I n t e r v e n t i o n a l Ra d i o l o g y

and B leeding Disord er s

What the Oral and Maxillofacial Surgeon
Needs to Know
Laura Gart, DMDa, Antoine M. Ferneini, MDb,c,*

KEYWORDS
 Embolization  Angiography  Bleeding  AV malformation  Epistaxis  Endovascular techniques
 Orthognathic surgery  TMJ ankylosis

KEY POINTS
 Endovascular techniques are essential for controlling acute head and neck bleeding that cannot be
controlled by local or systemic measures.
 Angiography is the gold standard for the diagnosis and localization of acute head and neck
bleeding.
 The oral and maxillofacial surgeon should refer a patient for an embolization procedure if local mea-
sures fail to achieve hemostasis.

INTRODUCTION occur secondary to trauma; tumor; radiotherapy;

coagulopathy; or vascular malformations or dis-
Hemostasis in the normal patient population in- eases, such as Osler-Weber-Rendu disease.
volves the interaction among four different biologic Another potential source of bleeding in surgical
systems: (1) the blood vessel wall, (2) the blood patients includes arteriovenous malformations
platelets, (3) the coagulation cascade, and (4) the (AVMs). Endovascular technology is actually
fibrinolytic system. Hemostasis occurs through used before surgical resection. More recently,
two independent processes: the coagulation this technology is used to provide complete and
cascade and the platelet activation pathway.1 persistent occlusion of mandibular AVMs.2 AVMs
Most perioperative bleeding in the maxillofacial re- are classified based on their blood flow character-
gion is usually controlled with local measures. Sug- istics. AVMs contain enlarged torturous arteries
gested management to control hemorrhage in the and veins with collateralization from contralateral
head and neck area includes unipolar and bipolar vessels. The pressure differential compared with
electrocautery, laser ablation, local anesthetics the surrounding tissues created by the low-
with vasoconstrictors, and direct pressure. How- pressure vascular channel creates an environment
ever, when bleeding cannot be controlled with where rapid shunting and recruitment of peripheral
local measures, endovascular techniques are indi- vessels can occur.3 They are described as high-
cated to achieve adequate hemostasis. flow or low-flow. Lesions containing arteries
Uncontrollable epistaxis is another bleeding are typically high-flow. Lesions consisting of capil-
state that may be encountered in patients. Most lary, venous, lymphatic, and venous-lymphatic
oralmaxsurgery.theclinics.com

cases (70%) are idiopathic, but epistaxis can

a
Division of Oral and Maxillofacial Surgery, Yale-New Haven Hospital, 333 Cedar St, New Haven, CT 06510,
USA; b Private Practice, Connecticut Vascular Center, PC, 280 State St, North Haven, CT 06473, USA;
c
Division of Vascular Surgery, Yale-New Haven Hospital/St. Raphael Campus, 1450 Chapel St, New Haven,
CT, 06511, USA
* Corresponding author. Private Practice, Connecticut Vascular Center, PC, 280 State St, North Haven, CT
06473, USA
E-mail address: [email protected]

Oral Maxillofacial Surg Clin N Am - (2016) -–-

http://dx.doi.org/10.1016/j.coms.2016.06.012
1042-3699/16/Ó 2016 Elsevier Inc. All rights reserved.
2 Gart & Ferneini

