Rare disease
CASE REPORT
Left maxillary artery pseudoaneurysm: a rare and late postoperative complication after head and neck cancer treatment Ganesh Kamath,1 Ravikiran Naalla,2 Vasudev Baburaya Pai,1 Ramakrishna Narayanan3 1
Department of Cardiac Surgery, Kasturba Medical College, Manipal, Karnataka, India 2 Department of General Surgery, Kasturba Medical College, Manipal, Karnataka, India 3 Department of Radiodiagnosis, Kasturba Medical College, Manipal, Karnataka, India Correspondence to Dr Ravikiran Naalla, [email protected] Accepted 19 February 2014
SUMMARY 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.
INVESTIGATIONS BACKGROUND Vascular complications after head and neck cancer surgery usually are haemorrhage, thrombosis, pseudoaneurysm and arteriovenous fistula.1 Delayed presentation of maxillary artery pseudoaneurysm (with a discharging sinus) in a patient who has undergone head and neck cancer treatment (surgery followed by chemoradiotherapy) has not been reported to the best of our knowledge. The delayed presentation is also unusual. There was no history of trauma or any recent surgery in that area. The common aetiology of pseudoaneurysms of the maxillary arteries is post-traumatic mandibular fractures.2 In our patient, no cause could be detected, and we have to presume that it is a case of late onset disruption in the arterial wall and may be related to irradiation. The ideal treatment is percutaneous embolisation and rarely surgery. In this case, the pseudoaneurysm was complicated with sinus formation and added infection hence surgical excision of the clots and ligation of the feeding vessel were necessary.
CASE PRESENTATION
To cite: Kamath G, Naalla R, Pai VB, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013203078
revealed a 5×3 cm swelling over and below the left zygomatic arch (figure 1), with expansile pulsations (video 1). There was local rise of temperature, slightly tender and inflamed. Systolic bruit was heard on auscultation and there was no continuous murmur. A 0.5 cm diameter sinus discharging (pulsatile) serosanguinous fluid and sometimes blood was noted in the inferior aspect of the swelling. Systemic examination did not reveal any other significant findings.
A 50-year-old man presented to us with a pulsatile swelling on the left face since 2 months and consequently developed a sinus 3 days prior to presentation, discharging blood-stained fluid. Three years earlier, he was operated for squamous cell carcinoma (SCC) of the left lower alveolus and underwent left hemimandibulectomy with therapeutic neck dissection and pectoralis major myocutaneous flap reconstruction followed by chemoradiotherapy. All treatments were completed 2 years ago. He had no symptoms or comorbid illnesses. He was on regular follow-up, and there was no evidence of carcinoma recurrence. He has facial asymmetry ( postsurgery) and a healthy flap. Inspection
Kamath G, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203078
Routine blood parameters were within normal limits. X-ray of the skull showed no erosion of zygomatic arch. Contrast-enhanced CT (CECT) scan sagittal and coronal section images (figures 2 and 3) clinched the diagnosis, and leak was visualised from the left maxillary artery at the distal part, rest of the swelling, which was non-enhancing, was due to organised clots.
DIFFERENTIAL DIAGNOSIS Arteriovenous malformation (AVM), haematoma, abscess, angiofibroma and parotid mass.
TREATMENT The patient was taken up for emergency aneurysm ligation. The incision started at the lower part of the left zygomatic arch anteriorly going backwards towards the tragus of the left pinna and downwards into the upper part of the neck up until the mid sternocleidomastoid muscle. There was dense adhesion due to prior radiation and therefore it was decided to directly open the aneurysmal sac. The clots were removed and the rent sutured with 5-0 monofilament suture. Next the area was dissected and the feeding vessel found out and ligated which was the proximal maxillary artery. (figure 4).
OUTCOME AND FOLLOW-UP Postoperative recovery was uneventful. On discharge, the sinus was still raw and required daily dressing for 2 weeks for healing to occur and later the patient was symptom free and doing well on follow-up after 1 month.
