND

Lung tumor embolization leading to acute myocardial infarction (AMI) is rare. Previouscases of lung tumor embolization were reported in the coronary artery. We describe here a case of lung tumor embolization leading to the simultaneous occurrence of AMI and lower extremity arterial embolism.

CASE PRESENTATION

A 64-year-old patient was admitted to the emergency department complaining of chest pain and was diagnosed with AMI.An echocardiography showed a mass in the left atrium that was speculated to be a myxoma. An emergency coronary angiography found no evidence of atherosclerosis. On the second day of admission, the patient was diagnosed with lower extremity arterial embolism. Initially, we speculated that the left atrium myxoma caused an embolism resulting in the AMI and lower extremity arterial embolism.However, a lung tumor was the real cause of both conditions. Unfortunately, the patient abandoned treatment when he learned of his disease and died three days later after being discharged from the hospital.

CONCLUSIONS

Lung tumor embolism is an extremely rare cause of AMI. Even rarer is the case presented here, in which a lung tumor embolism caused AMI and lower extremity arterial embolism. Clinicians should recognize lung tumor embolism as a potential cause of AMI.

[Revascularization delay and complications in acute upper limb ischemia]

INTRODUCTION

Acute upper limb ischemia is a medical and surgical emergency. Studies that have reported revascularization results in acute upper limb ischemia are rare. For this reason, the revascularization delay has remained poorly defined. The purpose of this study was to evaluate surgery results of acute upper limb ischemia related to revascularization delay.

METHODS

We report a retrospective study of patients operated for acute upper limb ischemia between 2008 and 2016. Patients with thrombotic, traumatic or iatrogenic ischemia were excluded from this study. Patients were divided into two groups (those operated before 12hours and those operated after 12hours). A statistical analysis was performed to compare surgery results between the two groups in terms of limb salvage rate and neurological sequelae rate.

RESULTS

Our population consisted of 138 patients. The average age was 69 [31,92]. There were 90 women and 48 men. The mean revascularization delay was 20hours [2,240]. Seventy-six patients were operated on before 12hours and 62 patients after 12hours. At one month, the mortality was 1.4% and the morbidity was 5.7%. The overall limb salvage rate was 86.9% and the overall neurologic sequelae rate was 31.8%. Statistical analysis showed that there was no significant difference between patients operated before or after 12hours in terms of limb salvage (86.8% versus 87%, P=0.258). However, there was a statistically significant difference in terms of neurological sequelae in favor of patients operated after 12hours (15.7% versus 51.6%, P=0.012).

CONCLUSION

Revascularization of acute embolic upper limb ischemia is often associated with good results even if performed late. Beyond 12hours of ischemia, amputation rate is not significantly higher, however, the rate of neurological sequelae can be high.

Mesenteric Ischemia

Mesenteric ischemia is an uncommon disease most often seen in the elderly. This disease results from blood flow in the mesenteric circulation that inadequately meets metabolic needs of the visceral organs and, if untreated, eventually leads to necrosis of the bowel wall. Mesenteric ischemia is divided into 2 types: acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Delayed diagnosis of CMI can lead to AMI. AMI is associated with extremely high mortalities. Early diagnosis via computed tomography angiography and prompt revascularization via endovascular therapy are recommended for symptomatic patients who have not developed bowel ischemia and necrosis.

Emergency color Doppler sonography of the extremity artery: A pictorial essay

Arterial color duplex sonography (CDUS) of the extremities is routinely analyzed in the field of emergency radiology. A retrospective review of 500 consecutive arterial CDUS extremity studies was performed in our emergency department. Abnormal CDUS examinations were classified into two groups according to their primary etiology: 1) traumatic arterial injuries (accidents or post-operative complications) and 2) acute arterial ischemia (thrombosis or embolism outside of the setting of acute trauma). This article reviews common CDUS imaging findings in a busy emergency radiology division including traumatic pseudoaneurysm, secondary pseudoaneurysm, arteriovenous fistula, acute ischemic arterial disease and chronic peripheral arterial disease. This essay highlights the crucial role of CDUS in the diagnosis of vascular abnormalities in the emergency setting. CDUS provides several advantages over other imaging modalities including high accuracy, rapid results, portability, lack of radiation, and low cost.