malformations are generally low-flow.3,4 High-flow the ECA or one of its branches is rare. In a series
lesions have the greatest potential for morbidity of more than 8000 aneurysms, 21 pseudoaneur-
and mortality, thus making them more difficult to ysms of the ECA were described, 19 of which
treat. Severe bleeding or exsanguination may occurred after surgery in the region of the carotid
often result with these high-flow lesions. artery.12 The rarity of an ECA pseudoaneurysm is
A considerable risk for hemorrhage exists in caused by the small size of the ECA branches,
temporomandibular joint (TMJ) ankylosis surgery. which makes cross-cutting more likely than a partial
During TMJ ankylosis surgery, many vessels that laceration. Pseudoaneurysms after orthognathic
lie near the medial aspect of the condylar neck surgery are also rare. The literature includes about
are traumatized. Vessels in the pterygoid fossa 18 case reports of pseudoaneurysms after orthog-
are a potential bleeding source during surgery. nathic surgery.11 Depending on the side of
Branches of the maxillary artery and the pterygoid bleeding, a selective angiogram of the ECA (of the
venous plexus can often be sources of hemor- affected side) is usually performed. Embolization
rhage. When compression alone fails to stop the can then be achieved. The goal of embolization is
bleeding, interventional radiology is a useful tool to deposit an embolic material within the aneurys-
to control bleeding that the oral and maxillofacial matic network and not to compromise the vascular
surgeon may encounter in the operating room.5 supply near the injury.13 Endovascular treatment
Complications associated with TMJ ankylosis sur- has been used to treat pseudoaneurysms of the
gery include damage to vascular structures. descending palatine artery and internal maxillary ar-
Methods used to achieve hemostasis include elec- tery.11,14 Endovascular methods to control hemor-
trocautery, laser ablation, local anesthetics with rhage are discussed in this article.
vasoconstrictors, direct pressure, embolization,
and ligation.6 The middle meningeal and maxillary
arteries are injured with a minimum amount of ENDOVASCULAR TECHNIQUES
trauma.7 To control the bleeding, pressure should Endovascular techniques have played a major role in
be first applied at the surgical site with packing the management of head and neck bleeding and le-
and manipulation of the systemic blood pressure. sions since selective embolization of the ECA was
If bleeding does not stop with pressure, electro- described by Djindjian and colleagues15 in 1972.
cautery is used. If cautery is not enough, coagula- Embolotherapy or embolization has rapidly devel-
tion products, such as topical thrombin or oxidized oped in recent years and is now standard of care in
cellulose, are used. If hemorrhage has not stopped most hospital centers. It is defined as the percuta-
with these measures, the external carotid artery neous application of one or more of a variety of
(ECA) is ligated above the level of the facial artery, agents or materials to accomplish vascular occlusion
or fluoroscopic embolization is considered.7 Addi- and bleeding control. Embolotherapy has evolved
tionally, if intraoperative bleeding is a concern, over the past 10 years and includes a wide variety
preoperative angiography and embolization are of clinical applications, including the following:
performed to localize and embolize the vessels.8
Endovascular technology is also used in orthog- 1. Vascular malformations: occlusion of congen-
nathic surgery intraoperatively to control hemor- ital or acquired aneurysms (cerebral, visceral,
rhage and postoperative. Excessive bleeding and or extremities), vascular malformations, and
injury to the internal maxillary artery, although un- pseudoaneurysms.
common, can occur during orthognathic surgery. 2. Trauma: for control of acute hemorrhage or un-
The inferior alveolar branch of the internal maxillary controllable bleeding.
artery is vulnerable to injury when osteotomies are 3. Uterine artery embolization: either to reduce in-
made. Intraoperatively, one of the first measures traoperative blood loss or devascularization of
to control intraoperative hemorrhage includes con- benign uterine leiomyomas.
servative measures, such as manipulating the sys- 4. Nontraumatic hemorrhage: caused by either
temic blood pressure and pressure. Packing should acute or recurrent hemorrhage. This includes he-
be used as the first attempt to tamponade the hem- moptysis, gastrointestinal bleeding, postpartum
orrhage. In the presence of hypovolemic shock and hemorrhage, and hemorrhagic neoplasms.
if conservative measures have failed, intraoperative 5. Oncologic embolization: either palliative or cura-
hemorrhage is controlled via transcatheter arterial tive. Embolization is performed to prevent or
embolization or ligation.9 Additionally, a complica- treat hemorrhage, relieve symptoms, reduce in-
tion of orthognathic surgery includes the formation traoperative blood loss, improve quality of life,
of a pseudoaneurysm, usually 1 to 8 weeks postop- and improve survival. Examples include renal
eratively.10,11 A pseudoaneurysm is treated with cell carcinoma, primary and secondary bone ma-
embolization and microcoils. Pseudoaneurysm of lignancies, and various hepatic malignancies.
 Interventional Radiology and Bleeding Disorders 3