DISCUSSION A pseudoaneurysm is a haematoma that forms as the result of a rent from an artery due to direct trauma or postoperative injury, where the arterial wall gets partially damaged. Another aetiology is 1
Rare disease
Figure 1 A swelling of 5×3 cm, superficial to and below the left zygomatic arch (yellow arrows), 0.5 cm sinus at the anteroinferior aspect of swelling (blue arrow).
Figure 2 Axial CT angiogram section showing the origin of superficial temporal branch (white arrow) of left external carotid artery just proximal to the pseudoaneurysm (black arrow) arising from the left maxillary artery, surrounded by eccentric non-enhancing isoattenuating soft-tissue mass consistent with thrombus (yellow arrows).
due to a near by prosthesis or metal rod, where the artery pulsation continuously abuts against the metal. Common cause is iatrogenic trauma2–4 whenever dissection near an artery partially injures the arterial adventitia or even deeper into the media of arterial wall and later leads to disruption of the vessel wall. The infective aetiology of pseudoaneurysms like mycotic aneurysms has been reported.5 The natural pathophysiology of pseudoaneurysm starts from the arterial leak which leads to haematoma formation and persists until the pressure in the haematoma is large enough to counterbalance the arterial pressure and tamponade the area by the surrounding tissues. By this tamponade effect the further arterial flow is diminished. Meanwhile, the haematoma turns into a clot, retracts and the central portion liquefies in seven or more days followed by the formation of endothelial lined continuity with the vessel wall owing to the pulsatile nature of the pseudoaneurysm.4 Externally, the haematoma forms a false vascular wall ( pseudocapsule). This pseudocapsule may rupture and cause haemorrhage. The clinical diagnosis of a pseudoaneurysm is based on the history of trauma or surgery to the involved region and subsequent development of a pulsatile mass, which gradually increases in size. They usually present within weeks to months
of injury,6 even they may present as late as 6 months to 3 years after initial injury.7 Our patient gives neither history of trauma nor any intervention post surgery, which might cause arterial injury, and there is no history suggestive of infection. Hence we attribute the aetiology to either trauma during previous surgery which has manifested very late or postirradiation.8 The chance of maxillary artery injury during extensive surgery appears remote as already 3 years have passed. Irradiation is a strong possibility which could have weakened the arterial wall due to radiation induced arteritis and resulted in the aneurysm. Radiation therapy affects all sizes of blood vessels within the field of treatment. Degeneration of the endothelium, vacuolisation and thickening of the intima associated with changes in the elastic fibres have been described in the radiated arteries of humans. However, vascular occlusion is the most common form of presentation.9 These changes manifest as early as 4 months or as late as 23 years after radiotherapy.10 Since then, Thomas and Forbus11 published the first report of radiation injury to blood vessels; literature review shows many numbers of similar reports of radiation-induced vasculopathy. Formation of aneurysm as a complication of radiation therapy in various sites like iliac artery,12 arteries of circle of Willis,13 carotid artery14 have been reported. Similarly, there are several reports of pseudoaneurysm of the external carotid artery following radical neck dissection and irradiation.15 The patient received a total of 60 Gy radiation doses, and it was 2 years ago. The expansile pulsation immediately points towards the diagnosis of aneurysm. For final confirmation other tests are required. Duplex scan is a non-invasive technique and clinches the diagnosis; the laminar thrombosis and the size of the leak area can be measured but it provides little information about the soft tissues and osseous structures adjacent to the lesion. Magnetic resonance angiography is non-invasive but expensive and it can highlight the soft tissue abnormality and its relationship to the adjacent soft tissues. Turbulent flow within a pseudoaneurysm could result in intervoxel dephasing, which could underestimate the size of the lesion or overestimate the amount
Video 1 Video clip showing the pulsatile nature of the swelling. 2
Kamath G, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203078
Rare disease
Figure 3 Coronal CT angiogram section shows: fusiform pseudoaneurysm arising from left maxillary artery (single thick arrow) surrounded by eccentric non-enhancing isoattenuating soft-tissue mass consistent with thrombus (double arrows), left external carotid artery.
