Bykowski Michael R, Hill Amber, Garland Catherine, Tobler William, Losee Joseph E, Goldstein Jesse A
Department of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA.
J Craniofac Surg. 2018 Jun;29(4):998-1001. doi: 10.1097/SCS.0000000000004396.
Although rare, pseudoaneurysms (PA) can develop following Le Fort I osteotomy and lead to life-threatening hemorrhage. However, the typical presentation of a PA following a Le Fort I osteotomy is not well characterized. Evidence-based guidelines are not currently available for evaluation of PA following Le Fort I osteotomy.
A case report is presented of a 27-year-old man who underwent Le Fort I advancement and subsequently developed a bleeding PA. A comprehensive search of journal articles was performed using the MEDLINE/PubMed database between 1964 and April 2016. Keywords and phrases used were "(osteotomy OR craniofacial OR orthognathic) AND (pseudoaneurysm OR aneurysm OR epistaxis)." Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines were followed.
The literature search yielded 13 reports of 18 patients. All 18 patients underwent Le Fort I osteotomy and subsequently developed a delayed postoperative bleeding PA. All studies were level IV or V evidence. Twenty-eight percent (N = 5) of the cases documented "excessive" intraoperative bleeding or more than 500 mL of estimated blood loss. The average time for the first bleeding episode and time until final bleed was 17.3 ± 14.3 days (range: 3-62 days) and 27.8 ± 21.2 days following surgery (range: 6-77 days), respectively. Sixty-seven percent (N = 12) had multiple episodes of bleeding. The duration between the bleeding events averaged 10.6 (± 7.9 days) with a range of 1 to 35 days. Bleeding PA's were treated with image-guided embolization (15/18 patients; 83.3%) or ligation or clamping (3/18 patients; 16.7%).
In the setting of recurrent and/or delayed postoperative epistaxis following Le Fort I osteotomy, surgeons should maintain a high clinical suspicion for PA. Ruptured PA's are often preceded by multiple episodes of progressively worsening epistaxis. Based on the presented case report and pooled data from the literature, angiography is recommended to evaluate for PA in the setting of recurrent epistaxis following Le Fort I osteotomy, especially within the first 4 weeks following surgery.
尽管罕见，但假性动脉瘤（PA）可在勒福Ⅰ型截骨术后发生，并导致危及生命的出血。然而，勒福Ⅰ型截骨术后PA的典型表现尚未得到很好的描述。目前尚无基于证据的指南用于评估勒福Ⅰ型截骨术后的PA。
报告一例27岁男性患者，其接受了勒福Ⅰ型前徙术，随后发生了出血性PA。使用MEDLINE/PubMed数据库对1964年至2016年4月间的期刊文章进行了全面检索。使用的关键词和短语为“（截骨术或颅面或正颌） AND （假性动脉瘤或动脉瘤或鼻出血）”。遵循系统评价和荟萃分析的首选报告项目（PRISMA）指南。
文献检索得出18例患者的13份报告。所有18例患者均接受了勒福Ⅰ型截骨术，随后发生了术后延迟出血性PA。所有研究均为Ⅳ级或Ⅴ级证据。28%（N = 5）的病例记录有“过多”的术中出血或估计失血量超过500 mL。首次出血事件的平均时间和直至最终出血的时间分别为术后17.3±14.3天（范围：3 - 62天）和27.8±21.2天（范围：6 - 77天）。67%（N = 12）有多次出血发作。出血事件之间的持续时间平均为10.6（±7.9天），范围为1至35天。出血性PA采用影像引导下栓塞治疗（15/18例患者；83.3%）或结扎或钳夹治疗（3/18例患者；16.7%）。
在勒福Ⅰ型截骨术后出现复发性和/或延迟性鼻出血的情况下，外科医生应高度怀疑PA。破裂的PA通常先有多次逐渐加重的鼻出血发作。基于所呈现的病例报告和文献汇总数据，建议在勒福Ⅰ型截骨术后复发性鼻出血的情况下，尤其是在术后4周内，进行血管造影以评估PA。