6. Tissue ablation: ablation of benign neoplastic In addition, intra-arterial embolization alone is

and nonneoplastic tissue. This includes hyper- often ineffective because the arterial pedicles
splenism, varicocele, pelvic congestion syn- occlude before complete filling of the venous
drome, priapism, and abdominal pregnancy. pouch, leading to a high recurrence rate. Thus,
7. Flow redistribution: to protect normal tissue. new techniques in interventional radiology have
For example, gastroduodenal artery and right been developed to replace the often ineffective
gastric artery embolization in hepatic artery surgical and endovascular occlusion methods.
chemoembolization and radioembolization. New techniques in interventional radiology
8. Regional therapy delivery: as a vehicle for deliv- include the percutaneous treatment method. This
ery of drugs and other agents. This includes method with possible use of embolization has
chemotherapy, b-emiting spheres, and onco- proven to reduce the need for surgical interven-
lytic viruses. tion.3,16,17 Highly selective embolization has been
9. Endoleak management: this includes direct sac used to decrease blood flow to AVMs, but there
puncture or collateral vessel embolization. is still a high risk for bleeding. The reason for this
is that collateral vessels are recruited from the
Endovascular techniques are the standard of contralateral circulation or from branches of the in-
care to diagnose and treat maxillofacial bleeding. ternal carotid artery (ICA).3
It plays a major role in acute bleeding and AVMs. Percutaneous or transosseous direct puncture
Simple curettage of AVMs alone carries high risks of the lesion directly accesses the lesion’s nidus
of morbidity, mortality, and recurrence (Fig. 1). to limit blood flow and limit the morbidity and mor-
Ligation (eg, ECA) or endovascular occlusion are tality that are inherent to these lesions. The lesion’s
methods that should not be used because they central varix is completely irradiated and the lesion
do not control the bleeding due to the ability of is hemostatic through the use of thrombogenic or
the lesion to rapidly recruit collateral vessels. sclerosing agents.3 The surrounding lesion is

Fig. 1. (A) Preoperative orthopantogram showing moth-eaten irregular radiolucency in left mandibular para-
symphysis body region with enlarged and torturous mandibular canal; adjacent teeth are displaced. (B) Axial
computed tomography and coronal computed tomography section demonstrating widespread destruction and
thinning of cortical plates. (From Singh V, Bhardwaj PK. Arteriovenous malformation of mandible: extracorporeal
curettage with immediate replantation technique. Natl J Maxillofac Surg 2010;1(1):46; with permission.)
4 Gart & Ferneini

resected if bleeding persists, with less blood loss In some cases, it may be necessary to perform
and morbidity and mortality than the traditional computed tomography angiography imaging
methods of embolization and resection. Surgery study to further characterize a hemorrhagic lesion.
is performed within 24 to 48 hours of the Technetium 99m–labeled red blood cell or techne-
embolization. tium 99m sulfur colloid scintigraphy is used in
computed tomography angiography to detect
and localize bleeding.19 Red cell scintigraphy can
ANGIOGRAPHY
allow for delayed scans up to 24 hours after the
Angiography is the gold standard for the diagnosis radioisotope is injected. Injection with radionu-
and localization of acute bleeding. Angiography is clides has a false localization rate of 22%.19
considered a noninvasive standard procedure for Metallic artifacts may also interfere with the visual-
a comprehensive imaging of the anatomy of the ization of the contrast and can lead to false-
vasculature of the head and neck (Figs. 2 and 3). positive results.19
It is the next step once medical management has
failed to control an active bleed. It allows for the EMBOLIZATION
use of embolization and vasopressin infusion
when other management options have failed. Embolization procedures for bleeding disorders in
Angiography allows the medical team to diagnose the head and neck region are mostly performed for
and formulate a treatment plan to achieve intractable epistaxis, intraoperative hemorrhage
hemostasis. (during orthognathic surgery or TMJ ankylosis sur-
Both the site and the source of bleeding are gery), or in the presence of a hypervascular tumor
identified through this imaging modality. Angiog- either before surgical removal or as a palliative
raphy has proven to be an accurate diagnostic treatment.21 Indications for endovascular emboli-
tool. This diagnostic imaging is used to accurately zation include occlusion of unresectable lesions,
assess the flow characteristics and feeding vessel staged occlusion for eventual resection, and
anatomy. For example, studies have shown that emergent preoperative hemostatic control. Embo-
angiography can detect flow rates of 0.3 mL/min lization has proven to be quite successful. The
and has a sensitivity of 50% to 86% and specificity cure rate achieved in most reported series is
of 92% to 95% for identifying lesions associated 80% or higher, particularly when the ipsilateral
with gastrointestinal bleeds.18 It is difficult to facial artery and contralateral sphenopalatine ar-
detect venous bleeding with angiography.19 Angi- tery are simultaneously embolized.22–26
ography is used for surgical planning and confir- Embolization can be performed under local
mation following surgery that the AVM was anesthesia. However, most cases are performed
completely removed or that hemostasis is under conscious sedation. However, general
achieved (Fig. 4).20 anesthesia is usually used in embolization

