What is the clinical significance and management of bleeding risks associated with the anterior superior alveolar arteries during surgical procedures?

From the Guidelines

The anterior superior alveolar arteries pose a significant bleeding risk during surgical procedures, and their management is crucial to prevent morbidity and mortality, with careful preoperative planning and precise surgical techniques being essential to minimize this risk. The clinical significance of the anterior superior alveolar arteries lies in their supply to the anterior maxillary teeth, nasal cavity floor, and anterior maxillary sinus wall, and damage to these vessels can lead to significant hemorrhage, hematoma formation, and potential compromise of adjacent structures 1. To manage the bleeding risks associated with these arteries, surgeons should employ careful preoperative planning with CT angiography when possible to identify vascular anatomy variations. During surgery, the use of epinephrine-containing local anesthetics (typically 1:100,000 concentration) helps reduce bleeding through vasoconstriction, and careful soft tissue reflection and subperiosteal dissection techniques minimize arterial damage. If bleeding occurs, direct pressure should be applied for 5-10 minutes, followed by electrocautery for small vessels or vascular clips for larger branches if necessary. Hemostatic agents like gelatin foam (Gelfoam) or oxidized cellulose (Surgicel) can be applied to bleeding sites. In severe cases, arterial ligation or embolization may be required, and particular caution is needed during Le Fort osteotomies, maxillary sinus procedures, and implant placement in the anterior maxilla, where these vessels are most vulnerable to injury. Some key points to consider in the management of bleeding risks associated with the anterior superior alveolar arteries include:

• Careful preoperative planning and identification of vascular anatomy variations
• Use of epinephrine-containing local anesthetics to reduce bleeding
• Precise surgical techniques to minimize arterial damage
• Application of direct pressure and use of hemostatic agents to control bleeding
• Consideration of arterial ligation or embolization in severe cases. The guidance document on the periprocedural management of patients on chronic oral anticoagulant therapy recommends standardized reporting of procedural/surgical bleed risk and patient-specific thromboembolic risk, which is essential in managing the bleeding risks associated with the anterior superior alveolar arteries 1.

From the Research

Clinical Significance of Anterior Superior Alveolar Arteries

• The anterior superior alveolar arteries play a crucial role in the vascularization of the alveolar process and the anterior maxilla wall 2.
• Procedures in this region can cause heavy bleeding due to the rich arterial network, highlighting the importance of understanding the anatomical course of these arteries during surgery 2.

Management of Bleeding Risks

• Knowledge of the arterial anastomoses in the region, including the connection between the infraorbital and posterior superior alveolar artery, can help surgeons choose appropriate incisions and minimize bleeding risks 2.
• The use of local hemostatic agents, such as tranexamic acid, can promote safe surgical site hemostasis and reduce bleeding after dental extraction in patients taking anticoagulant medications 3, 4, 5.
• Tranexamic acid has been shown to decrease bleeding after extraction in patients treated with non-vitamin K oral anticoagulants, and its use is being investigated in clinical trials to guide the management of these patients 5.

Surgical Considerations

• The location of the arterial anastomosis between the infraorbital and posterior superior alveolar artery can be predicted pre-operatively, allowing surgeons to plan their approach and minimize bleeding risks 2.
• The use of alveolar sutures and gauzes impregnated with tranexamic acid can help control bleeding after dental extraction in patients receiving dual antiplatelet therapy 3.
• Tranexamic acid has been associated with a lower risk of bleeding and transfusion requirements in patients undergoing coronary-artery surgery, but its use must be balanced against the potential risks of prothrombotic and proconvulsant effects 6.