Re-maxillary artery pseudoaneurysm as a complication of maxillofacial injuries report of three cases and literature review

• Published in: Sultan Qaboos University medical journal 2020-11, Vol.20 (4), p.401-403
• Main Authors: al-Balushi, Yarub, al-Shaqsi, Sultan, al-Sadi, Nur
• Format: Article
• Language: English
• Subjects: Aneurysm, False - diagnostic imaging; Aneurysm, False - etiology; Asymptomatic; Embolization, Therapeutic; Fistula; Humans; Injuries; Letter To The Editor; Literature reviews; Maxillary Artery - diagnostic imaging; Maxillofacial Injuries - complications; Pseudoaneurysm; Reconstructive surgery; Trauma; Veins & arteries
• ISSN: 2075-051X; 2075-0528
• DOI: 10.18295/squmj.2020.20.04.022

Dear Editor, We read with interest the case report by Al Saadi et al. published in November 2019 issue of SQUMJ and would like to commend the authors for their efforts in highlighting three examples of maxillary artery pseudoaneurysm.1 As indicated in their article it is a rare but devastating complication that could occur from maxillofacial trauma or its management. However, there were some points that we would like to discuss when attempting to understand the relationship between maxillofacial trauma and pseudoaneurysms of the vascular supply in the head and neck. There is usually a dilemma of what actually causes the pseudoaneurysm in the first place in the setting of maxillofacial trauma that undergoes a surgical intervention. Is it the initial injury or the surgery? It is difficult to definitively delineate the exact cause without pre-operative vascular imaging assessment such as a computed tomography-angiogram (CTA) or a conventional angiogram. In other words, in order to assume that the initial injury caused the pseudoaneurysm rather than manipulation during surgery, a detailed pre-operative vascular assessment is required. In the cases presented in the article, there is no evidence of pre-operative imaging provided for any of the cases and therefore pre-existing vascular injury cannot be excluded. Therefore, one cannot assume that the subsequent development of pseudoaneurysm is secondary to the initial injury. It could also be iatrogenic and caused by surgical manipulation or at least masked by the surgery itself. Surgical manipulation during maxillofacial trauma management could cause vascular injury by impacting sharp bony edges or excessive traction of already traumatised vessels. Therefore, surgical intervention is a known and reported cause of vascular injury in maxillofacial trauma.2,3 Some might argue that case two had evidence of mature arterio-venous fistula (AVF) during their digital subtraction angiography assessment which accounts for the chronicity of the pseudoaneurysm and therefore likely formed from the time of injury. However, acute arteriovenous fistulas has been reported in the literature and could be caused by surgical manipulation that usually leads to vessel trauma and haemorrhage.4–6 The question remains whether it even matters what caused the pseudoaneurysm, whether it is the initial trauma or the surgical trauma. We would argue that it is critical to be specific about the cause of rare but potentially devastating complicati