relationship with the osseous structures are clearly shown. In our case, AVM has been ruled out as there was no evidence for asymmetric early venous drainage. The maxillary artery is one of the larger terminal branches of the external carotid artery and is divided into three parts, mandibular, pterygoid and pterygopalatine. It arises below the temporomandibular joint and enters posterior to neck of the mandible, and through the substance of the parotid gland, it passes forward between the ramus of the mandible and the sphenomandibular ligament and then runs, either superficial or deep to the lateral pterygoid muscle, to the pterygopalatine fossa. It supplies the inner structures of the face. The third part of the maxillary artery was involved in our case. Treatment of the pseudoaneurysm usually depends on its severity, characteristics and the health status of the patient hence the treatment should be individualised.17 Options available are non-invasive ( prolonged manual compression) for very small aneurysms and at superficial areas and invasive ( percutaneous embolisation, surgical excision or both). In percutaneous embolisation, metallic coils, polyvinyl alcohol particles and absorbable gelatine sponge are used by occlusion where they convert a pseudoaneurysm into a haematoma, the later gets reabsorbed in due course. Surgical exploration and excision are undertaken when conservative or percutaneous embolisation have failed. However, pseudoaneurysms with local signs of infection are best treated surgically.17 Our patient underwent surgical excision and has fully recovered.
Learning points of thrombosis.16 There are several advantages with CT angiography like it can assess the patency and position of the vessels, true size of the pseudoaneurysm is accurately depicted,
▸ Iatrogenic pseudoaneurysm of arteries can present in a delayed fashion contrary to their common early presentation. ▸ Proper clinical examination can differentiate vascular lesions from more common lesions like abscesses particularly at an operated site to avoid torrential bleeding. ▸ Irradiation can lead to weakness in the arterial wall leading to complications. ▸ A level of suspicion of occult vascular injuries is required in patients with unilateral facial swellings following mandibular surgeries even after years after the procedure was recommended.
Contributors RavN contributed towards data collection, manuscript preparation and submission. GK and VBP modified and proof read the article. RamN provided legends to the CT scan images. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2 3
Figure 4 Intraoperative digital image shows the ligated left maxillary (single arrow), excised thrombus shown in the inset. Kamath G, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203078
4
Miller DR, Bergstrom L. Vascular complications of head and neck surgery. Arch Otolaryngol 1974;100:136–40. Kim SG, Park SS. Incidence of complications and problems related to orthognathic surgery. J Oral Maxillofac Surg 2007;65:2438–44. Stiefel MF, Park MS, McDougall CG, et al. Endovascular treatment of hemorrhagic alveolar artery pseudoaneurysm after tooth extraction: a case report. J Oral Maxillofac Surg 2010;68:2325–8. Zachariades N, Skoura C, Mezitis M, et al. Pseudoaneurysm after a routine transbuccal approach for bone screw placement. J Oral Maxillofac Surg 2000;58:671–3.
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Dunn GP, Uppaluri R, Hessler JL, et al. Mycotic pseudoaneurysm of the internal maxillary artery: case report and review of the literature. Arch Otolaryngol Head Neck Surg 2007;133:402–6. Yeo MS, Goh TL, Nallathamby V, et al. Maxillary artery injury associated with subcondylar mandible fractures: a novel treatment algorithm. Craniomaxillofac Trauma Reconstr 2012;5:83–8. Peick AL, Nichols WK, Curtis JJ, et al. Aneurysms and pseudoaneurysms of the superficial temporal artery caused by trauma. J Vasc Surg 1988;8:606–10. Yucesoy K, Feiz-Erfan I, Spetzler RF, et al. Anterior communicating artery aneurysm following radiation therapy for optic glioma: report of a case and review of the literature. Skull Base 2004;14:169–73. Yucesoy K, Feiz-Erfan I, Spetzler RF, et al. Anterior communicating artery aneurysm following radiation therapy for optic glioma: report of a case and review of the literature. Skull Base 2004;74:169–73. Brant-Zawadzki M, Anderson M, DeArmond SJ, et al. Radiation-induced large intracranial vessel occlusive vasculopathy. AJR Am J Roentgenol 1980;134:51–5. Thomas E, Forbus WD. Irradiation injury to the aorta and the lung. AMA Arch Pathol 1959;67:256–63.
