Vascular occlusions and protocols in managing one.

What is a vascular occlusion?

A vascular occlusion occurs when blood is no longer able to pass through a blood vessel. 1. It may be a complete occlusion or partial occlusion, resulting in a diminished blood supply. This can happen if filler is injected into a vessel during an aesthetic treatment. This is why it is so important to ensure that you are going to a medical provider who is either an RN, NP, PA or Physician. While a vascular occlusion can happen to anyone there are certainly things that can be done to decrease the risk. This is the scariest risk factor that patients and providers face when getting dermal fillers. It is a very scary complication. However, the outcome can range from minimal bruising and a minor inconvenience to death of tissue and that is dependent on the management of the occlusion.

So as a patient what questions should you be asking?

1. How long have you been injecting for? This isn't everything because there are many providers who have been doing it for over 10 years and don't keep up with their education and in that scenario I would rather you go to an injector with only 2 years of experience who has immersed themselves into learning everything they can about injectables. I

2. Ensure your provider has knowledge on anatomy. This is formed over years of learning, taking courses and cadaver classes and studying. Ask you provider what they do to keep up with their knowledge of anatomy and what courses they've attended.

3. What injection techniques do they use to make decrease the risk.

• Do they inject filler in high risk areas like the forehead, glabella or nose.

• Only using Hyaluronic based dermal fillers in high risk areas.

• Injecting down on bone. Vessels usually don't live down on bone so this is a safer place to inject in most instances.

• Only injecting small boluses and limiting the amount of gel placed in each location to 0.2mls

• Does your provider aspirate? Aspiration is a sign that can be helpful in avoiding vessels when used along with these other safety techniques.

• Do they believe in keeping their needle moving. This kind of goes with not injecting more than 0.2mL in any specific location.

• Use of cannula with a 25-gauge or larger in high risk areas.

• Do they check capillary refill after every injection point.

4. Have you ever had a vascular occlusion and if so how was it handled what was the outcome.

5. How many vials of Hylenex do you keep in stock. We personally keep a minimum of 20 vials in our office.

6. What is their plan if they run out of Hylenex. Make sure that they have people they can reach out to if they were to run out in the middle of treating a vascular occlusion. We have 4 offices that we collaborate with in the event that were to happen.

7. Ensure they have a relationship with a retinal surgeon in the case that their is a compromise in blood flow to the eye.

Signs of vascular compromise

The first signs of a vascular event are possible pain and/or quick blanching of skin in a defined pattern. A vascular occlusion can look like a sudden big blotch of lighter skin that changes later to duskiness, port-wine appearence and/or lacy/mottled. It can also present as extreme pain after injection upon palpation. May be followed by a vasovagal reaction. It can also look darker, with a brown stain appearance. Delayed ischemia can occur and may be venous in nature. Follow the same protocol below for delayed response. Assess for “mottled” appearance of redness with some patchy areas of blue and perhaps white as well. Initially it may resemble a bruise. If it changes to a darker, duskier appearance within a few hours, proceed to protocol below.

Our policy and procedure

When any of these signs are present our protocol is outlined below with citations for evidenced based practice.

1. Immediately stop treatment and assess capillary refill time

2. Firmly massage the area: Firm and prolonged massage can encourage blood flow and help remove any obstruction caused by a foreign body occluding a vessel. (Massage with cream Oxygenetix if available)

3. Aspirin: Stat dose of 325 mg should be given immediately, followed by 81 mg a day until the vascular occlusion has resolved when there are no contraindications.

4. Inject with hyaluronidase: This is a time-critical event. Inject area of occlusion with 500-1500 units of hyaluronidase* (Hylenex), mixed 1:1 with 2% Lidocaine Plain for first pass. Massage vigorously after injection. Inject entire area that is discolored, consider injecting with large (22 or 25 G) microcannula to avoid bruising. Repeated administration of relatively high doses of hyaluronidase, flood the area. Into the whole area of compromised tissue, not just where the filler was injected.

5. Apply heat: Encourages vasodilatation and increase blood flow.

6. Tap the area: Tapping over an area can dislodge intra-arterial emboli located at the site or further up in the vessel (King et. al, 2020).

7. Check for reperfusion with metal handle of instrument. If area hasn’t reperfused after 15 minutes, re-inject area with 500-1500 units of hyaluronidase. Continue re-injecting every 30 minutes until tissue perfused. Clinical resolution is denoted by improvements in capillary refill, skin color and pain (King et. al, 2020).

8. If sudden loss of vision 2nd option: Take to ophthalmologist or retinal specialist immediately for retro-orbital or intra-orbital hyaluronidase. Have a plan of action laid out with eye physician(s) before-hand. This step is extremely time sensitive, treatment within 15 minutes is optimal.