Anaplastic Lymphoma Kinase-Positive Anaplastic Large Cell Lymphoma with Cardiac Metastasis and Arterial Tumor Embolisms during First-Course Chemotherapy

We described an 11-year-old boy suffering from pediatric anaplastic lymphoma kinase-positive anaplastic large cell lymphoma with heart metastasis at diagnosis and arterial tumor embolisms during chemotherapy. Both the heart metastasis and pericardial effusion showed improvement with prednisolone, but numbness and pallor sequentially developed in his lower extremities during the first course of chemotherapy. Contrast-enhanced imaging revealed occlusion of the right anterior tibial artery and left popliteal artery. These symptoms were spontaneously remitted due to the compensation of other arteries. Arterial tumor embolism is a rare but possible complication when a lymphoma shows intracardiac infiltration.

Injury to the Anterior Tibial Artery during Bicortical Tibial Drilling in Anterior Cruciate Ligament Reconstruction

Many complications have been reported during or after anterior cruciate ligament (ACL) reconstruction, including infection, bleeding, tibial tunnel widening, arthrofibrosis, and graft failure. However, arterial injury has been rarely reported. This paper reports a case of an anterior tibial arterial injury during bicortical tibial drilling in arthroscopic ACL reconstruction, associated with an asymptomatic occlusion of the popliteal artery. The patient had a vague pain which led to delayed diagnosis of compartment syndrome and delayed treatment with fasciotomy. All surgeons should be aware of these rare but critical complications because the results may be disastrous like muscle necrosis as in this case.

Suspected cerebral arterial gas embolism during a laparoscopic Nissen fundoplication

We present the first case report known to us of a suspected cerebral arterial gas embolism (CAGE) leading to transient left-sided hemiparesis after a laparoscopic Nissen fundoplication. During the operation there was no evidence of hemodynamic compromise and the end-tidal carbon dioxide level and oxygen saturation had been within normal limits. Radiological studies and transesophageal echocardiography showed no abnormalities. We conclude that CAGE can occur during uncomplicated laparoscopic surgery even in the absence of demonstrable intracardiac shunts.

Arterial embolism

Surgical and intensive care patients are at a heightened risk for arterial embolization due to pre-existing conditions such as age, hypercoagulability, cardiac abnormalities and atherosclerotic disease. Most arterial emboli are clots that originate in the heart and travel to distant vascular beds where they cause arterial occlusion, ischemia, and potentially infarction. Other emboli form on the surface of eroded arterial plaque or within its lipid core. Thromboemboli are large clots that dislodge from the surface of athesclerotic lesions and occlude distal arteries causing immediate ischemia. Atheroemboli, which originate from fracturing the lipid core tend to cause a process of organ dysfunction and systemic inflammation, termed cholesterol embolization syndrome. The presentation of arterial emboli depends on the arterial bed that is affected. The most common manifestations are strokes and acute lower limb ischemia. Less frequently, emboli target the upper extremities, mesenteric or renal arteries. Treatment involves rapid diagnosis, which may be aided by precise imaging studies and restoration of blood flow. The type of emboli, duration of presentation, and organ system affected determines the treatment course. Long-term therapy includes supportive medical care, identification of the source of embolism and prevention of additional emboli. Patients who experienced arterial embolism as a result of clots formed in the heart should be anticoagulated. Arterial emboli from atherosclerotic disease of the aorta or other large arteries should prompt treatment to reduce the risk for atherosclerotic progression, such as anti-platelet therapy and the use of statin drugs. The use of anticoagulation and surgical intervention to reduce the risk of arterial embolization from atherosclerotic lesions is still being studied.

Recurrent leiomyosarcoma presenting as malignant arterial tumor thrombus

► The report reviews unique arterial embolic phenomena in the context of newly diagnosed recurrent leiomyosarcoma. ► Metastatic work-up should be initiated in those diagnosed with malignant arterial tumor emboli.