Fig. 2. Left lateral (A) and anteroposterior (B) digital subtraction angiograms of the right ECA show the first and
second segments (A) and third segment (B) of the maxillary artery. ADTA, anterior deep temporal artery; AMA, acces-
sory meningeal artery; BA, buccal artery; DPA, descending palatine artery; IDA, inferior dental artery; IOA, infraorbital
artery; MDTA, middle deep temporal artery; MMA, middle meningeal artery; PSDA, posterior superior dental artery;
SPA, sphenopalatine artery. (From Tanoue S, Kiyosue H, Mori H, et al. Maxillary artery: functional and imaging anat-
omy for safe and effective transcatheter treatment. Radiographics 2013;33(7):e212; with permission.)
 Interventional Radiology and Bleeding Disorders 5

Fig. 3. Three-dimensional anatomy of the maxillary artery in a patient with an ethmoidal dural arteriovenous fistula.
Left lateral (A) and anteroposterior (B) volume-rendered images from rotational angiographic data clearly depict the
three-dimensional relationships of the maxillary artery and its branches. The arteriovenous fistula is fed by the left
infraorbital artery (IOA) (arrowhead). BA, buccal artery; DPA, descending palatine artery; IDA, inferior dental artery;
MDTA, middle deep temporal artery; MMA, middle meningeal artery; PSDA, posterior superior dental artery; SPA,
sphenopalatine artery. (From Tanoue S, Kiyosue H, Mori H, et al. Maxillary artery: functional and imaging anatomy
for safe and effective transcatheter treatment. Radiographics 2013;33(7):e231; with permission.)

procedures to control intraoperative bleeding. The over a transfemoral access. These include the
embolization procedure requires four steps: following:
a. The radial artery is more superficial than the
1. Percutaneous arterial access: either femoral or
femoral one. Thus, there are no surrounding
radial. The femoral artery has been the primary
structures that are susceptible to injury.
access. However, over the last 10 years, the
Additionally, an inadvertent injury to the ar-
radial artery has become popular. There are
tery itself is significantly less detrimental to
many advantages for a transradial access
the patient because of the dual blood supply
to the hand.
b. The radial artery is readily compressible,
which decreases the incidence of postpro-
cedural bleeding complications. Hemostasis
is accomplished without the introduction of a
foreign body, such as a vascular closure
device.
c. Postoperative care and patient comfort are
usually easier with a transradial access. Af-
ter a transradial access, patients can ambu-
late immediately, sit up, and usually have a
quicker discharge.
2. Manipulation of catheters to selectively access
the target vessel and use of catheters and
microcatheters.
3. Handling and selection of various materials
used for embolization.
4. Assessment of the angiographic or imaging
Fig. 4. Preoperative angiography: left common ca- modality to evaluate the therapeutic end point.
rotid angiogram, lateral projection, and arterial phase A wide variety of agents is available for the
showing extensive mandibular AVM with arterial sup-
embolization of head and neck bleeding (Box 1).
ply from multiple sources and drainage into the
dilated inferior alveolar vein. (From Ferrés-Amat E, They are classified based on their physical state
Prats-Armengol J, Maura-Solivellas I, et al. Gingival (liquid or solid), mechanism of action (mechanical
bleeding of a high-flow mandibular arteriovenous vs chemical), and origin (autologous vs biosyn-
malformation in a child with 8-year follow-up. Case thetic).27 Several factors determine the correct
Rep Pediatr 2015;2015:745718; with permission.) agent for the given case. Particulate and
6 Gart & Ferneini

