Management of an internal carotid artery injury caused by a displaced titanium plate with a combination of interventional vascular radiology and surgery

Publication date: Available online 20 February 2018
Source:Journal of Oral and Maxillofacial Surgery
Author(s): Yoshitaka Shimizu, Takahito Okazaki, Tomoaki Hamana, Masahiro Irifune
Treatment of pseudoaneurysms in the internal carotid artery (ICA) is associated with a high risk of cerebral infarction; therefore, vessel ligation for hemostasis must be avoided. A 66-year-old man experienced intra-oral hemorrhaging. At the time of the initial examination, computed tomography angiography revealed jaw plate displacement near the ICA. A more detailed image was obtained using digital subtraction angiography. After evaluation of the image, a pseudoaneurysm was diagnosed. Six days later, there were concerns about aspiration and airway obstruction; therefore, tracheostomy was performed. Interventional vascular radiology and surgery were planned to facilitate complete recovery, removal of the jaw plate, and repair of the pseudoaneurysm. Before surgery, it was confirmed that it would be possible to block blood flow for approximately 20 minutes. Surgery was performed under general anesthesia. Before plate removal, cardiovascular surgeons exposed the left large saphenous vein and prepared it so that it could be used to patch the vascular wall defect. An embolic protection device (EPD) was placed so that it could be inflated at any time after plate removal via oral surgery. The pseudoaneurysm was found directly under the plate; however, it had adhered to the scar tissue. As removal progressed, hemorrhaging occurred. To achieve hemostasis, the EPD balloon was inflated. The pseudoaneurysm was removed and a red thrombus was aspirated. On postoperative day 41, bleeding reoccurred. Two days later, embolization using a platinum coil and stent placement were performed through interventional vascular radiology (IVR) monotherapy. Postoperative progress was favorable and the patient was discharged 83 days after treatment without neurologic sequelae. ICA pseudoaneurysms located near the skull base are risky and challenging to repair. However, for traumatic aneurysms such as this one, a combination of IVR therapy and surgery is useful for controlling intraoperative hemorrhage.



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