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de Baere T, Ousehal A, Kuoch V, et al. Endovascular management of bleeding iliac artery pseudoaneurysms complicating radiation therapy for pelvic malignancies. AJR Am J Roentgenol 1998;170:349–53. Holodny AI, Deck M, Petito CK. Induction and subsequent rupture of aneurysms of the circle of Willis after radiation therapy in Ehlers-Danlos syndrome: a plausible hypothesis. AJNR Am J Neuroradiol 1996;17:226–32. Murros KE, Toole JF. The effect of radiation on carotid arteries. A review article. Arch Neurol 1989;46:449–55. Minion DJ, Lynch TG, Baxter BT, et al. Pseudoaneurysm of the external carotid artery following radical neck dissection and irradiation: a case report and review of the literature. Cardiovasc Surg 1994;2:607–11. Walker MT, Liu BP, Salehi SA, et al. Superficial temporal artery pseudoaneurysm: diagnosis and preoperative planning with CT angiography. AJNR Am J Neuroradiol 2003;24:147–50. Silva AC, O’Ryan F, Beckley ML, et al. Pseudoaneurysm of a branch of the maxillary artery following mandibular sagittal split ramus osteotomy: case report and review of the literature. J Oral Maxillofac Surg 2007;65: 1807–16.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
4
Kamath G, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203078
CASE REPORT
Left maxillary artery pseudoaneurysm: a rare and late postoperative complication after head and neck cancer treatment Ganesh Kamath,1 Ravikiran Naalla,2 Vasudev Baburaya Pai,1 Ramakrishna Narayanan3 1
Department of Cardiac Surgery, Kasturba Medical College, Manipal, Karnataka, India 2 Department of General Surgery, Kasturba Medical College, Manipal, Karnataka, India 3 Department of Radiodiagnosis, Kasturba Medical College, Manipal, Karnataka, India Correspondence to Dr Ravikiran Naalla, [email protected] Accepted 19 February 2014
SUMMARY 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.
INVESTIGATIONS BACKGROUND Vascular complications after head and neck cancer surgery usually are haemorrhage, thrombosis, pseudoaneurysm and arteriovenous fistula.1 Delayed presentation of maxillary artery pseudoaneurysm (with a discharging sinus) in a patient who has undergone head and neck cancer treatment (surgery followed by chemoradiotherapy) has not been reported to the best of our knowledge. The delayed presentation is also unusual. There was no history of trauma or any recent surgery in that area. The common aetiology of pseudoaneurysms of the maxillary arteries is post-traumatic mandibular fractures.2 In our patient, no cause could be detected, and we have to presume that it is a case of late onset disruption in the arterial wall and may be related to irradiation. The ideal treatment is percutaneous embolisation and rarely surgery. In this case, the pseudoaneurysm was complicated with sinus formation and added infection hence surgical excision of the clots and ligation of the feeding vessel were necessary.
CASE PRESENTATION
To cite: Kamath G, Naalla R, Pai VB, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013203078
revealed a 5×3 cm swelling over and below the left zygomatic arch (figure 1), with expansile pulsations (video 1). There was local rise of temperature, slightly tender and inflamed. Systolic bruit was heard on auscultation and there was no continuous murmur. A 0.5 cm diameter sinus discharging (pulsatile) serosanguinous fluid and sometimes blood was noted in the inferior aspect of the swelling. Systemic examination did not reveal any other significant findings.