Box 1 resorbable. They adhere to the vessel wall and

Available agents for the embolization of head cause an inflammatory reaction and vessel
and neck bleeding fibrosis. The disadvantage of these particles is
that they have a tendency to clump together and
Particulate Agents: Absorbable may occlude at a more proximal position than
 Gelatin sponge particles intended.27 To avoid clumping of the particles,
careful technique is needed, which includes
 Gelatin sponge powder
proper suspension, dilution, slow infusion, and
 Microfibrillar collagen resuspension.
 Autologous clot Another embolic agent that has been used is
cyanoacrylate. The injection is continued into the
Particulate Agents: Nonabsorbable
bleeding area until no more angiographic shunt
 Coils or bleeding occurs. Nonliquid embolization mate-
 Polyvinyl alcohol rials have also been used in embolization, which
 Detachable balloons include gelatin sponge soaked in the thrombotic
agent and a detachable balloon.28 The use of coils
 Acrylic microspheres
is not recommended because proximal occlusion
Liquid Agents: Nonabsorbable may not only induce the development of collateral
 Silicone circulation but also close the door to repeat ac-
cess in case of recurrence.
 N-Butyl cyanoacrylate
The transcutaneous puncture embolization can
 Ethibloc also be performed with coils made of stainless
Liquid Agents: Cytotoxic steel or platinum that ideally completely fill the
AVM. The coils come in straight, helical, spiral,
 Doxycycline and complex three-dimensional shapes and a
 Sodium tetradecyl sulfate range of diameters (submillimeters to several cen-
 Ethanol 95% timeters). The coils serve to decrease blood flow
and increase turbulence in the AVMs.3 They are
 Chemotherapeutic agents
less likely to migrate in lesions with high flow
because of their great radial force.27 The disad-
vantage with coils is the possibility for a partial
absorbable embolic agents are usually preferred obstruction because they rely on mechanical
to decrease the severity and longevity of potential obstruction. Some coils may contain small fibers
ischemic events. Liquid and nonabsorbable attached to the metal, which aids in the formation
agents are usually indicated for head and neck pa- of a thrombus.30 The coils rely on the patient’s
thology where a more aggressive approach is indi- ability to form a clot and as a result their effective-
cated. The embolic materials most commonly ness may be unpredictable in coagulopathic
used are particles, either of gelatin sponge or poly- states. This creates an environment where a clot
vinyl alcohol, and more recently trisacryl gelatin can form.
microspheres.3,28 Liquid embolic agents are more difficult to con-
The gelatin sponge is the most commonly used trol. They function independently of the patient’s
temporary embolic agent.27 Gelatin sponge oc- coagulation system making them highly useful in
cludes the vessel for 3 to 6 weeks. The particle patients with severe coagulopathies. Liquids can
size can vary and vessels may be occluded causing also reach beyond the catheter tip when bleeding
ischemia. Gelatin sponge strips rolled into “tor- sites may be difficult to reach. Examples of liquid
pedoes” are used to occlude larger vessels. embolic agents include ethanol, sodium tetradecyl
Microfibrillar collagen and oxidized cellulose are sulfate, N-butyl cyanoacrylate, and ethylene vinyl
other temporary embolic agents that may be used. copolymer.
They are difficult to prepare, which makes them For epistaxis, selective angiography of bilateral
inferior to gelatin sponge. An autologous clot ICAs and ECAs is first performed with 4F or 5F
may also be considered an embolic agent in catheters. ICA angiography is useful for evaluating
some cases, but because of its rapid lysis it has any dangerous collateral vessels between the ECA
been shown to demonstrate little clinical suc- and ICA and to delineate the predominant supply
cess.29 Recanalization of the vessel can occur in to the ophthalmic artery. Moreover, ICA injection
hours to days. also helps to delineate the ethmoidal artery supply
Polyvinyl alcohol particles are derived from to the nasal cavity. It is generally unsafe to embo-
inert plastic sponges. These particles are not lize the anterior ethmoidal arteries with particulate
 Interventional Radiology and Bleeding Disorders 7

