Shimizu Yoshitaka, Okazaki Takahito, Hamana Tomoaki, Irifune Masahiro
Assistant Professor, Department of Dental Anesthesiology, Program of Dental Sciences, Integrated Health Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
Assistant Professor, Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
J Oral Maxillofac Surg. 2018 Jun;76(6):1377.e1-1377.e4. doi: 10.1016/j.joms.2018.02.006. Epub 2018 Feb 20.
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 had intraoral hemorrhaging. At the time of the initial examination, computed tomography angiography showed 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 (IVR) 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 with the patient 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. A balloon type of embolic protection device 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 balloon embolic protection device 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 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 the one in this case, a combination of IVR therapy and surgery is useful for controlling intraoperative hemorrhage.
颈内动脉假性动脉瘤的治疗与脑梗死的高风险相关；因此，必须避免为止血而进行血管结扎。一名66岁男性出现口腔内出血。在初次检查时，计算机断层血管造影显示颈内动脉附近有颌骨板移位。使用数字减影血管造影获得了更详细的图像。对图像进行评估后，诊断为假性动脉瘤。六天后，担心有误吸和气道阻塞的风险；因此，进行了气管切开术。计划采用介入血管放射学（IVR）和手术来促进完全康复、取出颌骨板并修复假性动脉瘤。手术前，确认可以阻断血流约20分钟。患者在全身麻醉下接受手术。在取出钢板之前，心血管外科医生暴露左大隐静脉并做好准备，以便用于修补血管壁缺损。放置了球囊型栓子保护装置，以便在通过口腔手术取出钢板后随时可以充气。假性动脉瘤直接位于钢板下方；然而，它已与瘢痕组织粘连。随着取出过程的进行，发生了出血。为实现止血，将球囊栓子保护装置充气。取出假性动脉瘤，并吸出红色血栓。术后第41天，再次出血。两天后，通过IVR单一疗法进行了铂线圈栓塞和支架置入。术后进展顺利，患者在治疗后83天出院，无神经后遗症。位于颅底附近的颈内动脉假性动脉瘤修复风险高且具有挑战性。然而，对于本例这样的创伤性动脉瘤，IVR治疗和手术相结合有助于控制术中出血。