A 50-year-old man presented to us with a pulsatile swelling on the left face since 2 months and consequently developed a sinus 3 days prior to presentation, discharging blood-stained fluid. Three years earlier, he was operated for squamous cell carcinoma (SCC) of the left lower alveolus and underwent left hemimandibulectomy with therapeutic neck dissection and pectoralis major myocutaneous flap reconstruction followed by chemoradiotherapy. All treatments were completed 2 years ago. He had no symptoms or comorbid illnesses. He was on regular follow-up, and there was no evidence of carcinoma recurrence. He has facial asymmetry ( postsurgery) and a healthy flap. Inspection
Kamath G, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203078
Routine blood parameters were within normal limits. X-ray of the skull showed no erosion of zygomatic arch. Contrast-enhanced CT (CECT) scan sagittal and coronal section images (figures 2 and 3) clinched the diagnosis, and leak was visualised from the left maxillary artery at the distal part, rest of the swelling, which was non-enhancing, was due to organised clots.
DIFFERENTIAL DIAGNOSIS Arteriovenous malformation (AVM), haematoma, abscess, angiofibroma and parotid mass.
TREATMENT The patient was taken up for emergency aneurysm ligation. The incision started at the lower part of the left zygomatic arch anteriorly going backwards towards the tragus of the left pinna and downwards into the upper part of the neck up until the mid sternocleidomastoid muscle. There was dense adhesion due to prior radiation and therefore it was decided to directly open the aneurysmal sac. The clots were removed and the rent sutured with 5-0 monofilament suture. Next the area was dissected and the feeding vessel found out and ligated which was the proximal maxillary artery. (figure 4).
OUTCOME AND FOLLOW-UP Postoperative recovery was uneventful. On discharge, the sinus was still raw and required daily dressing for 2 weeks for healing to occur and later the patient was symptom free and doing well on follow-up after 1 month.
DISCUSSION A pseudoaneurysm is a haematoma that forms as the result of a rent from an artery due to direct trauma or postoperative injury, where the arterial wall gets partially damaged. Another aetiology is 1
Rare disease
Figure 1 A swelling of 5×3 cm, superficial to and below the left zygomatic arch (yellow arrows), 0.5 cm sinus at the anteroinferior aspect of swelling (blue arrow).
Figure 2 Axial CT angiogram section showing the origin of superficial temporal branch (white arrow) of left external carotid artery just proximal to the pseudoaneurysm (black arrow) arising from the left maxillary artery, surrounded by eccentric non-enhancing isoattenuating soft-tissue mass consistent with thrombus (yellow arrows).
due to a near by prosthesis or metal rod, where the artery pulsation continuously abuts against the metal. Common cause is iatrogenic trauma2–4 whenever dissection near an artery partially injures the arterial adventitia or even deeper into the media of arterial wall and later leads to disruption of the vessel wall. The infective aetiology of pseudoaneurysms like mycotic aneurysms has been reported.5 The natural pathophysiology of pseudoaneurysm starts from the arterial leak which leads to haematoma formation and persists until the pressure in the haematoma is large enough to counterbalance the arterial pressure and tamponade the area by the surrounding tissues. By this tamponade effect the further arterial flow is diminished. Meanwhile, the haematoma turns into a clot, retracts and the central portion liquefies in seven or more days followed by the formation of endothelial lined continuity with the vessel wall owing to the pulsatile nature of the pseudoaneurysm.4 Externally, the haematoma forms a false vascular wall ( pseudocapsule). This pseudocapsule may rupture and cause haemorrhage. The clinical diagnosis of a pseudoaneurysm is based on the history of trauma or surgery to the involved region and subsequent development of a pulsatile mass, which gradually increases in size. They usually present within weeks to months