agents because of the associated risk of blind- Soft tissue necrosis has also been reported as a
ness. The embolization is generally performed complication, especially when more than one
under systemic anticoagulation and with superse- vessel is occluded (contralateral sphenopalatine
lective catheterization of target vessels. We artery or facial artery) or when liquid embolic
generally prefer microcatheters with larger bores agents are used. Small particles tend to produce
(0.019–0.021 inches) and the use of 100 to 300 a more distal occlusion and may also result in local
or 300 to 500 mm particles (Embospheres, Merit ischemia and even nasal septal perforation.40 At
Medical Systems, Inc, South Jordan, UT) for times, it is difficult to discern if the necrosis is sec-
embolization. The microcatheter is positioned ondary to the embolization procedure or to pro-
just proximal to the branches supplying the nasal longed packing. Ischemic injury may not only
mucosa, and care is taken to avoid nontargeted affect the mucosa but also the cranial nerves,
vessel embolization. If smaller particles (100– possibly resulting in temporary or permanent cra-
300 mm) are chosen, they are typically used in nial nerve palsy.41,42 Depending on the cranial
small quantities because aggressive embolization nerve affected, the presenting symptoms are vari-
with small particles is associated with a risk of ne- able, including diplopia, dysphagia, and numb-
crosis of the embolized territory. Gelatin sponge ness. A cranial nerve examination is necessary
pledgets may be placed in the vessel lumen after preoperatively.
completing the embolization with particulate The most severe complications are those con-
agents. Embolization is highly effective for treat- nected with the passage of embolic material into
ment of intractable epistaxis with reported suc- the intracranial arteries potentially leading to a
cess rates ranging from 71% to 100%.31–34 The stroke or blindness.35,43 This may occur because
most common cause of failure of this technique of reflux from the ECA into the ICA or through
is bleeding from the anterior ethmoidal artery.31–34 the passage of embolic material through
The selection process for an ideal embolic agent extracranial-intracranial anastomoses. At times, it
includes consideration of vessel size, duration of may become necessary to perform selective
occlusion desired, need for tissue viability (should embolization of branches originating from the
the tissue supplied by the vessel remain viable af- ophthalmic artery. In this situation, the microcath-
ter embolization), and patient’s clinical condi- eter should be advanced beyond the second
tion.35–37 Smaller embolic agents are more likely portion of the ophthalmic artery to prevent embolic
to occlude the primary and the collateral vessels. material from entering the central artery of the
Duration of occlusion is important to consider retina.36
when selecting an embolic agent. Embolic agents, In the presence of ipsilateral ICA stenosis or oc-
such as autologous clots, may be present for a few clusion, the use of particles may be particularly
hours, whereas nonresorbable liquid agents and dangerous because of the development of ECA
metals may remain in place permanently. to ICA anastomoses. In this situation, endovascu-
lar therapy may still be safely and effectively per-
POTENTIAL COMPLICATIONS OF THESE formed with coils in the pterygopalatine segment
PROCEDURES of the internal maxillary artery.37
Ligation of the ECA is no longer the treatment of
The most common complication encountered from choice for hemorrhage because continued
embolization is headache or temporofacial pain, bleeding can occur when collateral vessels are
more common in cases where two or more arteries recruited from the contralateral ECA or the verte-
are embolized with gelatin sponge. Siniluoto and bral artery. Once the ECA is ligated, transarterial
colleagues17 reported that 96.8% of their patients embolization is difficult. Embolization can take
experienced mild to moderate pain in the temporal place if the distal part of the ligated ECA is surgi-
area during the first 24 hours after embolization.19,38 cally exposed and punctured. The challenge with
Risks specific to transcutaneous puncture this procedure is that the ECA becomes fibrotic
embolization include pulmonary embolism and ce- at the ligation site and access to this vessel is diffi-
rebrovascular accident. It is possible for the coils cult. There exists a high rate of complications
to permeate through the venous outflow tract if associated with puncture of the ECA. Alternatively,
the coils are too small.39 Additional risks include embolization is performed using a transsuperficial
necrosis or ischemia to surrounding vessels temporal artery approach.44 This method is also
caused by decreased vascularity in the area and useful when other feeding vessels are too tortuous
peripheral and central nervous system arterial to be navigated with a catheter. Complications of
spasm or vessel rupture. Other complications this approach include damage to the superficial
include groin hematoma, facial numbness, temporal nerve and vasospasm. Other methods
mucosal necrosis, and acute infection. also include transvenous embolization by direct
8 Gart & Ferneini

Fig. 5. (A) Neck dissection. (B) Bifurcation of the common carotid into the external and internal carotid arteries.

