Abstract
Objective
We report 2 patients with iatrogenic pseudoaneurysms, which developed following sinus surgery.
Method
Case reports and a review of literature of the management of iatrogenic pseudoaneurysm.
Results
For one patient who presented with massive epistaxis, the only lifesaving option available was to perform an urgent angiogram followed by selective embolization of the feeding vessel. In the second patient who presented with persistent nasal obstruction and discharge and no epistaxis, a traumatic aneurysm of the internal carotid artery was demonstrated on magnetic resonance imaging scan that was later confirmed by angiography; he, however, declined further treatment.
Conclusion
Iatrogenic pseudoaneurysms that develop following a vascular injury, though rare, can cause life-threatening epistaxis or a thromboembolism. In this report, we describe 2 different manifestations of iatrogenic vascular malformations following sinus surgery. The role of angiography and subsequent endovascular therapy in the management of these lesions is emphasized.
1
Introduction
The presence of massive or recurrent epistaxis in a patient who has undergone prior sinonasal surgery is an unusual phenomenon that should trigger the suspicion of the presence of an iatrogenic vascular malformation. These could include pseudoaneurysms or arterio-venous (A-V) malformations.
A pseudoaneurysm or false aneurysm develops usually following an injury, involving all the 3 layers of the arterial wall. Later, a fibrous capsule develops from the surrounding perivascular connective tissue and surrounds the extravasated blood. As the aneurysm expands, it ruptures, eventually resulting in massive hemorrhage. Pseudoaneurysms have been reported to develop following any major surgery, routine arterial puncture, penetrating wounds, blunt trauma, fractures, and, rarely, infections . Their association with sinonasal surgery, however, has not been frequently described.
Our experience with 2 patients with profuse epistaxis immediately following sinonasal surgery is presented. We emphasize the need to consider the possibility of iatrogenic vascular malformations so that radiological investigations that are essential in confirming the vascular pathology are ordered followed by appropriate definitive treatment.
1.1
Case report 1
A 17-year-old male patient presented with a history of profuse epistaxis a month following sinonasal surgery at his hometown. He had presented to the local ENT surgeon 20 months ago with a history of a gradually progressive swelling in the region of right medial canthus of 2 months’ duration. With a preoperative diagnosis of ethmoid abscess, a lateral rhinotomy approach was used to drain the same. No documented operative details were available. Intraoperatively, he developed profuse epistaxis that was controlled with nasal packing. Attempts at removing the pack 5 days later resulted in recurrence of profuse epistaxis. He was immediately reexplored through an extended lateral rhinotomy approach, and bone was removed from the region of the anteromedial aspect of the maxilla. The histopathology report was giant cell tumor. (The slide review performed at our hospital when he presented to us confirmed the diagnosis. Further categorization was not possible because of scanty lesional tissue.) Several blood transfusions were given. Postoperatively, the bleeding persisted. The patient was immediately taken up for surgery again; and the wound was reexplored, but no single bleeding point was located. Right external carotid artery ligation was also performed at the same sitting. Before the nasal packs were removed, he also received hemostatic radiation of 24 Gy over 12 days.
The patient continued to have recurrent episodes of moderate to severe right-sided epistaxis since then. He presented to us about a month after the last surgery. On examination, he was found to have an extended lateral rhinotomy scar with an infected antrocutaneous fistula in the region of the ascending process of maxilla. The nasal cavity was filled with purulent discharge. Rigid nasal endoscopy showed bilateral mucopurulent discharge with multiple synechiae between the middle turbinate and lateral nasal wall on the right side. No active bleeding sites or mass lesions were seen.
He was initially treated with a course of oral antibiotics and daily dressings of the fistula. Five days later, he presented to the Emergency Department of the hospital with profuse bleeding from the nose, oral cavity, and the antrocutaneous fistula that did not subside despite tight packing with a medicated gauze pack. His packed cell volume (PCV) dropped considerably, and he was urgently transfused 1 unit of whole blood and 2 units of packed cells.
Urgent angiography was performed. This revealed a 7-mm × 4-mm pseudoaneurysm from a branch of the internal maxillary artery ( Fig. 1 A ). A stricture was seen at the previously ligated right external carotid artery segment ( Fig. 1 B). The arterial branch with pseudoaneurysm was selectively cannulated with a microcatheter, and Gelfoam was injected followed by coil insertion. Postprocedural angiographic runs showed no flow into the pseudoaneurysm ( Fig. 1 B).
The medicated nasal pack was removed 6 days after embolization, and there was no further epistaxis. At follow-up 6 months later, the patient was found to have no further episodes of epistaxis. The antrocutaneous fistula had healed. A repeat computed tomographic (CT) scan with contrast of the paranasal sinuses (PNS) showed no evidence of any mass lesion or opacification of the sinuses
1.2
Case report 2
A 54-year-old gentleman presented with complaints of profuse nasal discharge and obstruction, mainly on the right side. He had undergone endoscopic sinus surgery 3 years back in a hospital at his hometown. The surgery had been abandoned intraoperatively because of complications that included profuse hemorrhage and periorbital swelling. No documentation of the intraoperative events was available with the patient.
Examination revealed right-sided, profuse, mucopurulent discharge with synechiae between the middle and inferior turbinates and septum bilaterally. A tiny gauze piece (left behind after previous surgery) was found in the right middle meatus on rigid endoscopy.
CT scanning with contrast of the paranasal sinuses showed polypoidal mucosal thickening filling the right maxillary and ethmoid sinuses. Deossification of the bony septa of the right ethmoidal sinus and lamina papyracea was also noted. Opacification of the sphenoid sinus with a bony defect in the roof and floor was noted. There was no preoperative CT scan available for comparison. Magnetic resonance imaging (MRI) scan of the sinuses was performed to better define the sphenoid sinus mass that on T1-weighted image showed hyperintense signal and on T2-weighted images showed hypointense signal in the sphenoid sinus.
The patient underwent endoscopic release of synechiae, uncinectomy, and middle meatal antrostomy under general anesthesia. Retained gauze piece was visualized entangled in the soft tissue up to the skull base. This was carefully extracted. Left sphenoidotomy revealed a pale, firm, nonpulsatile mass. Needle aspiration of the mass was attempted with a gush of blood into the syringe, which suggested the presence of an aneurysm in the sphenoid sinus. Review of the axial and coronal proton density (PD) images of the MRI scan showed that the mass in the sphenoid sinus had concentric layering consistent with an organized traumatic aneurysm ( Fig. 2 A, B).
