Transarterial embolization of the external carotid artery in the treatment of life-threatening haemorrhage following blunt maxillofacial trauma

Abstract

BackgroundSevere bleeding after blunt maxillofacial trauma is a rare but life-threatening event. Non-responders to conventional treatment options with surgically inaccessible bleeding points can be treated by transarterial embolization (TAE) of the external carotid artery (ECA) or its branches. Case series on such embolizations are small; considering the relatively high incidence of maxillofacial trauma, the ECA TAE procedure has been hypothesized either underused or underreported. In addition, the literature on the ECA TAE using novel non-adhesive liquid embolization agents is remarkably scarce.Patients and methodsPubMed review was performed to identify the ECA TAE literature in the context of blunt maxillofacial trauma. If available, the location of the ECA injury, the location of embolization, the chosen embolization agent, and efficacy and safety of the TAE were noted for each case. Survival prognostic factors were also reviewed. Additionally, we present an illustrative TAE case using a precipitating hydrophobic injectable liquid (PHIL) to safely and effectively control a massive bleeding originating bilaterally in the ECA territories.Results and conclusionsBased on a review of 205 cases, the efficacy of TAE was 79.4–100%, while the rate of major complications was about 2–4%. Successful TAE haemostasis, Glasgow Coma Scale score ≥ 8 at presentation, injury severity score ≤ 32, shock index ≤ 1.1 before TAE and ≤ 0.8 after TAE were significantly correlated with higher survival rate. PHIL allowed for fast yet punctilious application, thus saving invaluable time in life-threatening situations while simultaneously diminishing the possibility of inadvertent injection into the ECA-internal carotid artery (ICA) anastomoses.

Systematic review and meta‐analysis of arterial embolization compared with traditional management on outcomes of traumatic massive facial haemorrhage

“…The focus of this review was to determine if TAE was associated with better outcomes than non‐TAE management of massive haemorrhage following maxillofacial trauma. Although relatively infrequent, the mortality rate associated with this presentation is significant 2–7 . Our analysis did not find a statistically significant difference in mortality rates between each cohort, however, the meta‐analysis favoured embolization as beneficial for survival.…”

“…In patients with maxillofacial trauma, it is important to be aware of the potential for significant and rapid airway compromise, cervical spine injuries and significant bleeding. 4 Establishment of a patent airway and adequate circulation are a priority and precede further investigation of injuries or interventions. Airway management in patients with facial trauma is of particular importance, as they are at risk of rapidly losing their airway secondary to oedema or haemorrhage.…”

“…Initial management of any trauma patient involves stabilization according to ATLS guidelines. In patients with maxillofacial trauma, it is important to be aware of the potential for significant and rapid airway compromise, cervical spine injuries and significant bleeding 4 . Establishment of a patent airway and adequate circulation are a priority and precede further investigation of injuries or interventions.…”

“…Transarterial embolization (TAE) was pioneered in 1930 by Brooks, 22 with Rosch and Dotter utilizing it for the first time in management of a traumatic vascular injury in 1972 23 . In recent years, TAE has had a growing role in the management of traumatic haemorrhage, particularly in the unstable haemorrhagic patient, where super‐selective embolization can occur quickly and without the need for a general anaesthetic 3,4,6 . Outside of these advantages, embolization offers rapid and definitive localization of the site of bleeding with angiography, the ability to rapidly control multiple local points of bleeding, as well as occlusion of small vessel branches often not amenable to surgical access and ligation 3,4,6 .…”

Craniofacial Trauma and Vascular Injury

“…Endovascular embolization can access surgically inaccessible vessels relatively rapidly. 78,[81][82][83][84][85][86]…”