transosseous venous puncture or by transfemoral direct transcutaneous puncture embolization,

catheterization. have been developed and can limit the morbidity
and mortality associated with a coagulation
WHAT THE ORAL AND MAXILLOFACIAL defect. ECA ligation should be a last resort if
SURGEON NEEDS TO KNOW embolization fails. The oral and maxillofacial sur-
geon should refer a patient for an embolization
For most intraoperative and postoperative procedure if local measures fail to achieve
bleeding, local measures are usually adequate to hemostasis.
achieve hemostasis. Angiography is now consid- As a last resort, if hemostasis cannot be
ered the gold standard to better localize the exact achieved, it may be necessary to unilaterally ligate
location of the bleeding. New techniques, such as the ECA (Fig. 5). Surgical ligation of the ECA is

Fig. 6. Flow chart for acute hemorrhage.

 Interventional Radiology and Bleeding Disorders 9

performed safely without risk to cerebral perfu- 4. Wehrli M, Lieberherr U, Valavanis A. Superselective
sion.44,45 Risks of ECA ligation include compro- embolization for intractable epistaxis: experiences
mised arterial blood flow to the eye via the with 19 patients. Clin Otolaryngol 1988;13:
middle meningeal artery. Because of the extensive 415–20.
collateral circulation in the face, ligation at the 5. Kumar S, Bansal V, Agarwal R. An effective intra-
origin of the ECA may not be effective, making operative method to control bleeding from vessels
ligation a less desirable approach to control medial to the temporomandibular joint. J Maxillofac
hemostasis.9 Oral Surg 2009;8(4):371.
In cases where the oral and maxillofacial sur- 6. Cillo JE Jr, Sinn D, Truelson JM. Management of
geon needs to remove vascular lesions, such as middle meningeal and superficial temporal artery
angiofibromas and hypervascular metastases, hemorrhage from total temporomandibular joint
microembolization may be indicated. Advantages replacement surgery with a gelatin-based hemostat-
include shorter operative times, reduced blood ic agent. J Craniofac Surg 2005;16(2):309–12.
loss, and faster recovery.46–48 Microembolization 7. Dattilo DJ. Resection of the severely ankylosed
serves to selectively occlude the ECA feeders temporomandibular joint. Atlas Oral Maxillofac
through intratumoral deposition of embolic mate- Surg Clin North Am 2011;19(2):207–20.
rial. Ideally, embolization is performed 24 to 8. Susarla SM, Peacock Z, Williams WB, et al. Role of
72 hours before surgical thrombosis. This is an computed tomographic angiography in treatment
ideal time range to allow for thrombosis of the of patients with temporomandibular joint ankylosis.
vessel and prevent recanalization of the occluded J Oral Maxillofac Surg 2014;72(2):267–76.
arteries or formation of collateral arterial channels. 9. Khanna S, Dagum A. A critical review of the litera-
After a microcatheter is inserted into the artery that ture and an evidence-based approach for life-
feeds the tumor, angiography of the ICA and ECA threatening hemorrhage in maxillofacial surgery.
is performed. Caution must be exercised during Ann Plast Surg 2012;69(4):474–8.
the angiography because of the possibility for 10. Manafi A, Ghenaati H, Dezham F, et al. Massive
anastomoses between the ECA and ICA. Embolic repeated nose bleeding after bimaxillary osteotomy.
material is then injected using fluoroscopic moni- J Craniofac Surg 2007;18(6):1491–3.
toring.46 A major risk of embolization includes un- 11. Avelar RL, Goelzer JG, Becker OE, et al. Emboliza-
intended ischemia in nonneoplastic tissue.47 tion of pseudoaneurysm of the internal maxillary ar-
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SUMMARY 12. McCollum CH, Wheeler WG, Noon GP, et al. Aneu-
rysm of the extracranial carotid artery. Twenty-one
Endovascular techniques are essential for control-
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ling acute head and neck bleeding that cannot be
13. Zachariades N, Rallis G, Papademetriou G, et al.
controlled by local or systemic measures (Fig. 6).
Embolization for the treatment of pseudoaneurysm
Detailed knowledge of the head and neck vascular
and transection of facial vessels. Oral Surg Oral
anatomy, advances in catheterization techniques,
Med Oral Pathol Oral Radiol Endod 2001;92:491–4.
and the availability of new embolic materials
14. Fernandez-Prieto A, Garcia-Raya P, Burgueno M,
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