of injury,6 even they may present as late as 6 months to 3 years after initial injury.7 Our patient gives neither history of trauma nor any intervention post surgery, which might cause arterial injury, and there is no history suggestive of infection. Hence we attribute the aetiology to either trauma during previous surgery which has manifested very late or postirradiation.8 The chance of maxillary artery injury during extensive surgery appears remote as already 3 years have passed. Irradiation is a strong possibility which could have weakened the arterial wall due to radiation induced arteritis and resulted in the aneurysm. Radiation therapy affects all sizes of blood vessels within the field of treatment. Degeneration of the endothelium, vacuolisation and thickening of the intima associated with changes in the elastic fibres have been described in the radiated arteries of humans. However, vascular occlusion is the most common form of presentation.9 These changes manifest as early as 4 months or as late as 23 years after radiotherapy.10 Since then, Thomas and Forbus11 published the first report of radiation injury to blood vessels; literature review shows many numbers of similar reports of radiation-induced vasculopathy. Formation of aneurysm as a complication of radiation therapy in various sites like iliac artery,12 arteries of circle of Willis,13 carotid artery14 have been reported. Similarly, there are several reports of pseudoaneurysm of the external carotid artery following radical neck dissection and irradiation.15 The patient received a total of 60 Gy radiation doses, and it was 2 years ago. The expansile pulsation immediately points towards the diagnosis of aneurysm. For final confirmation other tests are required. Duplex scan is a non-invasive technique and clinches the diagnosis; the laminar thrombosis and the size of the leak area can be measured but it provides little information about the soft tissues and osseous structures adjacent to the lesion. Magnetic resonance angiography is non-invasive but expensive and it can highlight the soft tissue abnormality and its relationship to the adjacent soft tissues. Turbulent flow within a pseudoaneurysm could result in intervoxel dephasing, which could underestimate the size of the lesion or overestimate the amount
Video 1 Video clip showing the pulsatile nature of the swelling. 2
Kamath G, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203078
Rare disease
Figure 3 Coronal CT angiogram section shows: fusiform pseudoaneurysm arising from left maxillary artery (single thick arrow) surrounded by eccentric non-enhancing isoattenuating soft-tissue mass consistent with thrombus (double arrows), left external carotid artery.
relationship with the osseous structures are clearly shown. In our case, AVM has been ruled out as there was no evidence for asymmetric early venous drainage. The maxillary artery is one of the larger terminal branches of the external carotid artery and is divided into three parts, mandibular, pterygoid and pterygopalatine. It arises below the temporomandibular joint and enters posterior to neck of the mandible, and through the substance of the parotid gland, it passes forward between the ramus of the mandible and the sphenomandibular ligament and then runs, either superficial or deep to the lateral pterygoid muscle, to the pterygopalatine fossa. It supplies the inner structures of the face. The third part of the maxillary artery was involved in our case. Treatment of the pseudoaneurysm usually depends on its severity, characteristics and the health status of the patient hence the treatment should be individualised.17 Options available are non-invasive ( prolonged manual compression) for very small aneurysms and at superficial areas and invasive ( percutaneous embolisation, surgical excision or both). In percutaneous embolisation, metallic coils, polyvinyl alcohol particles and absorbable gelatine sponge are used by occlusion where they convert a pseudoaneurysm into a haematoma, the later gets reabsorbed in due course. Surgical exploration and excision are undertaken when conservative or percutaneous embolisation have failed. However, pseudoaneurysms with local signs of infection are best treated surgically.17 Our patient underwent surgical excision and has fully recovered.
Learning points of thrombosis.16 There are several advantages with CT angiography like it can assess the patency and position of the vessels, true size of the pseudoaneurysm is accurately depicted,
▸ Iatrogenic pseudoaneurysm of arteries can present in a delayed fashion contrary to their common early presentation. ▸ Proper clinical examination can differentiate vascular lesions from more common lesions like abscesses particularly at an operated site to avoid torrential bleeding. ▸ Irradiation can lead to weakness in the arterial wall leading to complications. ▸ A level of suspicion of occult vascular injuries is required in patients with unilateral facial swellings following mandibular surgeries even after years after the procedure was recommended.
