Delayed transcutaneous extrusion of embolic coils after embolization of facial artery pseudoaneurysm

Endovascular coils extrusion after internal carotid artery occlusion: From management to follow-up

KEY POINTS

ICA coil extrusion (ICA-CE) occurs most frequently in the nasopharyngeal/sinonasal site. Evaluating the ICA coils stability, through an angiography, is of primary importance. ICA-CE management needs to be decided based on the patient's symptoms and general status.

Head and Neck Arteriovenous Malformations: Clinical Manifestations and Endovascular Treatments

Arteriovenous malformations (AVMs) are vascular malformations that present high-flow direct communication between the arteries and veins, not involving the capillary beds. They can be progressive and lead to various manifestations, including abnormal skin or mucosal findings, ischemia, hemorrhage, and high-output heart failure in severe cases. AVMs often involve the head and neck region. Head and neck AVMs can present region-specific clinical manifestations, angioarchitecture, and complications, especially in cosmetic appearance and ingestion, respiratory, and neuronal functions. Therefore, when planning endovascular treatment of head and neck AVMs, physicians should consider not only the treatment strategy but also the preservation of the cosmetic appearance and critical functions. Knowledge of the functional vascular anatomy as well as treatment techniques should facilitate a successful management. This review summarizes AVMs' clinical manifestations, imaging findings, treatment strategy, and complications.

Traumatic pseudoaneurysms of external carotid artery branch: Case series and treatment considerations

PURPOSE

To explore the diagnosis and treatment of traumatic external carotid branch pseudoaneurysms.

METHODS

Eleven cases of traumatic external carotid artery branch pseudoaneurysms were admitted in our hospital. Digital subtraction angiography was performed in all patients. It revealed that the pseudoaneurysms originated from the internal maxillary artery in 5 cases, superficial temporal artery in 5 cases and occipital artery in 1 case. Five cases of internal maxillary artery pseudoaneurysms and 2 cases of superficial temporal artery pseudoaneurysms were treated by embolization; the other 3 cases were surgically resected.

RESULTS

Complete cessation of nasal bleeding was achieved in all the 5 pseudoaneurysms of internal maxillary artery after the endovascular therapies. Scalp bleeding stopped and scalp defect healed up in 2 patients with superficial temporal artery pseudoaneurysms treated by interventional therapy. All patients were followed up for 0.5-2.0 years without recurrence of nosebleed and scalp lump.

CONCLUSION

For patients with repeated severe epistaxis after craniocerebral injury, digital subtraction angiography should be performed as soon as possible to confirm traumatic pseudoaneurysm. Endovascular therapy is an effective method for traumatic internal maxillary artery pseudoaneurysms. For patients with scalp injuries and pulsatile lumps, further examinations including digital subtraction angiography should be performed to confirm the diagnosis. Surgical treatment or endovascular therapy for scalp traumatic pseudoaneurysm is effective.

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

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

Delayed intranasal coil extrusion after internal carotid artery pseudoaneurysm embolization

Internal carotid artery (ICA) injury is a rare but potentially life-threatening complication of skull base and neck surgery. Although usually manifested by massive intraoperative haemorrhage, impairment of the ICA might go unnoticed and result in formation of a pseudoaneurysm, causing delayed bleeding. Often additional complications are observed such as thrombosis, spasm, embolism or carotico-cavernous fistula formation. The risk of carotid artery injury in aggressive endonasal skull base surgical interventions ranges from 1% to 9%. Digital subtracted angiography remains the gold standard for evaluation of patients with iatrogenic carotid artery injury as it allows for endovascular treatment at the time of the procedure. Endovascular embolization is currently the preferred method for treating ICA pseudoaneurysms and a successful alternative to the surgical approach. Even though endovascular approaches are considered the safer option, delayed complications have been registered, such as endovascular coil extrusion and migration, which increases the risk of further episodes of bleeding. We present our experience with late coil extrusion in a patient who was previously treated with flow diverter stent and coiling for iatrogenic ICA pseudoaneurysm.

Delayed extrusion of embolic coils into the airway after embolization of an external carotid artery pseudoaneurysm

Carotid blowout syndrome (CBS) is a known devastating complication of head and neck surgery. The risk of developing CBS increases in the setting of radiation therapy, wound breakdown, or tumor recurrence. Traditionally, the treatment of choice for CBS is surgical ligation of the bleeding artery; however, recently, endovascular occlusion has become a more common option. If a pseudoaneurysm is present, treatment consists of trapping with endovascular coils or occlusion with a liquid embolic agent. Delayed migration of embolization coils into the airway causing acute respiratory distress is a rare occurrence. This report presents a case of a 57-year-old woman who presented to her otolaryngologist after experiencing an episode of acute respiratory distress which resolved when she expectorated embolization coil material from her tracheostomy tube. Three months prior to the episode she underwent coil embolization of an external carotid artery pseudoaneurysm for life-threatening hemorrhage.

Delayed extrusion of embolic coils into the airway after embolization of an external carotid artery pseudoaneurysm

Carotid blowout syndrome (CBS) is a known devastating complication of head and neck surgery. The risk of developing CBS increases in the setting of radiation therapy, wound breakdown, or tumor recurrence. Traditionally, the treatment of choice for CBS is surgical ligation of the bleeding artery; however, recently, endovascular occlusion has become a more common option. If a pseudoaneurysm is present, treatment consists of trapping with endovascular coils or occlusion with a liquid embolic agent. Delayed migration of embolization coils into the airway causing acute respiratory distress is a rare occurrence. This report presents a case of a 57-year-old woman who presented to her otolaryngologist after experiencing an episode of acute respiratory distress which resolved when she expectorated embolization coil material from her tracheostomy tube. Three months prior to the episode she underwent coil embolization of an external carotid artery pseudoaneurysm for life-threatening hemorrhage.

Endovascular Management of a Traumatic Infraorbital Pseudoaneurysm Causing Orbital Compartment Syndrome

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

Embolization treatment of pseudoaneurysms originating from the external carotid artery

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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