Contributors RavN contributed towards data collection, manuscript preparation and submission. GK and VBP modified and proof read the article. RamN provided legends to the CT scan images. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2 3
Figure 4 Intraoperative digital image shows the ligated left maxillary (single arrow), excised thrombus shown in the inset. Kamath G, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203078
4
Miller DR, Bergstrom L. Vascular complications of head and neck surgery. Arch Otolaryngol 1974;100:136–40. Kim SG, Park SS. Incidence of complications and problems related to orthognathic surgery. J Oral Maxillofac Surg 2007;65:2438–44. Stiefel MF, Park MS, McDougall CG, et al. Endovascular treatment of hemorrhagic alveolar artery pseudoaneurysm after tooth extraction: a case report. J Oral Maxillofac Surg 2010;68:2325–8. Zachariades N, Skoura C, Mezitis M, et al. Pseudoaneurysm after a routine transbuccal approach for bone screw placement. J Oral Maxillofac Surg 2000;58:671–3.
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Dunn GP, Uppaluri R, Hessler JL, et al. Mycotic pseudoaneurysm of the internal maxillary artery: case report and review of the literature. Arch Otolaryngol Head Neck Surg 2007;133:402–6. Yeo MS, Goh TL, Nallathamby V, et al. Maxillary artery injury associated with subcondylar mandible fractures: a novel treatment algorithm. Craniomaxillofac Trauma Reconstr 2012;5:83–8. Peick AL, Nichols WK, Curtis JJ, et al. Aneurysms and pseudoaneurysms of the superficial temporal artery caused by trauma. J Vasc Surg 1988;8:606–10. Yucesoy K, Feiz-Erfan I, Spetzler RF, et al. Anterior communicating artery aneurysm following radiation therapy for optic glioma: report of a case and review of the literature. Skull Base 2004;14:169–73. Yucesoy K, Feiz-Erfan I, Spetzler RF, et al. Anterior communicating artery aneurysm following radiation therapy for optic glioma: report of a case and review of the literature. Skull Base 2004;74:169–73. Brant-Zawadzki M, Anderson M, DeArmond SJ, et al. Radiation-induced large intracranial vessel occlusive vasculopathy. AJR Am J Roentgenol 1980;134:51–5. Thomas E, Forbus WD. Irradiation injury to the aorta and the lung. AMA Arch Pathol 1959;67:256–63.
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14 15
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de Baere T, Ousehal A, Kuoch V, et al. Endovascular management of bleeding iliac artery pseudoaneurysms complicating radiation therapy for pelvic malignancies. AJR Am J Roentgenol 1998;170:349–53. Holodny AI, Deck M, Petito CK. Induction and subsequent rupture of aneurysms of the circle of Willis after radiation therapy in Ehlers-Danlos syndrome: a plausible hypothesis. AJNR Am J Neuroradiol 1996;17:226–32. Murros KE, Toole JF. The effect of radiation on carotid arteries. A review article. Arch Neurol 1989;46:449–55. Minion DJ, Lynch TG, Baxter BT, et al. Pseudoaneurysm of the external carotid artery following radical neck dissection and irradiation: a case report and review of the literature. Cardiovasc Surg 1994;2:607–11. Walker MT, Liu BP, Salehi SA, et al. Superficial temporal artery pseudoaneurysm: diagnosis and preoperative planning with CT angiography. AJNR Am J Neuroradiol 2003;24:147–50. Silva AC, O’Ryan F, Beckley ML, et al. Pseudoaneurysm of a branch of the maxillary artery following mandibular sagittal split ramus osteotomy: case report and review of the literature. J Oral Maxillofac Surg 2007;65: 1807–16.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
4
Kamath G, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203078
